Comparison of COVID-19 Pandemic Waves in 10 Countries in Southern Africa, 2020-2021.

We used publicly available data to describe epidemiology, genomic surveillance, and public health and social measures from the first 3 COVID-19 pandemic waves in southern Africa during April 6, 2020-September 19, 2021. South Africa detected regional waves on average 7.2 weeks before other countries. Average testing volume 244 tests/million/day) increased across waves and was highest in upper-middle-income countries. Across the 3 waves, average reported regional incidence increased (17.4, 51.9, 123.3 cases/1 million population/day), as did positivity of diagnostic tests (8.8%, 12.2%, 14.5%); mortality (0.3, 1.5, 2.7 deaths/1 million populaiton/day); and case-fatality ratios (1.9%, 2.1%, 2.5%). Beta variant (B.1.351) drove the second wave and Delta (B.1.617.2) the third. Stringent implementation of safety measures declined across waves. As of September 19, 2021, completed vaccination coverage remained low (8.1% of total population). Our findings highlight opportunities for strengthening surveillance, health systems, and access to realistically available therapeutics, and scaling up risk-based vaccination.

Scaling Up Testing for Human Immunodeficiency Virus Infection Among Contacts of Index Patients - 20 Countries, 2016-2018.

In 2017, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that worldwide, 36.9 million persons were living with human immunodeficiency virus (HIV) infection, the virus infection that causes acquired immunodeficiency syndrome (AIDS). Among persons with HIV infection, approximately 75% were aware of their HIV status, leaving 9.4 million persons with undiagnosed infection (1). Index testing, also known as partner notification or contact tracing, is an effective case-finding strategy that targets the exposed contacts of HIV-positive persons for HIV testing services. This report summarizes data from HIV tests using index testing in 20 countries supported by CDC through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) during October 1, 2016-March 31, 2018. During this 18-month period, 1,700,998 HIV tests with 99,201 (5.8%) positive results were reported using index testing. The positivity rate for index testing was 9.8% among persons aged ≥15 years and 1.5% among persons aged <15 years. During the reporting period, HIV positivity increased 64% among persons aged ≥15 years (from 7.6% to 12.5%) and 67% among persons aged <15 years (from 1.2% to 2.0%). Expanding index testing services could help increase the number of persons with HIV infection who know their status, are initiated onto antiretroviral treatment, and consequently reduce the number of persons who can transmit the virus.

eSIP-Saúde: Mozambique's novel approach for a sustainable human resources for health information system.

INTRODUCTION: Over the past decade, governments and international partners have responded to calls for health workforce data with ambitious investments in human resources information systems (HRIS). However, documentation of country experiences in the use of HRIS to improve strategic planning and management has been lacking. The purpose of this case presentation is to document for the first time Mozambique's novel approach to HRIS, sharing key success factors and contributing to the scant global knowledge base on HRIS. CASE PRESENTATION: Core components of the system are a Government of Mozambique (GOM) registry covering all workers in the GOM payroll and a "health extension" which adds health-sector-specific data to the GOM registry. Separate databases for pre-service and in-service training are integrated through a business intelligence tool. The first aim of the HRIS was to identify the following: who and where are Mozambique's health workers? As of July 2015, 95 % of countrywide health workforce deployment information was populated in the HRIS, allowing the identification of health professionals' physical working location and their pay point. HRIS data are also used to quantify chronic issues affecting the Ministry of Health (MOH) health workforce. Examples include the following: HRIS information was used to examine the deployment of nurses trained in antiretroviral therapy (ART) vis-à-vis the health facilities where ART is being provided. Such results help the MOH align specialized skill sets with service provision. Twenty-five percent of the MOH health workforce had passed the 2-year probation period but had not been updated in the MOH information systems. For future monitoring of employee status, the MOH established a system of alerts in semi-monthly reports. As of August 2014, 1046 health workers were receiving their full salary but no longer working at the facilities. The MOH is now analyzing this situation to improve the retirement process and coordination with Social Security. CONCLUSION: The Mozambican system is an important example of an HRIS built on a local platform with local staff. Notable models of strategic data use demonstrate that the system is empowering the MOH to improve health services delivery, health workforce allocation, and management. Combined with committed country leadership and ownership of the program, this suggests strong chances of sustainability and real impact on public health equity and quality.

Legal and regulatory framework for health worker retention in Mozambique: Public health law research to strengthen health systems and services.

Realizing the fundamental contribution of human resources to public health, the World Health Organization (WHO) issued policy recommendations for health worker retention. We reviewed Mozambique's laws and regulations and assessed the extent to which this legal and regulatory framework governing public sector health workers aligns with the WHO health worker retention recommendations. We provide guidance for future analysis of non-binding policies that may fill gaps identified in our review. We also indicate how to link legal analysis to the cycle by which research informs policy, policy informs practice, and practice leads to improvements in health systems and population health. Finally, we demonstrate the relevance of understanding and analyzing the impact of domestic laws on global health. Future research should assess implementation of health worker allowances and any associations with increased hiring, more equitable distribution, and improved retention - all are essential to public health in Mozambique.Journal of Public Health Policy advance online publication, 26 May 2016; doi:10.1057/jphp.2016.22.

HIV testing service awareness and service uptake among female heads of household in rural Mozambique: results from a province-wide survey.

BACKGROUND: HIV voluntary counseling and testing (VCT) utilization remains low in many sub-Saharan African countries, particularly in remote rural settings. We sought to identify factors associated with service awareness and service uptake of VCT among female heads of household in rural Zambézia Province of north-central Mozambique which is characterized by high HIV prevalence (12.6%), poverty, and suboptimal health service access and utilization. METHODS: Our population-based survey of female heads of household was administered to a representative two-stage cluster sample using a sampling frame created for use on all national surveys and based on census results. The data served as a baseline measure for the Ogumaniha project initiated in 2009. Survey domains included poverty, health, education, income, HIV stigma, health service access, and empowerment. Descriptive statistics and logistic regression were used to describe service awareness and service uptake of VCT. RESULTS: Of 3708 women surveyed, 2546 (69%) were unaware of available VCT services. Among 1162 women who were aware of VCT, 673 (58%) reported no prior testing. In the VCT aware group, VCT awareness was associated with higher education (aOR = 2.88; 95% CI = 1.61, 5.16), higher income (aOR = 1.41, 95% CI = 1.06, 1.86), higher numeracy (aOR = 1.05, CI 1.03, 1.08), more children < age 5 in the home (aOR = 1.53; 95% CI = 1.07, 2.18), closer proximity to a health facility (aOR = 1.05; 95% CI = 1.03, 1.07), and mobile phone ownership (aOR = 1.37; 95% CI = 1.03, 1.84) (all p-values < 0.04). Having a higher HIV-associated stigma score was the factor most strongly associated with being less likely to test. (aOR = 0.41; 95% CI = 0.23, 0.71; p<0.001). CONCLUSIONS: Most women were unaware of available VCT services. Even women who were aware of services were unlikely to have been tested. Expanded VCT and social marketing of VCT are needed in rural Mozambique with special attention to issues of community-level stigma reduction.

Multidimensional poverty in rural Mozambique: a new metric for evaluating public health interventions.

BACKGROUND: Poverty is a multidimensional phenomenon and unidimensional measurements have proven inadequate to the challenge of assessing its dynamics. Dynamics between poverty and public health intervention is among the most difficult yet important problems faced in development. We sought to demonstrate how multidimensional poverty measures can be utilized in the evaluation of public health interventions; and to create geospatial maps of poverty deprivation to aid implementers in prioritizing program planning. METHODS: Survey teams interviewed a representative sample of 3,749 female heads of household in 259 enumeration areas across Zambézia in August-September 2010. We estimated a multidimensional poverty index, which can be disaggregated into context-specific indicators. We produced an MPI comprised of 3 dimensions and 11 weighted indicators selected from the survey. Households were identified as "poor" if were deprived in >33% of indicators. Our MPI is an adjusted headcount, calculated by multiplying the proportion identified as poor (headcount) and the poverty gap (average deprivation). Geospatial visualizations of poverty deprivation were created as a contextual baseline for future evaluation. RESULTS: In our rural (96%) and urban (4%) interviewees, the 33% deprivation cut-off suggested 58.2% of households were poor (29.3% of urban vs. 59.5% of rural). Among the poor, households experienced an average deprivation of 46%; thus the MPI/adjusted headcount is 0.27 ( = 0.58×0.46). Of households where a local language was the primary language, 58.6% were considered poor versus Portuguese-speaking households where 73.5% were considered non-poor. Living standard is the dominant deprivation, followed by health, and then education. CONCLUSIONS: Multidimensional poverty measurement can be integrated into program design for public health interventions, and geospatial visualization helps examine the impact of intervention deployment within the context of distinct poverty conditions. Both permit program implementers to focus resources and critically explore linkages between poverty and its social determinants, thus deriving useful findings for evidence-based planning.

Negative labeling and social exclusion of people living with human immunodeficiency virus/acquired immune deficiency syndrome in the antiretroviral therapy era: insight from attitudes and behavioral intentions of female heads of households in Zambézia Province, Mozambique.

In the age of antiretroviral therapy (ART), unraveling specific aspects of stigma that impede uptake and adherence to human immunodeficiency virus (HIV) services and the complex intersections among them might enhance the efficacy of stigma-reduction interventions targeted at the general public. Few studies have described community stigma in high HIV prevalence regions of Mozambique where program scale-up has been concentrated, but fear of stigma persists as a barrier to HIV service uptake. Principal components analysis of attitudinal data from 3749 female heads of households surveyed in Zambézia Province was used to examine patterns of agreement with stigmatizing attitudes and behavior toward people living with HIV. Inferences were based on comparison of factor loadings and commonality estimates. Construct validity was established through correlations with levels of knowledge about HIV transmission and consistency with the labeling theory of stigma. Two unique domains of community stigma were observed: negative labeling and devaluation (NLD, α = 0.74) and social exclusion (SoE, α = 0.73). NLD is primarily an attitudinal construct, while SoE captures behavioral intent. About one-third of the respondents scored in the upper tertile of the NLD stigma scale (scale: 0-100 stigma points) and the equivalent was 41.3% in the SoE stigma scale. Consistent with literature, NLD and SoE stigma scores were inversely correlated with HIV transmission route knowledge. In item level analysis, fear of being labeled a prostitute/immoral and of negative family affect defined the nature of stigma in this sample. Thus, despite ART scale-up and community education about HIV/acquired immune deficiency syndrome (AIDS), NLD and SoE characterized the community stigma of HIV in this setting. Follow-up studies could compare the impact of these stigma domains on HIV services uptake, in order to inform domain-focused stigma-reduction interventions.

Community stigma endorsement and voluntary counseling and testing behavior and attitudes among female heads of household in Zambézia Province, Mozambique.

BACKGROUND: Some aspects of HIV-related stigma have been shown to be a barrier to HIV services uptake and adherence to antiretroviral treatment (ART). Distinguishing which domains of stigma impact HIV services uptake can enhance the efficacy and efficiency of stigma-reduction interventions. METHODS: The relationships between use of voluntary counseling and testing (VCT) services and two domains of community stigma identified through factor analysis, negative labeling/devaluation and social exclusion, were investigated among 3749 female heads of household. Data were from a general household survey conducted in rural Mozambique. Multivariable logistic regression outcomes were: lifetime VCT use, past-6-months VCT use and VCT endorsement. RESULTS: Thirteen percent (13%) of the participants reported lifetime VCT use, 10% reported past-6-months VCT use and 63% endorsed VCT. A 25-point decrease (from 50 to 25) in the score for negative labeling and devaluation stigma was associated with increased lifetime VCT use (adjusted OR: 1.6, 95% CI: 1.1-2.3) and past-6-months VCT use (adjusted OR: 1.6, 95% CI: 1.1-2.4). A decrease from 50 to 25-points in the score for social exclusion stigma was associated with 1.5 and 1.3-fold increase in odds for past-6-months VCT use and endorsing VCT use, respectively (p < 0.001 for both). Compared with never-testers, considerably high endorsement of VCT use was observed among testers who did not receive HIV test results (adjusted OR: 2.7, 95% CI: 1.6-4.6) and much higher among testers who received results (adjusted OR: 7.3, 95% CI: 4.9-11.0). Distance from health facilities was associated with lower VCT use, but not lower endorsement of VCT. CONCLUSIONS: VCT use and endorsement might differ by domains of stigma held by individuals in the community. Greater uptake and favorable disposition towards use of VCT services in rural settings might be achieved by addressing stigma via domain-specific interventions and by improving the proximity of services and the dissemination of HIV test results.

Consensus on context-specific strategies for reducing the stigma of human immunodeficiency virus/acquired immunodeficiency syndrome in Zambézia Province, Mozambique.

Stigma has been implicated in poor outcomes of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) care. Reducing stigma is important for HIV prevention and long-term treatment success. Although stigma reduction interventions are conducted in Mozambique, little is known about the current nature of stigma and the efficacy and effectiveness of stigma reduction initiatives. We describe action research to generate consensus on critical characteristics of HIV stigma and anti-stigma interventions in Zambézia Province, Mozambique. Qualitative data gathering methods, including in-depth key-informant interviews, community interviews and consensus group sessions, were utilized. Delphi methods and the strategic options development analysis technique were used to synthesize qualitative data. Key findings are that stigma enacted by the general public might be declining in tandem with the HIV/AIDS epidemic in Mozambique, but there is likely excessive residual fear of HIV disease and community attitudes that sustain high levels of perceived stigma. HIV-positive women accessing maternal and child health services appear to shoulder a disproportionate burden of stigma. Unintentional biases among healthcare providers are currently the critical frontier of stigmatization, but there are few interventions designed to address them. Culturally sensitive psychotherapies are needed to address psychological distress associated with internalized stigma and these interventions should complement current supports for voluntary counseling and testing. While advantageous for defining stakeholder priorities for stigma reduction efforts, confirmatory quantitative studies of these consensus positions are needed before the launch of specific interventions.

The association among literacy, numeracy, HIV knowledge and health-seeking behavior: a population-based survey of women in rural Mozambique.

BACKGROUND: Limited literacy skills are common in the United States (US) and are related to lower HIV knowledge and worse health behaviors and outcomes. The extent of these associations is unknown in countries like Mozambique, where no rigorously validated literacy and numeracy measures exist. METHODS: A validated measure of literacy and numeracy, the Wide Range Achievement Test, version 3 (WRAT-3) was translated into Portuguese, adapted for a Mozambican context, and administered to a cross-section of female heads-of-household during a provincially representative survey conducted from August 8 to September 25, 2010. Construct validity of each subscale was examined by testing associations with education, income, and possession of socioeconomic assets, stratified by Portuguese speaking ability. Multivariable regression models estimated the association among literacy/numeracy and HIV knowledge, self-reported HIV testing, and utilization of prenatal care. RESULTS: Data from 3,557 women were analyzed; 1,110 (37.9%) reported speaking Portuguese. Respondents' mean age was 31.2; 44.6% lacked formal education, and 34.3% reported no income. Illiteracy was common (50.4% of Portuguese speakers, 93.7% of non-Portuguese speakers) and the mean numeracy score (10.4) corresponded to US kindergarten-level skills. Literacy or numeracy was associated (p<0.01) with education, income, age, and other socioeconomic assets. Literacy and numeracy skills were associated with HIV knowledge in adjusted models, but not with HIV testing or receipt of clinic-based prenatal care. CONCLUSION: The adapted literacy and numeracy subscales are valid for use with rural Mozambican women. Limited literacy and numeracy skills were common and associated with lower HIV knowledge. Further study is needed to determine the extent to which addressing literacy/numeracy will lead to improved health outcomes.

Predictors of successful early infant diagnosis of HIV in a rural district hospital in Zambézia, Mozambique.

BACKGROUND: A key challenge inhibiting the timely initiation of pediatric antiretroviral treatment is the loss to follow-up of mothers and their infants between the time of mothers' HIV diagnoses in pregnancy and return after delivery for early infant diagnosis of HIV. We sought to identify barriers to follow-up of HIV-exposed infants in rural Zambézia Province, Mozambique. METHODS: We determined follow-up rates for early infant diagnosis and age at first test in a retrospective cohort of 443 HIV-infected mothers and their infants. Multivariable logistic regression models were used to identify factors associated with successful follow-up. RESULTS: Of the 443 mother-infant pairs, 217 (49%) mothers enrolled in the adult HIV care clinic, and only 110 (25%) infants were brought for early infant diagnosis. The predictors of follow-up for early infant diagnosis were larger household size (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.09-1.53), independent maternal source of income (OR, 10.8; 95% CI, 3.42-34.0), greater distance from the hospital (OR, 2.14; 95% CI, 1.01-4.51), and maternal receipt of antiretroviral therapy (OR, 3.15; 95% CI, 1.02-9.73). The median age at first test among 105 infants was 5 months (interquartile range, 2-7); 16% of the tested infants were infected. CONCLUSIONS: Three of four HIV-infected women in rural Mozambique did not bring their children for early infant HIV diagnosis. Maternal receipt of antiretroviral therapy has favorable implications for maternal health that will increase the likelihood of early infant diagnosis. We are working with local health authorities to improve the linkage of HIV-infected women to HIV care to maximize early infant diagnosis and care.

Sociocultural and epidemiological aspects of HIV/AIDS in Mozambique.

BACKGROUND: A legacy of colonial rule coupled with a devastating 16-year civil war through 1992 left Mozambique economically impoverished just as the human immunodeficiency virus (HIV) epidemic swept over southern Africa in the late 1980s. The crumbling Mozambican health care system was wholly inadequate to support the need for new chronic disease services for people with the acquired immunodeficiency syndrome (AIDS). METHODS: To review the unique challenges faced by Mozambique as they have attempted to stem the HIV epidemic, we undertook a systematic literature review through multiple search engines (PubMed, Google Scholar, SSRN, AnthropologyPlus, AnthroSource) using Mozambique as a required keyword. We searched for any articles that included the required keyword as well as the terms 'HIV' and/or 'AIDS', 'prevalence', 'behaviors', 'knowledge', 'attitudes', 'perceptions', 'prevention', 'gender', drugs, alcohol, and/or 'health care infrastructure'. RESULTS: UNAIDS 2008 prevalence estimates ranked Mozambique as the 8th most HIV-afflicted nation globally. In 2007, measured HIV prevalence in 36 antenatal clinic sites ranged from 3% to 35%; the national estimate of was 16%. Evidence suggests that the Mozambican HIV epidemic is characterized by a preponderance of heterosexual infections, among the world's most severe health worker shortages, relatively poor knowledge of HIV/AIDS in the general population, and lagging access to HIV preventive and therapeutic services compared to counterpart nations in southern Africa. Poor education systems, high levels of poverty and gender inequality further exacerbate HIV incidence. CONCLUSIONS: Recommendations to reduce HIV incidence and AIDS mortality rates in Mozambique include: health system strengthening, rural outreach to increase testing and linkage to care, education about risk reduction and drug adherence, and partnerships with traditional healers and midwives to effect a lessening of stigma.

Lessons learned while implementing an HIV/AIDS care and treatment program in rural Mozambique.

Mozambique has severe resource constraints, yet with international partnerships, the nation has placed over 145,000 HIV-infected persons on antiretroviral therapies (ART) through May-2009. HIV clinical services are provided at > 215 clinical venues in all 11 of Mozambique's provinces. Friends in Global Health (FGH), affiliated with Vanderbilt University in the United States (US), is a locally licensed non-governmental organization (NGO) working exclusively in small city and rural venues in Zambézia Province whose population reaches approximately 4 million persons. Our approach to clinical capacity building is based on: 1) technical assistance to national health system facilities to implement ART clinical services at the district level, 2) human capacity development, and 3) health system strengthening. Challenges in this setting are daunting, including: 1) human resource constraints, 2) infrastructure limitations, 3) centralized care for large populations spread out over large distances, 4) continued high social stigma related to HIV, 5) limited livelihood options in rural areas and 6) limited educational opportunities in rural areas. Sustainability in rural Mozambique will depend on transitioning services from emergency foreign partners to local authorities and continued funding. It will also require "wrap-around" programs that help build economic capacity with agricultural, educational, and commercial initiatives. Sustainability is undermined by serious health manpower and infrastructure limitations. Recent U.S. government pronouncements suggest that the U.S. President's Emergency Plan for AIDS Relief will support concurrent community and business development. FGH, with its Mozambican government counterparts, see the evolution of an emergency response to a sustainable chronic disease management program as an essential and logical step. We have presented six key challenges that are essential to address in rural Mozambique.

A survey of refugee health assessments in the United States.

We conducted a survey among nine geographically dispersed, large metropolitan refugee health programs to estimate the number of U.S. refugee arrivals during 1997 and 1998, the number receiving health assessments, and the percentage of sites offering health services. The nine sites received an estimated 40% of all U.S. refugee arrivals during the study period. Of these refugees, 76% received a health assessment. The completeness of health assessments, including services offered, varied by site; some services were provided by the private sector. Most sites offered services for infectious diseases and vaccinations. While 78% of the sites offered mental health care, but only 33% actually performed mental status examinations. These statistics show that such health services need to be provided on a broader basis and possibly reflect a need to address cultural and language barriers that might be preventing their delivery to this diverse population.