HIV care retention in three multi-month ART dispensing: a retrospective cohort study in mozambique.

OBJECTIVE: Evaluate the effect of three multi-month dispensing (3MMD) of antiretroviral therapy (ART) on HIV care retention in southern Mozambique. DESIGN: Retrospective cohort study. METHODS: We analysed routine health data from people living with HIV (PLHIV) ≥10 years old who started ART between January 2018 and March 2021. Individuals were followed until December 2021. Cox proportional-hazards models were used to compare attrition (lost to follow-up, death, and transfer out) between 3MMD and monthly ART dispensing. Results were stratified by time on ART before 3MMD enrolment: "early enrollers" (<6 months on ART) and "established enrollers" (≥6 months on ART), and age groups: adolescents and youth (AYLHIV) (10-24 years) and adults (≥25 years). RESULTS: We included 7,378 PLHIV (25% AYLHIV, 75% adults), with 59% and 62% enrolled in 3MMD, respectively. Median follow-up time was 11.3 (IQR: 5.7-21.6) months for AYLHIV and 10.2 (IQR: 4.8-20.9) for adults. Attrition was lower in PLHIV enrolled in 3MMD compared to monthly ART dispensing, in both established (aHR AYLHIV = 0.65; 95%CI: 0.54-0.78 and aHR adults = 0.50; 95%CI: 0.44-0.56) and early enrollers (aHR AYLHIV = 0.70; 95%CI: 0.58-0.85 and aHR adults = 0.63; 95%CI: 0.57-0.70). Among individuals in 3MMD, male gender (aHR = 1.30; 95%CI: 1.18-1.44) and receiving care in a medium/low-volume healthcare facility (aHR = 1.18; 95%CI: 1.03-1.34) increased attrition risk. Conversely, longer ART time before 3MMD enrolment (aHR = 0.93; 95% CI: 0.92-0.94 per one-month increase) and age ≥45 years (aHR = 0.77, 95%CI: 0.67-0.89) reduced risk of attrition. CONCLUSIONS: 3MMD improves retention in care compared to monthly dispensing among established and early enrollers, although to a lesser extent among the latter.

Scaling-up and scaling-out the Systems Analysis and Improvement Approach to optimize the hypertension diagnosis and care cascade for HIV infected individuals (SCALE SAIA-HTN): a stepped-wedge cluster randomized trial.

BACKGROUND: Undiagnosed and untreated hypertension is a main driver of cardiovascular disease and disproportionately affects persons living with HIV (PLHIV) in low- and middle-income countries. Across sub-Saharan Africa, guideline application to screen and manage hypertension among PLHIV is inconsistent due to poor service readiness, low health worker motivation, and limited integration of hypertension screening and management within HIV care services. In Mozambique, where the adult HIV prevalence is over 13%, an estimated 39% of adults have hypertension. As the only scaled chronic care service in the county, the HIV treatment platform presents an opportunity to standardize and scale hypertension care services. Low-cost, multi-component systems-level strategies such as the Systems Analysis and Improvement Approach (SAIA) have been found effective at integrating hypertension and HIV services to improve the effectiveness of hypertension care delivery for PLHIV, reduce drop-offs in care, and improve service quality. To build off lessons learned from a recently completed cluster randomized trial (SAIA-HTN) and establish a robust evidence base on the effectiveness of SAIA at scale, we evaluated a scaled-delivery model of SAIA (SCALE SAIA-HTN) using existing district health management structures to facilitate SAIA across six districts of Maputo Province, Mozambique. METHODS: This study employs a stepped-wedge design with randomization at the district level. The SAIA strategy will be "scaled up" with delivery by district health supervisors (rather than research staff) and will be "scaled out" via expansion to Southern Mozambique, to 18 facilities across six districts in Maputo Province. SCALE SAIA-HTN will be introduced over three, 9-month waves of intensive intervention, where technical support will be provided to facilities and district managers by study team members from the Mozambican National Institute of Health. Our evaluation of SCALE SAIA-HTN will be guided by the RE-AIM framework and will seek to estimate the budget impact from the payer's perspective. DISCUSSION: SAIA packages user-friendly systems engineering tools to support decision-making by frontline health workers and to identify low-cost, contextually relevant improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial will determine an effective strategy for national scale-up and inform program planning. TRIAL REGISTRATION: ClinicalTrials.gov NCT05002322 (registered 02/15/2023).

Implementation outcomes of the integrated district evidence to action (IDEAs) program to reduce neonatal mortality in central Mozambique: an application of the RE-AIM evaluation framework.

BACKGROUND: Scarce evidence exists on audit and feedback implementation processes in low-resource health systems. The Integrated District Evidence to Action (IDEAs) is a multi-component audit and feedback strategy designed to improve the implementation of maternal and child guidelines in Mozambique. We report IDEAs implementation outcomes. METHODS: IDEAs was implemented in 154 health facilities across 12 districts in Manica and Sofala provinces between 2016 and 2020 and evaluated using a quasi-experimental design guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Reach is the proportion of pregnant women attending IDEAs facilities. Adoption is the proportion of facilities initiating audit and feedback meetings. Implementation is the fidelity to the strategy components, including readiness assessments, meetings (frequency, participation, action plan development), and targeted financial support and supervision. Maintenance is the sustainment at 12, 24, and 54 months. RESULTS: Across both provinces, 56% of facilities were exposed to IDEAs (target 57%). Sixty-nine and 73% of pregnant women attended those facilities' first and fourth antenatal consultations (target 70%). All facilities adopted the intervention. 99% of the expected meetings occurred with an average interval of 5.9 out of 6 months. Participation of maternal and child managers was high, with 3076 attending meetings, of which 64% were from the facility, 29% from the district, and 7% from the province level. 97% of expected action plans were created, and 41 specific problems were identified. "Weak diagnosis or management of obstetric complications" was identified as the main problem, and "actions to reinforce norms and protocols" was the dominant subcategory of micro-interventions selected. Fidelity to semiannual readiness assessments was low (52% of expected facilities), and in completing micro-interventions (17% were completed). Ninety-six and 95% of facilities sustained the intervention at 12 and 24 months, respectively, and 71% had completed nine cycles at 54 months. CONCLUSION: Maternal and child managers can lead audit and feedback processes in primary health care in Mozambique with high reach, adoption, and maintenance. The IDEAs strategy should be adapted to promote higher fidelity around implementing action plans and conducting readiness assessments. Adding effectiveness to these findings will help to inform strategy scale-up.

Drivers of success: improving implementation research tools for better health outcomes.

A thorough examination of context, and how it influences implementation of evidence-based interventions, is a promising strategy for enhancing child survival initiatives. Spreading approaches that are identified as drivers of successful reduction in under-five mortality from 'exemplar' countries could be pivotal in leading to reductions in other settings facing stagnant mortality rates, in particular for low- and middle-income countries with high disease burden and insufficient programmatic capacity to effectively implement evidence-based interventions at scale. Yet there remains a lack of robust analytic methods to accurately assess mortality and describe the drivers of interventions' implementation success at both national and subnational levels. The field of implementation science and its defining targets and tools is well positioned to address this knowledge gap by integrating qualitative and quantitative research methods into an adaptable evaluation framework that can be tailored to meet the specific needs across varying country contexts. These tools enhance the measurement of population health outcomes and provide crucial evidence on implementation barriers and facilitators that can inform policies that can be adjusted for diverse contexts. This commentary aims to emphasize the role of implementation research in understanding how exemplar countries achieved significant improvements in child survival and in identifying replicable lessons for other settings. Ultimately, all manuscripts underscore the relevance of implementation research in bolstering the reduction of under-five mortality.

Gaps and Opportunities for Strengthening In-School Support for Youth Living With HIV.

OBJECTIVES: With optimized antiretroviral treatment youth living with HIV (YLH) now spend most of their time in schools, making schools an important venue to optimize outcomes. We evaluated school support for YLH. METHODS: We conducted surveys with public secondary/high schools in 3 Kenyan counties (Nairobi, Homa Bay, and Kajiado) to determine policies and training related to HIV. Chi-squared tests and Poisson regression were used to compare policy availability and staff training by county HIV prevalence and school type. RESULTS: Of 512 schools in the 3 counties, we surveyed 100. The majority (60%) of schools surveyed had boarding facilities. The median student population was 406 (IQR: 200, 775). Only half (49%) of schools had medication use policies; more in boarding than day schools (65% vs 30%, p = .003). While most schools (82%) had clinic attendance policies; policy availability was higher in higher HIV prevalence counties (Homa Bay [100%], Nairobi [82%], Kajiado [56%], p < .05). Overall, 64% had confidentiality policies with higher policy availability in higher HIV prevalence regions (p < .05). Few schools had staff trained in HIV-related topics: HIV prevention (37%), HIV treatment (18%), HIV stigma reduction (36%). Few were trained in confidentiality (41%), psychosocial support (40%), or mental health (26%). Compared to day schools, boarding school were more likely to have staff trained in HIV prevention (prevalence ratio: 2.1 [95% confidence interval 1.0, 4.0], p = .037). CONCLUSION: In this survey of Kenyan schools, there were notable gaps in HIV care policy availability and training, despite high HIV burden. Development and implementation of national school HIV policies and staff training as well as strengthening clinic and family support may improve outcomes for YLH.

Impact of differentiated service delivery models on 12-month retention in HIV treatment in Mozambique: an interrupted time-series analysis.

BACKGROUND: HIV treatment has been available in Mozambique since 2004, but coverage of, and retention in, antiretroviral therapy (ART) remain suboptimal. Therefore, to increase health system efficiency and reduce HIV-associated mortality, in November, 2018, the Ministry of Health launched national guidelines on implementing eight differentiated service delivery models (DSDMs) for HIV treatment. We assessed the effect of this implementation on retention in ART 12 months after initiation, and explored the associated effects of COVID-19. METHODS: In this uncontrolled interrupted time-series analysis, data were extracted from the Mozambique ART database, which contains data on individuals in ART care from 1455 health facilities providing ART in Mozambique. We included individual-level data from facilities that were providing ART at the beginning of the study period (Jan 1, 2016) and at the start of DSDM implementation (Dec 1, 2018). We compared the proportion of individuals retained in ART 12 months after initiation between the periods before (Jan 1, 2017, to Nov 30, 2018) and after (Dec 1, 2019, to June 30, 2021) implementation of the DSDMs, overall and stratified by sex and age. We applied a generalised estimating equation model with a working independence correlation and cluster-robust standard errors to account for clustering at the facility level. In a secondary analysis, we assessed the effect of COVID-19 response measures during the post-intervention period on ART retention. FINDINGS: The study included 613 facilities and 1 131 118 individuals who started ART during the inclusion period up to June 30, 2020, of whom 79 178 (7·0%) were children (age ≤14 years), 226 224 (20·0%) were adolescents and young adults (age 15-24 years), and 825 716 (73·0%) were adults (age ≥25 years). 731 623 (64·7%) were female and 399 495 (35·3%) were male. Introduction of the DSDMs was associated with an estimated increase of 24·5 percentage points (95% CI 21·1 to 28·0) in 12-month ART retention by the end of the study period, compared with the counterfactual scenario without DSDM implementation. By age, the smallest effect was estimated in children (6·1 percentage points, 1·3 to 10·9) and the largest effect in adolescents and young adults (28·8 percentage points, 24·2 to 33·4); by sex, a larger effect was estimated in males (29·7 percentage points, 25·6 to 33·7). Our analysis showed that COVID-19 had an overall negative effect on 12-month retention in ART compared with a counterfactual scenario based on the post-intervention period without COVID-19 (-10·0 percentage points, -18·2 to -1·8). INTERPRETATION: The implementation of eight DSDMs for HIV treatment had a positive impact on 12-month retention in ART. COVID-19 negatively influenced this outcome. FUNDING: None. TRANSLATION: For the Portuguese translation of the abstract see Supplementary Materials section.

HIV viral load testing and monitoring in Côte d'Ivoire: A survival analysis of viral load testing and suppression, and evaluation of adherence to national recommendations.

Routine viral load (VL) monitoring is the standard of care in Côte d'Ivoire and allows for effective treatment guidance for people living with human immunodeficiency virus (HIV) to reach viral load suppression (VLS). For VL monitoring to be effective in reducing the impact of HIV, it must be provided in accordance with national guidance. This study aimed to evaluate VL testing, VLS rates and adherence to national guidance for VL testing using data collected from three national laboratories. We collected data on VL testing between 2015-2018 from OpenELIS (OE), an open-source electronic laboratory information system. We merged data by unique patient ID for patients (0-80 years old) who received multiple VL tests to calculate time between tests. We defined VLS as HIV RNA ≤1,000 copies/mL based on Côte d'Ivoire national and WHO guidance at the time of data collection. We used the Kaplan-Meier survival estimator to estimate time between ART (antiretroviral therapy) initiation and the first VL test, time between subsequent VL tests, and to estimate the proportion of people living with HIV (PLHIV) who were virally suppressed within 12 months of ART initiation. At the first documented VL test, 79.6% of patients were virally suppressed (95% CI: 78.9-80.3). Children under 15 were the least likely to be virally suppressed (55.2%, 95% CI: 51.5-58.8). The median time from ART initiation to the first VL sample collection for testing was 7.8 months (IQR:6.2-13.4). 72.4% of patients were virally suppressed within one year of treatment initiation (95% CI:71.5-73.3). Approximately 30% of patients received a second VL test during the 4-year study period. The median time between the first and second VL tests was 24.9 months (IQR: 4.7->40). Most PLHIV received their first VL test within the recommended 12 months of ART initiation but did not receive subsequent VL monitoring tests within the recommended time frame, reducing the benefits of VL monitoring. While VLS was fairly high, children were least likely to be virally suppressed. Our findings highlight the importance of regular VL monitoring after the first VL test, especially for children.

Reasons for non-disclosure of HIV-Positive status to healthcare providers: a mixed methods study in Mozambique.

BACKGROUND: Non-disclosure of known HIV status by people living with HIV but undergoing HIV testing leads to waste of HIV testing resources and distortion of estimates of HIV indicators. In Mozambique, an estimated one-third of persons who tested positive already knew their HIV-positive status. To our knowledge, this study is the first to assess the factors that prevent people living with HIV (PLHIV) from disclosing their HIV-positive status to healthcare providers during a provider-initiated counseling and testing (PICT) campaign. METHODS: This analysis was nested in a larger PICT cross-sectional study performed in the Manhiça District, Southern Mozambique from January to July 2019, in which healthcare providers actively asked patients about their HIV-status. Patients who tested positive for HIV were crosschecked with the hospital database to identify those who had previously tested positive and were currently or previously enrolled in care. PLHIV who did not disclose their HIV-positive status were invited to participate and provide consent, and were interviewed using a questionnaire designed to explore barriers, patterns of community/family disclosure, and stigma and discrimination. RESULTS: We found that 16.1% of participants who tested positive during a PICT session already knew their HIV-positive status but did not disclose it to the healthcare provider. All the participants reported previous mistreatment by general healthcare providers as a reason for nondisclosure during PICT. Other reasons included the desire to know if they were cured (33.3%) or to re-engage in care (23.5%). Among respondents, 83.9% reported having disclosed their HIV-status within their close community, 48.1% reported being victims of verbal or physical discrimination following their HIV diagnosis, and 46.7% reported that their HIV status affected their daily activities. CONCLUSION: Previous mistreatment by healthcare workers was the main barrier to disclosing HIV-positive status. The high proportion of those disclosing their HIV status to their community but not to healthcare providers suggests that challenges with patient-provider relationships affect this care behavior rather than social stigma and discrimination. Improving patient-provider relationships could increase trust in healthcare providers, reduce non-disclosures, and help optimize resources and provide accurate estimates of the UNAIDS first 95 goal.

Early effects of COVID-19 on maternal and child health service disruption in Mozambique.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. Introduction: After the World Health Organization declared COVID-19 a pandemic, more than 184 million cases and 4 million deaths had been recorded worldwide by July 2021. These are likely to be underestimates and do not distinguish between direct and indirect deaths resulting from disruptions in health care services. The purpose of our research was to assess the early impact of COVID-19 in 2020 and early 2021 on maternal and child healthcare service delivery at the district level in Mozambique using routine health information system data, and estimate associated excess maternal and child deaths. Methods: Using data from Mozambique's routine health information system (SISMA, Sistema de Informação em Saúde para Monitoria e Avaliação), we conducted a time-series analysis to assess changes in nine selected indicators representing the continuum of maternal and child health care service provision in 159 districts in Mozambique. The dataset was extracted as counts of services provided from January 2017 to March 2021. Descriptive statistics were used for district comparisons, and district-specific time-series plots were produced. We used absolute differences or ratios for comparisons between observed data and modeled predictions as a measure of the magnitude of loss in service provision. Mortality estimates were performed using the Lives Saved Tool (LiST). Results: All maternal and child health care service indicators that we assessed demonstrated service delivery disruptions (below 10% of the expected counts), with the number of new users of family planing and malaria treatment with Coartem (number of children under five treated) experiencing the largest disruptions. Immediate losses were observed in April 2020 for all indicators, with the exception of treatment of malaria with Coartem. The number of excess deaths estimated in 2020 due to loss of health service delivery were 11,337 (12.8%) children under five, 5,705 (11.3%) neonates, and 387 (7.6%) mothers. Conclusion: Findings from our study support existing research showing the negative impact of COVID-19 on maternal and child health services utilization in sub-Saharan Africa. This study offers subnational and granular estimates of service loss that can be useful for health system recovery planning. To our knowledge, it is the first study on the early impacts of COVID-19 on maternal and child health care service utilization conducted in an African Portuguese-speaking country.

Effects of primary healthcare reform on routine health information systems (RHISs): a mixed-methods study in Lesotho.

BACKGROUND AND OBJECTIVE: The Ministry of Health of Lesotho and Partners In Health piloted the Lesotho National Primary Health Care Reform (LPHCR) from July 2014 to June 2017 to improve quality and quantity of service delivery and enhance health system management. This initiative included improvement of routine health information systems (RHISs) to map disease burden and reinforce data utilisation for clinical quality improvement. METHODS AND ANALYSIS: The WHO Data Quality Assurance framework's core indicators were used to compare the completeness of health data before versus after the LPHCR in 60 health centres and 6 hospitals across four districts. To examine change in data completeness, we conducted an interrupted time series analysis using multivariable logistic mixed-effects regression. Additionally, we conducted 25 key informant interviews with healthcare workers (HCWs) at the different levels of Lesotho's health system, following a purposive sampling approach. Interviews were analysed using deductive coding based on the Performance of Routine Information System Management framework, which inspected organisational, technical and behavioural factors influencing RHIS processes and outputs associated with the LPHCR. RESULTS: In multivariable analyses, trends in monthly data completion rate were higher after versus before the LPHCR for: documenting first antenatal care visit (adjusted OR (AOR): 1.24, 95% CI: 1.14 to 1.36) and institutional delivery (AOR: 1.19, 95% CI: 1.07 to 1.32). When discussing processes, HCWs highlighted the value of establishing clear roles and responsibilities in reporting under a new organisational structure, improved community programmes among district health management teams, and enhanced data sharing and monitoring by districts. CONCLUSION: The Ministry of Health had a strong data completion rate pre-LPHCR, which was sustained throughout the LPHCR despite increased service utilisation. The data completion rate was optimised through improved behavioural, technical and organisational factors introduced as part of the LPHCR.

Using testing history to estimate HIV incidence in mothers living in resource-limited settings: Maximizing efficiency of a community health survey in Mozambique.

Obtaining rapid and accurate HIV incidence estimates is challenging because of the need for long-term follow-up for a large cohort. We estimated HIV incidence among women who recently delivered in southern Mozambique by leveraging data available in routine health cards. A cross-sectional household HIV-testing survey was conducted from October 2017 to April 2018 among mothers of children born in the previous four years in the Manhiça Health Demographic Surveillance System area. Randomly-selected mother-child pairs were invited to participate and asked to present documentation of their last HIV test result. HIV-testing was offered to mothers with no prior HIV-testing history, or with negative HIV results obtained over three months ago. HIV incidence was estimated as the number of mothers newly diagnosed with HIV per total person-years, among mothers with a prior documented HIV-negative test. Among 5000 mother-child pairs randomly selected, 3069 were interviewed, and 2221 reported a previous HIV-negative test. From this group, we included 1714 mothers who had taken a new HIV test during the survey. Most of mothers included (83.3%,1428/1714) had a previous documented HIV test result and date. Median time from last test to survey was 15.5 months (IQR:8.0-25.9). A total of 57 new HIV infections were detected over 2530.27 person-years of follow-up. The estimated HIV incidence was 2.25 (95% CI: 1.74-2.92) per 100 person-years. Estimating HIV incidence among women who recently delivered using a community HIV-focused survey coupled with previous HIV-testing history based on patients' clinical documents is an achievable strategy.

State Policy Removing the Personal Belief Exemption for Measles, Mumps, and Rubella (MMR) School Immunization Requirement, Washington State, 2014-2022.

Objectives. To assess the impact of Washington State's 2019 Engrossed House Bill (EHB) 1638-which removed measles, mumps, and rubella (MMR) personal belief exemptions-on MMR vaccine series completion and exemption rates in K-12 students. Methods. We used interrupted time-series analyses to examine changes in MMR vaccine series completion rates before and after EHB 1638 was passed and the χ2 test for differences in exemption rates. Results. EHB 1638 implementation was associated with a 5.4% relative increase in kindergarten MMR vaccine series completion rates (95% confidence interval = 3.8%, 7.1%; P ≤ .001), and results were similar with Oregon as a control state (no change observed in Oregon; P = .68). MMR exemptions overall decreased 41% (from 3.1% in 2018-2019 to 1.8% in 2019-2020; P ≤ .001), and religious exemptions increased 367% (from 0.3% to 1.4%; P ≤ .001). Conclusions. EHB 1638 was associated with an increase in MMR vaccine series completion rates and a decrease in any MMR exemption. However, effects were partially offset by an increase in religious exemption rates. Public Health Implications. Removal of personal belief exemptions for the MMR immunization requirement only may be an effective approach to increase MMR vaccine coverage rates statewide and among underimmunized communities. (Am J Public Health. 2023;113(7):795-804. https://doi.org/10.2105/AJPH.2023.307285).

Assisted Partner Notification Services Are Safe and Effective as They Are Brought to Scale in Mozambique.

BACKGROUND: The World Health Organization recommends that persons diagnosed with HIV be offered assisted partner notification services (APS). There are limited data on the safety of APS as implemented in public health programs. SETTING: Three public health centers in Maputo, Mozambique, 2016-2019. METHODS: Counselors offered APS to persons with newly diagnosed HIV and, as part of a program evaluation, prospectively assessed the occurrence of adverse events (AEs), including (1) pushing, abandonment, or yelling; (2) being hit; and (3) loss of financial support or being expelled from the house. RESULTS: Eighteen thousand nine hundred sixty-five persons tested HIV-positive in the 3 clinics, 13,475 (71%) were evaluated for APS eligibility, 9314 were eligible and offered APS, and 9219 received APS. Index cases (ICs) named 8933 partners without a previous HIV diagnosis, of whom 6137 tested and 3367 (55%) were diagnosed with HIV (case-finding index = 0.36). APS counselors collected follow-up data from 6680 (95%) of 7034 index cases who had untested partners who were subsequently notified; 78 (1.2%) experienced an AE. Among 270 ICs who reported a fear of AEs at their initial APS interview, 211 (78%) notified ≥1 sex partner, of whom 5 (2.4%) experienced an AE. Experiencing an AE was associated with fear of loss of support (odds ratio [OR] 4.28; 95% confidence interval [CI]: 1.50 to 12.19) and having a partner who was notified, but not tested (OR 3.47; 95% CI: 1.93 to 6.26). CONCLUSION: Case-finding through APS in Mozambique is high and AEs after APS are uncommon. Most ICs with a fear of AEs still elect to notify partners with few experiencing AEs.

Scrutinizing human resources for health availability and distribution in Mozambique between 2016 and 2020: a subnational descriptive longitudinal study.

INTRODUCTION: Overall, resilient health systems build upon sufficient, qualified, well-distributed, and motivated health workers; however, this precious resource is limited in numbers to meet people's demands, particularly in LMICs. Understanding the subnational distribution of health workers from different lens is critical to ensure quality healthcare and improving health outcomes. METHODS: Using data from Health Personnel Information System, facility-level Service Availability and Readiness Assessment, and other sources, we performed a district-level longitudinal analysis to assess health workforce density and the ratio of male to female health workers between January 2016 and June 2020 across all districts in Mozambique. RESULTS: 22 011 health workers were sampled, of whom 10 405 (47.3%) were male. The average age was 35 years (SD: 9.4). Physicians (1025, 4.7%), maternal and child health nurses (4808, 21.8%), and nurses (6402, 29.1%) represented about 55% of the sample. In January 2016, the average district-level workforce density was 75.8 per 100 000 population (95% CI 65.9, 87.1), and was increasing at an annual rate of 8.0% (95% CI 6.00, 9.00) through January 2018. The annual growth rate declined to 3.0% (95% CI 2.00, 4.00) after January 2018. Two provinces, Maputo City and Maputo Province, with 268.3 (95% CI 186.10, 387.00) and 104.6 (95% CI 84.20, 130.00) health workers per 100 000 population, respectively, had the highest workforce density at baseline (2016). There were 3122 community health workers (CHW), of whom 72.8% were male, in January 2016. The average number of CHWs per 10 000 population was 1.33 (95% CI 1.11, 1.59) in 2016 and increased by 18% annually between January 2016 and January 2018. This trend reduced to 11% (95% CI 0.00, 13.00) after January 2018. The sex ratio was twice as high for all provinces in the central and northern regions relative to Maputo Province. Maputo City (OR: 0.34; 95% CI 0.32, 0.34) and Maputo Province (OR: 0.56; 95% CI 0.49, 0.65) reported the lowest sex ratio at the baseline. Encouragingly, important sex ratio improvements were observed after January 2018, particularly in the northern and central regions. CONCLUSION: Mozambique made substantial progress in health workers' availability during the study period; however, with a critical slowdown after 2018. Despite the progress, meaningful shortages and distribution disparities persist.

Development of treatment-decision algorithms for children evaluated for pulmonary tuberculosis: an individual participant data meta-analysis.

BACKGROUND: Many children with pulmonary tuberculosis remain undiagnosed and untreated with related high morbidity and mortality. Recent advances in childhood tuberculosis algorithm development have incorporated prediction modelling, but studies so far have been small and localised, with limited generalisability. We aimed to evaluate the performance of currently used diagnostic algorithms and to use prediction modelling to develop evidence-based algorithms to assist in tuberculosis treatment decision making for children presenting to primary health-care centres. METHODS: For this meta-analysis, we identified individual participant data from a WHO public call for data on the management of tuberculosis in children and adolescents and referral from childhood tuberculosis experts. We included studies that prospectively recruited consecutive participants younger than 10 years attending health-care centres in countries with a high tuberculosis incidence for clinical evaluation of pulmonary tuberculosis. We collated individual participant data including clinical, bacteriological, and radiological information and a standardised reference classification of pulmonary tuberculosis. Using this dataset, we first retrospectively evaluated the performance of several existing treatment-decision algorithms. We then used the data to develop two multivariable prediction models that included features used in clinical evaluation of pulmonary tuberculosis-one with chest x-ray features and one without-and we investigated each model's generalisability using internal-external cross-validation. The parameter coefficient estimates of the two models were scaled into two scoring systems to classify tuberculosis with a prespecified sensitivity target. The two scoring systems were used to develop two pragmatic, treatment-decision algorithms for use in primary health-care settings. FINDINGS: Of 4718 children from 13 studies from 12 countries, 1811 (38·4%) were classified as having pulmonary tuberculosis: 541 (29·9%) bacteriologically confirmed and 1270 (70·1%) unconfirmed. Existing treatment-decision algorithms had highly variable diagnostic performance. The scoring system derived from the prediction model that included clinical features and features from chest x-ray had a combined sensitivity of 0·86 [95% CI 0·68-0·94] and specificity of 0·37 [0·15-0·66] against a composite reference standard. The scoring system derived from the model that included only clinical features had a combined sensitivity of 0·84 [95% CI 0·66-0·93] and specificity of 0·30 [0·13-0·56] against a composite reference standard. The scoring system from each model was placed after triage steps, including assessment of illness acuity and risk of poor tuberculosis-related outcomes, to develop treatment-decision algorithms. INTERPRETATION: We adopted an evidence-based approach to develop pragmatic algorithms to guide tuberculosis treatment decisions in children, irrespective of the resources locally available. This approach will empower health workers in primary health-care settings with high tuberculosis incidence and limited resources to initiate tuberculosis treatment in children to improve access to care and reduce tuberculosis-related mortality. These algorithms have been included in the operational handbook accompanying the latest WHO guidelines on the management of tuberculosis in children and adolescents. Future prospective evaluation of algorithms, including those developed in this work, is necessary to investigate clinical performance. FUNDING: WHO, US National Institutes of Health.

Managers' and providers' perspectives on barriers and facilitators for the implementation of differentiated service delivery models for HIV treatment in Mozambique: a qualitative study.

INTRODUCTION: In 2018, Mozambique's Ministry of Health launched a guideline for a nationwide implementation of eight differentiated service delivery models to optimize HIV service delivery and achieve universal coverage of HIV care and treatment. The models were (1) Fast-track, (2) Three-month Antiretrovirals Dispensing, (3) Community Antiretroviral Therapy Groups, (4) Adherence Clubs, (5) Family-approach, and three one-stop shop models for (6) Tuberculosis, (7) Maternal and Child Health, and (8) Adolescent-friendly Health Services. This study identified drivers of implementation success and failure across these differentiated service delivery models. METHODS: Twenty in-depth individual interviews were conducted with managers and providers from the Ministry of Health and implementing partners from all levels of the health system between July and September 2021. National-level participants were based in the capital city of Maputo, and participants at provincial, district and health facility levels were from Sofala province, a purposively selected setting. The Consolidated Framework for Implementation Research (CFIR) guided data collection and thematic analysis. Deductively selected constructs were assessed while allowing for additional themes to emerge inductively. RESULTS: The CFIR constructs of Relative Advantage, Complexity, Patient Needs and Resources, and Reflecting and Evaluating were identified as drivers of implementation, whereas Available Resources and Access to Knowledge and Information were identified as barriers. Fast-track and Three-month Antiretrovirals Dispensing models were deemed easier to implement and more effective in reducing workload. Adherence Clubs and Community Antiretroviral Therapy Groups were believed to be less preferred by clients in urban settings. COVID-19 (an inductive theme) improved acceptance and uptake of individual differentiated service delivery models that reduced client visits, but it temporarily interrupted the implementation of group models. CONCLUSIONS: This study described important determinants to be addressed or leveraged for the successful implementation of differentiated service delivery models in Mozambique. The models were considered advantageous overall for the health system and clients when compared with the standard of care. However, successful implementation requires resources and ongoing training for frontline providers. COVID-19 expedited individual models by loosening the inclusion criteria; this experience can be leveraged to optimize the design and implementation of differentiated service delivery models in Mozambique and other countries.

Trends and Determinants of Full Immunisation among Children Aged 12-23 Months: Analysis of Pooled Data from Mozambican Household Surveys between 1997 and 2015.

The 1974 Expanded Program on Immunisation has saved millions of children worldwide by promoting full immunisation coverage (FIC). However, forty years later, many sub-Saharan African countries remain well below its target of 90% FIC. This study analysed the level, trends and determinants of FIC in 4322 Mozambican children aged 12-23 months from pooled data from four national surveys between 1997 and 2015. Descriptive statistics and multivariable logistic regression models were performed to analyse the factors associated with full immunisation coverage. Overall, the coverage of fully immunised children increased from 47.9% in 1997 to 66.5% in 2015, corresponding to a 1.8% yearly increase. The needed FIC growth rate post-2015 was 4.3 times higher. Increased maternal education and a higher household wealth index were associated with higher odds of FIS. Furthermore, attending antenatal care (ANC) visits, institutional delivery and living in southern provinces were also associated with increased odds of FIS. Between 1997 and 2015, FIC among 12-23-month-old children made modest annual gains but remained well below international targets. Factors related to access to healthcare, educational level, socioeconomic status and geographical location were associated with improved FIC. Targeted interventions to expand these factors will improve immunisation coverage among Mozambican children.

Effects of the COVID-19 pandemic on essential health and nutrition service utilisations in Ghana: interrupted time-series analyses from 2016 to 2020.

OBJECTIVES: This study aimed to assess the national-level and subnational-level effects of the COVID-19 pandemic on essential health and nutrition service utilisation in Ghana. DESIGN: Interrupted time-series. SETTING AND PARTICIPANTS: This study used facility-level data of 7950 governmental and non-governmental health facilities in Ghana between January 2016 and November 2020. OUTCOME MEASURES: As the essential health and nutrition services, we selected antenatal care (ANC); institutional births, postnatal care (PNC); first and third pentavalent vaccination; measles vaccination; vitamin A supplementations (VAS); and general outpatient care. We performed segmented mixed effects linear models for each service with consideration for data clustering, seasonality and autocorrelation. Losses of patient visits for essential health and nutrition services due to the COVID-19 pandemic were estimated as outcome measures. RESULTS: In April 2020, as an immediate effect of the COVID-19 pandemic, the number of patients for all the services decreased except first pentavalent vaccine. While some services (ie, institutional birth, PNC, third pentavalent and measles vaccination) recovered by November 2020, ANC, VAS and outpatient services had not recovered to prepandemic levels. The total number of lost outpatient visits in Ghana was estimated to be 3 480 292 (95% CI: -3 510 820 to -3 449 676), followed by VAS (-180 419, 95% CI: -182 658 to -177 956) and ANC (-87 481, 95% CI: -93 644 to -81 063). The Greater Accra region was the most affected region by COVID-19, where four out of eight essential services were significantly disrupted. CONCLUSION: COVID-19 pandemic disrupted the majority of essential healthcare services in Ghana, three of which had not recovered to prepandemic levels by November 2020. Millions of outpatient visits and essential ANC visits were lost. Furthermore, the immediate and long-term impacts of the COVID-19 pandemic on service utilisation varied by service type and region.

Pregnancy outcomes after first-trimester treatment with artemisinin derivatives versus non-artemisinin antimalarials: a systematic review and individual patient data meta-analysis.

BACKGROUND: Malaria in the first trimester of pregnancy is associated with adverse pregnancy outcomes. Artemisinin-based combination therapies (ACTs) are a highly effective, first-line treatment for uncomplicated Plasmodium falciparum malaria, except in the first trimester of pregnancy, when quinine with clindamycin is recommended due to concerns about the potential embryotoxicity of artemisinins. We compared adverse pregnancy outcomes after artemisinin-based treatment (ABT) versus non-ABTs in the first trimester of pregnancy. METHODS: For this systematic review and individual patient data (IPD) meta-analysis, we searched MEDLINE, Embase, and the Malaria in Pregnancy Library for prospective cohort studies published between Nov 1, 2015, and Dec 21, 2021, containing data on outcomes of pregnancies exposed to ABT and non-ABT in the first trimester. The results of this search were added to those of a previous systematic review that included publications published up until November, 2015. We included pregnancies enrolled before the pregnancy outcome was known. We excluded pregnancies with missing estimated gestational age or exposure information, multiple gestation pregnancies, and if the fetus was confirmed to be unviable before antimalarial treatment. The primary endpoint was adverse pregnancy outcome, defined as a composite of either miscarriage, stillbirth, or major congenital anomalies. A one-stage IPD meta-analysis was done by use of shared-frailty Cox models. This study is registered with PROSPERO, number CRD42015032371. FINDINGS: We identified seven eligible studies that included 12 cohorts. All 12 cohorts contributed IPD, including 34 178 pregnancies, 737 with confirmed first-trimester exposure to ABTs and 1076 with confirmed first-trimester exposure to non-ABTs. Adverse pregnancy outcomes occurred in 42 (5·7%) of 736 ABT-exposed pregnancies compared with 96 (8·9%) of 1074 non-ABT-exposed pregnancies in the first trimester (adjusted hazard ratio [aHR] 0·71, 95% CI 0·49-1·03). Similar results were seen for the individual components of miscarriage (aHR=0·74, 0·47-1·17), stillbirth (aHR=0·71, 0·32-1·57), and major congenital anomalies (aHR=0·60, 0·13-2·87). The risk of adverse pregnancy outcomes was lower with artemether-lumefantrine than with oral quinine in the first trimester of pregnancy (25 [4·8%] of 524 vs 84 [9·2%] of 915; aHR 0·58, 0·36-0·92). INTERPRETATION: We found no evidence of embryotoxicity or teratogenicity based on the risk of miscarriage, stillbirth, or major congenital anomalies associated with ABT during the first trimester of pregnancy. Given that treatment with artemether-lumefantrine was associated with fewer adverse pregnancy outcomes than quinine, and because of the known superior tolerability and antimalarial effectiveness of ACTs, artemether-lumefantrine should be considered the preferred treatment for uncomplicated P falciparum malaria in the first trimester. If artemether-lumefantrine is unavailable, other ACTs (except artesunate-sulfadoxine-pyrimethamine) should be preferred to quinine. Continued active pharmacovigilance is warranted. FUNDING: Medicines for Malaria Venture, WHO, and the Worldwide Antimalarial Resistance Network funded by the Bill & Melinda Gates Foundation.

Changes in prevalence and the cascade of care for type 2 diabetes over ten years (2005-2015): results of two nationally representative surveys in Mozambique.

BACKGROUND: Sub-Saharan Africa is predicted to have the steepest increase in the prevalence of diabetes in the next 25 years. The latest Mozambican population-based STEPS survey (STEPS 2005) estimated a 2.9% prevalence of diabetes in the adult population aged 25-64 years. We aimed to assess the change in prevalence, awareness, and management of diabetes in the national STEPS survey from 2014/2015 compared to 2005. METHODS: We conducted an observational, quantitative, cross-sectional study following the WHO STEPS surveillance methodology in urban and rural settings, targeting the adult population of Mozambique in 2015. We collected sociodemographic data, anthropometric, and 12 hour fasting glucose blood samples in a sample of 1321 adults. The analysis consisted of descriptive measures of the prevalence of impaired fasting glucose (IFG), diabetes and related risk factors by age group, sex, and urban/rural residence and compared the findings to those of the 2005 survey results. RESULTS: The prevalence of IFG and diabetes was 4.8% (95CI: 3.6-6.3) and 7.4% (95CI: 5.5-10.0), respectively. These prevalence of IFG and diabetes did not differ significantly between women and men. The prevalence of diabetes in participants classified with overweight/obesity [10.6% (95CI: 7.5-14.6)] and with central obesity (waist hip ratio) [11.0% (95CI: 7.4-16.1)] was almost double the prevalence of their leaner counterparts, [6.3% (95CI, 4.0-9.9)] and [5.2% (95CI: 3.2-8.6)], respectively. Diabetes prevalence increased with age. There were 50% more people with diabetes in urban areas than in rural. Only 10% of people with diabetes were aware of their disease, and only 44% of those taking oral glucose-lowering drugs. The prevalence of IFG over time [2.0% (95CI: 1.1-3.5) vs 4.8% (95CI: 3.6-6.3)] and diabetes [2.9% (95CI: 2.0-4.2) vs 7.4% (95CI: 5.5-10.0)] were more than twofold higher in 2014/2015 than in 2005. However, awareness of disease and being on medication decreased by 3% and by 50%, respectively. Though this was not statistically significant. CONCLUSIONS: While the prevalence of diabetes in Mozambique has increased from 2005 to 2015, awareness and medication use have declined considerably. There is an urgent need to improve the capacity of primary health care and communities to detect, manage and prevent the occurrence of NCDs and their risk factors.