Time spent at health facility is a key driver of patient satisfaction, but did not influence retention to HIV care: A serial cross-sectional study in Mozambique.

INTRODUCTION: Patient satisfaction with clinical services can have an effect on retention in HIV care and adherence to antiretroviral therapy. This study assessed patient satisfaction and its association with retention and viral suppression in Zambézia Province, Mozambique. METHODS: Monthly exit interviews with persons living with HIV were completed from August 2017-January 2019 in 20 health facilities; clinical data were extracted from medical records. Regression analyses assessed the effect of satisfaction scores on retention and viral suppression, adjusting for age, sex, education, civil status, time on treatment, and site. Satisfaction scores were correlated with time spent at health facilities using generalized linear regression models. RESULTS: Data from 4388 patients were analyzed. Overall median satisfaction score was 75% (IQR 53%-84%); median time spent at facilities (from arrival until completion of clinical services) was 2h54min (IQR 1h48min-4h). Overall satisfaction score was not associated with higher odds of retention or viral suppression, but association was seen between satisfaction regarding attention given to patient and respect and higher odds of viral suppression. Patient satisfaction was negatively associated with time spent in facility (Spearman's correlation -0.63). Increased time spent at facility (from 1 to 3 hours) was not associated with lower retention in care (OR 0.72 [95%CI:0.52-1.01] and 0.83 [95%CI: 0.63-1.09] at 6- and 12-months, respectively), nor with a lower odds of viral suppression (OR 0.96 [95%CI: 0.71-1.32]). CONCLUSIONS: Strategies to reduce patient wait times at the health facility warrant continued prioritization. Differentiated models of care have helped considerably, but novel approaches are still needed to further decongest crowded health facilities. In addition, a good client-provider communication and positive attitude can improve patient satisfaction with health services, with an overall improved retention.

Healthcare Providers' Perspectives on a Novel Couple-Based HIV Treatment Intervention: A Qualitative Assessment of the Facilitators, Barriers, and Proposed Improvements to Implementation in Zambézia Province, Mozambique.

Mozambique has one of the world's highest HIV/AIDS burdens. Despite significant investment in HIV care and treatment, pregnant and lactating women's retention in care remains suboptimal. One reason for poor maternal retention is lack of male partner support. We tested an interventional couple-based HIV care and treatment, including joint clinical appointments and couple-based educational and support sessions provided by a health counselor and peer educators, respectively. Healthcare providers delivering care for seroconcordant individuals were interviewed regarding their perspectives on facilitators and barriers to the couple-based intervention implementation. Analysis of interview responses was done using MAXQDA. Results pertaining to providers' perspectives on implementation and intervention characteristics were organized, interpreted, and contextualized using the Consolidated Framework for Implementation Research (CFIR 2.0), while providers' suggestions for improvements were coded and organized apart from CFIR. Providers felt the intervention was largely compatible with the local culture, and offered a significant advantage over standard individual-based care by facilitating patient follow-up and reducing wait times by prioritizing couples for services. They also believed it facilitated HIV treatment access through the provision of couple-based counseling that encouraged supportive behaviors towards retention. However, providers reported insufficient privacy to deliver couple-based care at some health facilities and concerns that women in difficult relationships may struggle to meaningfully participate. They suggested providing sessions in alternate clinic settings and offering a limited number of women-only visits. The facilitators and barriers described here contribute to informing the design and implementation of future couple-based interventions to improve HIV care for seroconcordant expectant couples.

Measuring the burden of SARS-CoV-2 infection among persons living with HIV and healthcare workers and its impact on service delivery in Mozambique: protocol of a prospective cohort study.

INTRODUCTION: As COVID-19 continues to spread globally and within Mozambique, its impact among immunosuppressed persons, specifically persons living with HIV (PLHIV), and on the health system is unknown in the country. The 'COVid and hIV' (COVIV) study aims to investigate: (1) the seroprevalence and seroincidence of SARS-CoV-2 among PLHIV and healthcare workers providing HIV services; (2) knowledge, attitudes, practices and perceptions regarding SARS-CoV-2 infection; (3) the pandemic's impact on HIV care continuum outcomes and (4) facility level compliance with national COVID-19 guidelines. METHODS AND ANALYSIS: A multimethod study will be conducted in a maximum of 11 health facilities across Mozambique, comprising four components: (1) a cohort study among PLHIV and healthcare workers providing HIV services to determine the seroprevalence and seroincidence of SARS-CoV-2, (2) a structured survey to assess knowledge, attitudes, perceptions and practices regarding COVID-19 disease, (3) analysis of aggregated patient data to evaluate retention in HIV services among PLHIV, (4) an assessment of facility implementation of infection prevention and control measures. ETHICS AND DISSEMINATION: Ethical approval was obtained from the National Health Bioethics Committee, and institutional review boards of implementing partners. Study findings will be discussed with local and national health authorities and key stakeholders and will be disseminated in clinical and scientific forums. TRIAL REGISTRATION NUMBER: NCT05022407.

Inverse Probability Weights for Quasicontinuous Ordinal Exposures With a Binary Outcome: Method Comparison and Case Study.

Inverse probability weighting (IPW), a well-established method of controlling for confounding in observational studies with binary exposures, has been extended to analyses with continuous exposures. Methods developed for continuous exposures may not apply when the exposure is quasicontinuous because of irregular exposure distributions that violate key assumptions. We used simulations and cluster-randomized clinical trial data to assess 4 approaches developed for continuous exposures-ordinary least squares (OLS), covariate balancing generalized propensity scores (CBGPS), nonparametric covariate balancing generalized propensity scores (npCBGPS), and quantile binning (QB)-and a novel method, a cumulative probability model (CPM), in quasicontinuous exposure settings. We compared IPW stability, covariate balance, bias, mean squared error, and standard error estimation across 3,000 simulations with 6 different quasicontinuous exposures, varying in skewness and granularity. In general, CBGPS and npCBGPS resulted in excellent covariate balance, and npCBGPS was the least biased but the most variable. The QB and CPM approaches had the lowest mean squared error, particularly with marginally skewed exposures. We then successfully applied the IPW approaches, together with missing-data techniques, to assess how session attendance (out of a possible 15) in a partners-based clustered intervention among pregnant couples living with human immunodeficiency virus in Mozambique (2017-2022) influenced postpartum contraceptive uptake.

Attitudes and perceptions towards postpartum contraceptive use among seroconcordant partners with HIV in rural Mozambique: a qualitative study.

BACKGROUND: Postpartum contraceptive uptake reduces short interpregnancy intervals, unintended pregnancies, and their negative sequalae: poor maternal and fetal outcomes. Healthy timing and spacing of pregnancy in people living with HIV (PLHIV) also allows time to achieve viral suppression to reduce parent-to-child HIV transmission. There is scant understanding about how couples-based interventions impact postpartum contraceptive uptake among PLHIV in sub-Saharan Africa. METHODS: We interviewed 38 recently pregnant people and 26 of their partners enrolled in the intervention arm of the Homens para Saúde Mais (HoPS+) [Men for Health Plus] trial to assess their perceptions of, attitudes towards, and experiences with contraceptive use. Individuals in the HoPS+ intervention arm received joint-as opposed to individual-HIV-related services during pregnancy and postpartum periods, six counseling and skills sessions, and nine sessions with a peer support couple. Our thematic analysis of the 64 in-depth interviews generated 14 deductive codes and 3 inductive codes across themes within the Information, Motivation, and Behavior Model of health behavior change. RESULTS: Participants reported accurate and inaccurate information about birth spacing and contraceptive methods. They described personal (health, economic, and religious) and social (gender norms, desired number of children) motivations for deciding whether to use contraceptives-with slightly different motivations among pregnant and non-pregnant partners. Finally, they explained the skills needed to overcome barriers to contraceptive use including how engagement in HoPS+ improved their shared decision-making skills and respect amongst partners-which facilitated postpartum contraceptive uptake. There were also several cases where non-pregnant partners unilaterally made family planning decisions despite disagreement from their partner. CONCLUSIONS: These findings suggest that couples-based interventions during pregnancy and post-partum periods aimed at increasing postpartum contraceptive uptake must center pregnant partners' desires. Specifically, pregnant partners should be allowed to titrate the level of non-pregnant partner involvement in intervention activities to avoid potentially emboldening harmful gender-based intercouple decision-making dynamics.

Favorable Impact of Community Adherence Support Groups on Retention in Care and Viral Suppression Rates Among Persons with HIV Receiving Antiretroviral Therapy in Mozambique.

The community adherence support group (CASG) was one of the first differentiated service delivery (DSD) models introduced in Mozambique. This study assessed the impact of this model on retention in care, loss to follow-up (LTFU), and viral suppression among antiretroviral therapy (ART)-treated adults in Mozambique. A retrospective cohort study included CASG-eligible adults enrolled between April 2012 and October 2017 at 123 health facilities in Zambézia Province. Propensity score matching (1:1 ratio) was used to allocate CASG members and those who never enrolled in a CASG. Logistic regressions were performed to estimate the impact of CASG membership on 6- and 12-month retention and viral load (VL) suppression. Cox proportional regression was used to model differences in LTFU. Data from 26,858 patients were included. The median age at CASG eligibility was 32 years and 75% were female, with 84% residing in rural areas. A total of 93% and 90% of CASG members were retained in care at 6 and 12 months, respectively, while 77% and 66% non-CASG members were retained during the same periods. The odds of being retained in care at 6 and 12 months were significantly higher among patients receiving ART through CASG support (adjusted odds ratio [aOR] = 4.19 [95% confidence interval; CI: 3.79-4.63], p < .001, and aOR = 4.43 [95% CI: 4.01-4.90], p < .001, respectively). Among 7,674 patients with available VL measurements, the odds of being virally suppressed were higher among CASG members (aOR = 1.14 [95% CI: 1.02-1.28], p < .001). Non-CASG members had a significantly higher likelihood of being LTFU (adjusted hazard ratio = 3.45 [95% CI: 3.20-3.73], p < .001). While Mozambique rapidly scales up multi-month drug dispensation as the preferred DSD model, this study emphasizes the continued importance of CASG as an efficacious DSD alternative, especially among patients residing in rural areas, where CASG acceptability is higher.

Correlated depressive symptoms within seroconcordant, expectant partners living with HIV in Zambézia Province, Mozambique: a cross-sectional study.

Approximately 15% of people with HIV in sub-Saharan Africa have comorbid depression, which impacts treatment outcomes. We describe predictors of baseline depressive symptoms in 1079 female and 1079 male participants in a cluster-randomized trial in Zambézia Province, Mozambique from November 2017 to December 2020. We modeled each partners' depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) using proportional odds models adjusted for enrollment date, age, body mass index [BMI], partner's PHQ-9 score, district, relationship status, education, occupation, WHO HIV clinical stage, and antiretroviral therapy use history. A post hoc analysis assessed covariate-adjusted rank correlation between partner depressive symptoms. Females were younger than males (median 23 vs. 28 years) and more likely to report no education (20.7% vs. 7.9%). Approximately 10% screened positive for depression (PHQ-9 score ≥ 10). Partner depressive symptoms were predictive of higher participant PHQ-9 scores. A male partner PHQ-9 score of 10 (versus 5) increased the odds that the female partner would have a higher PHQ-9 score (adjusted odds ratio: 7.25, 95% Confidence Interval [CI]: 5.43-9.67). Partner PHQ-9 scores were highly correlated after covariate adjustment (Spearman's rho 0.65, 95% CI 0.57-0.72). Interventions aimed to reduce depressive symptoms and improve HIV-related outcomes during pregnancy should address both partners' depressive symptoms.

Health care services for survivors of gender-based violence: a community and clinic-based intervention in Zambézia province, Mozambique.

Mozambique introduced guidelines for integrated gender-based violence (GBV) services in 2012. In 2017, we trained providers on empathetic and supportive services to GBV survivors and introduced home-based services for survivors who are loss-to-follow up. Rate ratios of clinic visits were compared before and after intervention initiation, using exact significance tests. Data of 1,806 GBV survivors were reviewed, with a total of 2005 events. The median age was 23 years (IQR 17-30) and 89% were women. Among those reporting violence, 69% reported physical violence, 18% reported sexual violence (SV), and 12% reported psychological violence. Rates of care-seeking behavior were higher in the intervention period (rate ratio 1.31 [95%CI: 1.18-1.46]); p < 0.01. Among those eligible for post-exposure prophylaxis (PEP), 94% initiated PEP. Uptake of HIV retesting improved in percentage points by 34% (14% to 48%), 34% (8% to 42%) and 26% (5% to 31%) at 1-, 3- and 6-months, respectively. The intervention led to an increase in the rate of GBV survivors seeking health care services, and improved rates of follow-up care among SV survivors initiating PEP. Strengthening of PEP adherence counseling remains crucial for improving GBV services.

The effect of a Mentor Mothers program on prevention of vertical transmission of HIV outcomes in Zambézia Province, Mozambique: a retrospective interrupted time series analysis.

INTRODUCTION: Mentor Mothers (MM) provide peer support to pregnant and postpartum women living with HIV (PPWH) and their infants with perinatal HIV exposure (IPE) throughout the cascade of prevention of vertical transmission (PVT) services. MM were implemented in Zambézia Province, Mozambique starting in August 2017. This evaluation aimed to determine the effect of MM on PVT outcomes. METHODS: A retrospective interrupted time series analysis was done using routinely collected aggregate data from 85 public health facilities providing HIV services in nine districts of Zambézia. All PPWH (and their IPE) who initiated antiretroviral therapy (ART) from August 2016 through April 2019 were included. Outcomes included the proportion per month per district of: PPWH retained in care 12 months after ART initiation, PPWH with viral suppression and IPE with HIV DNA PCR test positivity by 9 months of age. The effect of MM on outcomes was assessed using logistic regression. RESULTS: The odds of 12-month retention increased 1.5% per month in the pre-MM period, compared to a monthly increase of 7.6% with-MM (35-61% pre-MM, 56-72% with-MM; p < 0.001). The odds of being virally suppressed decreased by 0.9% per month in the pre-MM period, compared to a monthly increase of 3.9% with-MM (49-85% pre-MM, 59-80% with-MM; p < 0.001). The odds of DNA PCR positivity by 9 months of age decreased 8.9% per month in the pre-MM period, compared to a monthly decrease of 0.4% with-MM (0-14% pre-MM, 4-10% with-MM; p < 0.001). The odds of DNA PCR uptake (the proportion of IPE who received DNA PCR testing) by 9 months of age were significantly higher in the with-MM period compared to the pre-MM period (48-100% pre-MM, 87-100% with-MM; p < 0.001). CONCLUSIONS: MM services were associated with improved retention in PVT services and higher viral suppression rates among PPWH. While there was ongoing but diminishing improvement in DNA PCR positivity rates among IPE following MM implementation, this might be explained by increased uptake of HIV testing among high-risk IPE who were previously not getting tested. Additional efforts are needed to further optimize PVT outcomes, and MM should be one part of a comprehensive strategy to address this critical need.

Reaching Men and Young Adults in a Pharmacy-Based HIV Self-Testing Strategy: Results from an Acceptability Study in Mozambique.

HIV self-testing (HIVST) is a WHO-recommended strategy to increase testing, especially among key populations, men, and young adults. Between May and December 2019, a pilot was implemented in Zambézia province, Mozambique, allowing clients to purchase HIV self-tests in 14 public/private pharmacies. The study assessed the strategy's acceptability and uptake. Pharmacy-based exit surveys were conducted among a random sample of clients, during the first three months of the pilot, independent of HIVST purchase. Another random sample of clients who bought an HIVST completed a survey 1-12 weeks after purchase. Chi-square and Mann-Whitney tests were used for the analysis, comparing clients who purchased an HIVST versus not. A total of 1,139 adults purchased 1,344 tests. Buyers were predominantly male (70%) and younger (52% between 15 and 34 years of age). Surveys were completed by 280 exiting pharmacy clients and 82 clients who purchased an HIVST. Main advantages were confidentiality and lack of need of a health provider visit, with main disadvantages being absence of nearby counseling and fear of results. No differences were seen between buyers and non-buyers for these factors. Among all undergoing HIVST, 71 (92%) perceived the instructions to be clear, however, 29 (38%) stated they would have benefitted from additional pre-test information or counseling. Ten (13%) reported following up at a nearby health facility to confirm results and/or receive care. Offering HIVST at public/private pharmacies was acceptable among people who traditionally tend to have a lower HIV testing coverage, such as men and young adults. However, additional resources and/or enhanced educational materials to address the lack of counseling, and linkage-to-care systems need to be put into place before scaling up this strategy.

CD4 Trends With Evolving Treatment Initiation Policies Among Children Living With HIV in Zambézia Province, Mozambique, 2012-2018.

BACKGROUND: Historically, antiretroviral therapy (ART) initiation was based on CD4 criteria, but this has been replaced with "Test and Start" wherein all people living with HIV are offered ART. We describe the baseline immunologic status among children relative to evolving ART policies in Mozambique. METHODS: This retrospective evaluation was performed using routinely collected data. Children living with HIV (CL aged 5-14 years) with CD4 data in the period of 2012-2018 were included. ART initiation "policy periods" corresponded to implementation of evolving guidelines: in period 1 (2012-2016), ART was recommended for CD4 <350 cells/mm3; during period 2 (2016-2017), the CD4 threshold increased to <500 cells/mm3; Test and Start was implemented in period 3 (2017-2018). We described temporal trends in the proportion of children with severe immunodeficiency (CD4 <200 cells/mm3) at enrollment and at ART initiation. Multivariable regression models were used to estimate associations with severe immunodeficiency. RESULTS: The cohort included 1815 children with CD4 data at enrollment and 1922 at ART initiation. The proportion of children with severe immunodeficiency decreased over time: 20% at enrollment into care in period 1 vs. 16% in period 3 (P = 0.113) and 21% at ART initiation in period 1 vs. 15% in period 3 (P = 0.004). Children initiating ART in period 3 had lower odds of severe immunodeficiency at ART initiation compared with those in period 1 [adjusted odds ratio (aOR) = 0.67; 95% CI: 0.51 to 0.88]. Older age was associated with severe immunodeficiency at enrollment (aOR = 1.13; 95% CI: 1.06 to 1.20) and at ART initiation (aOR = 1.14; 95% CI: 1.08 to 1.21). CONCLUSIONS: The proportion of children with severe immunodeficiency at ART initiation decreased alongside more inclusive ART initiation guidelines. Earlier treatment of children living with HIV is imperative.

Young at risk-people in Maputo City, Mozambique, present a high willingness to participate in HIV trials: Results from an HIV vaccine preparedness cohort study.

INTRODUCTION: Vaccine efficacy testing requires engagement of willing volunteers with high disease incidence. We evaluated factors associated with willingness to participate in potential future HIV vaccine trials in Maputo, Mozambique. METHODS: Adults aged 18-35 years without HIV and who reported at least two sexual partners in the 3 months prior to screening were enrolled into a 24-month observational study. They were asked at screening and exit if they would be willing to participate in a theoretical HIV vaccine study. Bivariate and multivariate logistic regression analyses were done between willingness to participate, demographic, sexual behavior, and motivational factors for screening visit data. Logistic regression with generalized estimating equations (GEE) was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for factors potentially associated with willingness to participate for data from both visits. RESULTS: A total of 577 participants without HIV were eligible, including 275 (48%) women. The mean age was 22.2 (SD ± 3.9) years. At screening 529 (92%) expressed willingness to participate and the proportion remained stable at 378 (88%) of the 430 participants retained through the exit visit (p = 0.209). Helping the country (n = 556) and fear of needles (n = 26) were the top motive and barrier for willingness to participate, respectively. Results from the GEE binary logistic regression (screening visit and exit visit) showed that wanting to learn how to avoid risk behaviors (aOR 3.33, 95% CI: 1.61-6.86) and feeling protected against HIV infection (aOR 2.24, 95% CI: 1.07-4.7) were associated with willingness to participate in HIV vaccine studies. CONCLUSION: The majority of our study population in Mozambique expressed willingness to participate in a theoretical HIV vaccine trial. Participation in a HIV vaccine trial was seen as a way to contribute to the fight against HIV but was associated with some unrealistic expectations such as protection against HIV. This reinforces the need for continuous mobilization and awareness of potential participants to HIV vaccine trial.

Pre-exposure prophylaxis use among HIV serodiscordant couples: a qualitative study in Mozambique.

BACKGROUND: Pre-exposure prophylaxis (PrEP) has the potential to reduce HIV transmission and stem the HIV epidemic. Unfortunately, PrEP uptake in rural sub-Saharan Africa has been slow and medication adherence has been suboptimal. OBJECTIVE: To explore the perspectives, attitudes, and experiences of HIV serodiscordant partners taking PrEP and develop a messaging campaign to improve PrEP uptake in rural Mozambique to reduce HIV transmission among serodiscordant partners. METHODS: In this qualitative study, we interviewed 20 people in serodiscordant relationships using PrEP at a rural health center in Zambézia province, Mozambique and employed inductive and deductive coding to elicit their perspectives, attitudes, and experiences related to learning their partner's HIV status, barriers to PrEP uptake, obstacles to PrEP adherence, and decisions to disclose their PrEP use with family and friends using thematic analysis. RESULTS: Our analysis generated nine themes across various levels of the socioecological model. Participants reported a strong desire to stay in the discordant relationship and highlighted the importance of working together to ensure PrEP and antiretroviral therapy adherence, with the majority skeptical that adherence could be achieved without both partners' support (individual and interpersonal). Although most participants were reticent about sharing their serodiscordant status with family and friends (individual and interpersonal), those who did found their family and friends supportive (interpersonal). Participants suggested increasing community health agent availability to help people navigate HIV prevention and treatment (organizational). We then created three oral stories, using themes from the interviews, with examples from various levels of the socioecological model that will be used to generate support for PrEP use among community members. CONCLUSIONS: Our findings informed oral template stories that will be used to emphasize how couples can work together to improve PrEP uptake and reduce incident HIV infections in serodiscordant couples elsewhere in rural Mozambique.

Effect of a storytelling intervention on the retention of serodiscordant couples in ART/PrEP services at antenatal clinic in Namacurra province in Zambézia, Mozambique.

BACKGROUND: Sub-Saharan Africa reported 550,000 new HIV infections among women in 2018. Pregnancy and the postpartum period are associated with an increased risk of HIV acquisition (adjusted risk ratio [RR]: 2.8 during pregnancy and 4.0 in postpartum period vs. non-pregnant or postpartum women, respectively). Acquisition of HIV during pregnancy and breastfeeding increases risk of mother to child transmission. We propose to test the impact of a peer-delivered oral storytelling intervention to increase retention in, and adherence to, pre-exposure prophylaxis (PrEP)/combination antiretroviral treatment (ART) among expectant couples. DESIGN: We propose a randomized controlled trial (RCT) (35 intervention and 35 control couples) at a health facility where 11% of expectant couples were in serodiscordant relationships in 2018. Couples randomized to the storytelling arm will be visited by a two community volunteers and who successfully adhered to PrEP/ART during a recent pregnancy. This expert couple will orate to participating couples three stories (at 1, 3 and 5 weeks after study enrollment) designed to empower, educate, and establish "ideal" interpersonal communication strategies within couples/families, and support adherence practices among participants. The primary outcome among HIV-uninfected women will be adherence to PrEP at 3 months. CONCLUSIONS: PrEP among at-risk pregnant women must be implemented so that high levels of adherence and retention are achievable for them and their partners. We will test our storytelling intervention to identify an optimal strategy for PrEP education and family engagement in a region with high HIV prevalence. Our results will have an impact by effectively engaging serodiscordant couples in prevention/treatment during pregnancy and beyond.

Interpersonal reactivity index adaptation among expectant seroconcordant couples with HIV in Zambézia Province, Mozambique.

BACKGROUND: The ability to understand another's emotions and act appropriately, empathy, is an important mediator of relationship function and health intervention fidelity. We adapted the Interpersonal Reactivity Index (IRI) - an empathy scale - among seroconcordant expectant couples with HIV in the Homens para Saúde Mais (HoPS+) trial - a cluster randomized controlled trial assessing couple-based versus individual treatment on viral suppression - in Zambézia Province, Mozambique. METHODS: Using baseline data from 1332 HoPS+ trial participants (666 couples), an exploratory factor analysis assessed culturally relevant questions from the IRI. Because empathy is interdependent among couples, we validated the results of the exploratory factor analysis using a dyadic confirmatory factor analysis (CFA) with dyadic measurement invariance testing. Finally, we assessed the relationship between scores on our final scale and basic demographic characteristics (sex, age, education, and depression) using t-tests. RESULTS: We found two subscales: 1) a seven-item cognitive empathy subscale (Cronbach's alpha 0.78) and 2) a six-item affective empathy subscale (Cronbach's alpha 0.73). The dyadic CFA found acceptable model fit and metric invariance across partners (Comparative Fit Index (CFI) = 0.914, Tucker Lewis Index = 0.904, Root Mean Squared Error of Approximation = 0.056, ΔCFI = 0.011). We observed higher cognitive (p: 0.012) and affective (p: 0.049) empathy among males and higher cognitive (p: 0.031) and affective (p: 0.030) empathy among younger participants. More educated participants had higher affective empathy (p: 0.017) and depressed participants had higher cognitive empathy (p: < 0.001). This two-subscale, 13-item version of the IRI measures cognitive and affective empathy in HoPS+ trial participants and adults while accounting for the interdependent nature of empathy within partner dyads. CONCLUSIONS: This scale will allow us to assess the interplay between empathy and other psychometric constructs (stigma, social support, etc.) in the HoPS+ trial and how each relates to retention in HIV, adherence to treatment, and prevention of maternal to child HIV transmission. Furthermore, this scale can be adapted for other sub-Saharan African populations, which will allow researchers to better assess HIV-related intervention efficacy. TRIAL REGISTRATION: This study is within the context of the HoPS+ trial, registered at ClinicalTrials.gov as number NCT03149237 . Registered May 11, 2017.

Immunodeficiency at Antiretroviral Therapy Start: Five-Year Adult Data (2012-2017) Based on Evolving National Policies in Rural Mozambique.

Before the 2015 implementation of "Test and Start," the initiation of combination antiretroviral therapy (ART) was guided by specific CD4 cell count thresholds. As scale-up efforts progress, the prevalence of advanced HIV disease at ART initiation is expected to decline. We analyzed the temporal trends in the median CD4 cell counts among adults initiating ART and described factors associated with initiating ART with severe immunodeficiency in Zambézia Province, Mozambique. We included all HIV-positive, treatment-naive adults (age ≥ 15 years) who initiated ART at a Friends in Global Health (FGH)-supported health facility between September 2012 and September 2017. Quantile regression and multivariable logistic regression models were applied to ascertain the median change in CD4 cell count and odds of initiating ART with severe immunodeficiency, respectively. A total of 68,332 patients were included in the analyses. The median change in CD4 cell count under "Test and Start" was higher at +68 cells/mm3 (95% CI: 57.5-78.4) compared with older policies. Younger age and female sex (particularly those pregnant/lactating) were associated with higher median CD4 cell counts at ART initiation. Male sex, advanced age, WHO Stage 4 disease, and referrals to the health facility through inpatient provider-initiated testing and counseling (PITC) were associated with higher odds of initiating ART with severe immunodeficiency. Although there were reassuring trends in increasing median CD4 cell counts with ART initiation, ongoing efforts are needed that target universal HIV testing to ensure the early initiation of ART in men and older patients.

Barriers to access and adherence to tuberculosis services, as perceived by patients: A qualitative study in Mozambique.

INTRODUCTION: Tuberculosis (TB) continues to be a leading cause of death in Sub-Saharan Africa, including Mozambique. While diagnostic methods and total notifications are improving, significant gaps remain between total numbers of TB cases annually, and the number that are notified. The purpose of this study was to elicit Mozambican patients with drug sensitive TB (DS-TB), TB/HIV and Multi drug resistant tuberculosis (MDR-TB) understanding and assessment of the quality of care for DS-TB, HIV/TB and MDR-TB services in Mozambique, along with challenges to effectively preventing, diagnosing and treating TB. MATERIALS AND METHODS: Qualitative data was collected via separate focus group discussions consisting of patients with DS-TB, TB/HIV and MDR-TB at four health centers in Sofala and Manica Province, Mozambique, to describe knowledge on TB, HIV and MDR-TB, and identify barriers to access and adherence to services and their recommendations for improvement. A total of 51 patients participated in 11 discussions. Content analysis was done and main themes were identified. RESULTS: Focus groups shared a number of prominent themes. Respondents identified numerous challenges including delays in diagnosis, stigma related with diagnosis and treatment, long waits at health facilities, the absence of nutritional support for patients with TB, the absence of a comprehensive psychosocial support program, and the lack of overall knowledge about TB or multi drug resistant TB in the community. DISCUSSION: TB patients in central Mozambique identified many challenges to effectively preventing, diagnosing and treating tuberculosis. Awareness strengthening in the community, continuous quality monitoring and in-service training is needed to increase screening, diagnosis and treatment for TB, HIV/TB and MDR-TB.

Innovations and challenges in early infant diagnosis of HIV.

PURPOSE OF REVIEW: This article aims at examining the key recent advances in the field of EID, as well as at discussing approaches for resolving the major bottlenecks faced by health systems in the identification and linkage to care of HIV-infected infants. RECENT FINDINGS: Programmatic experience in South Africa and research in other high-burden countries showed that birth HIV testing is accurate, feasible and has the potential to decrease infant mortality. Substantial evidence has mounted on the accuracy of point-of-care testing for EID, including for birth testing. Importantly, it has now been demonstrated that point-of-care EID improves the rate of results return to patients and has significant positive effect on ART initiation rates. Finally, there are good examples of how EID fits into more comprehensive and integrated packages of services covering the antenatal, birth and postpartum periods. SUMMARY: Point-of-care testing for EID, including for birth testing, should be widely implemented to complement laboratory-based testing in high-burden countries. Most of the current barriers for timely EID testing and ART initiation in infants are related to weaknesses in the health system, and will require the implementation of comprehensive approaches aiming at scaling-up these interventions within strengthened primary healthcare services.

Intervention heroes of Mozambique from 1997 to 2015: estimates of maternal and child lives saved using the Lives Saved Tool.

BACKGROUND: As one of several countries that pledged to achieve the Millennium Development Goals (MDGs), Mozambique sought to reduce child, neonatal, and maternal mortality by two thirds by 2015. This study examines the impact of Mozambique's efforts between 1997 and 2015, highlighting the increases in intervention coverage that contributed to saving the most lives. METHODS: A retrospective analysis of available household survey data was conducted using the Lives Saved Tool (LiST). Baseline mortality rates, cause-of-death distributions, and coverage of child, neonatal, and maternal interventions were entered as inputs. Changes in mortality rates, causes of death, and additional lives saved were calculated as results. Due to limited coverage data for the year 2015, we reported most results for the period 1997-2011. For 2011-2015 we reported additional lives saved for a subset of interventions. All analyses were performed at national and provincial level. RESULTS: Our modelled estimates show that increases in intervention coverage from 1997 to 2011 saved an additional 422 282 child lives (0-59 months), 85 450 neonatal lives (0-1 month), and 6528 maternal lives beyond those already being saved at baseline coverage levels in 1997. Malaria remained the leading cause of child mortality from 1997 to 2011; prematurity, asphyxia, and sepsis remained the leading causes of neonatal mortality; and hemorrhage remained the leading cause of maternal mortality. Interventions to reduce acute malnutrition and promote artemisinin-based combination therapy (ACT) for malaria were responsible for the largest number of additional child lives saved in the 1997-2011 period. Increases in coverage of delivery management were responsible for most additional newborn and maternal lives saved in both periods in Mozambique. CONCLUSION: Mozambique has made impressive gains in reducing child mortality since 1997. Additional effort is needed to further reduce maternal and neonatal mortality in all provinces. More lives can be saved by continuing to increase coverage of existing health interventions and exploring new ways to reach underserved populations.