Lipoarabinomannan Antigen Assay (TB-LAM) for Diagnosing Pulmonary Tuberculosis in Children with Severe Acute Malnutrition in Mozambique.

BACKGROUND: Tuberculosis (TB) and malnutrition are important causes of morbidity and mortality in children in the developing world. AIMS: To assess the prevalence of pulmonary TB in severely malnourished children and evaluate TB detection using the urine lipoarabinomannan antigen assay (TB-LAM). METHODS: A retrospective analysis was conducted in all pediatric inpatients with severe acute malnutrition at a rural health center in Mozambique, from February to August 2018. All children underwent a physical examination and chest X-ray, and their nasopharyngeal aspirates and stool specimens were studied for mycobacterial culture and subjected to the Xpert MTB/RIF assay. TB-LAM tests were performed on urine. RESULTS: Of 45 included cases, 17 (37.8%) were clinically diagnosed as pulmonary TB. None of these were detected by the Xpert MTB test; 4 (8.9%) nasopharyngeal aspirates were TB-culture positive. Seventeen patients (37.8%)-all clinically diagnosed with TB-tested positive on the TB-LAM, while 23 (51.1%) were negative. In 5 (11.1%), the urine LAM was not done. CONCLUSION: Although our sample size was small, TB was diagnosed and treated in more than a third of included children. The urine TB-LAM test showed a perfect correlation with clinical diagnosis of childhood TB. LAY SUMMARY: Severe acute malnutrition makes children more vulnerable to tuberculosis (TB) infections, but it is difficult to detect TB in children because they cannot always cough up phlegm, which is used in diagnostic processes. This study aimed to find out how many severely malnourished children had TB in Gaza, Mozambique, and to test the accuracy of a less-used diagnostic test: the lipoarabinomannan assay (TB-LAM). Of the 45 severely malnourished children who were admitted to our hospital, 17 were diagnosed with TB by their doctor. The TB-LAM corroborated the clinical diagnosis in all cases, while the other tests (Xpert MTB/RIF assay) and cultures failed to detect most of them. Overall, more than a third of severely malnourished children had TB, and the TB-LAM test-a simple, point-of-care method-was a highly accurate way to diagnose them. While larger studies are needed to confirm these results, our findings suggest that the TB-LAM could vastly improve TB diagnosis in malnourished children.

The rollout of paediatric dolutegravir and virological outcomes among children living with HIV in Mozambique.

Background: In 2022, Mozambique introduced Dolutegravir 10mg (pDTG), as part of paediatric antiretroviral therapy for children weighing < 20 kg. Understanding real-world challenges during national rollout can strengthen health systems in resource-limited settings. Objectives: We described the transition rate to, and new initiation of, pDTG, viral load suppression (VLS) post-pDTG, and factors associated with VLS among children living with HIV. Method: We conducted a retrospective cohort study involving children aged < 9 years and abstracted data from clinical sources. We used logistic regression to assess VLS and pDTG initiation predictors. Results: Of 1353 children, 1146 initiated pDTG; 196 (14.5%) had no recorded weight. Post-pDTG switch, 98.9% (950/961) of children maintained the same nucleoside reverse transcriptase inhibitor backbone. After initiating Abacavir/Lamivudine+pDTG, 834 (72.8%) children remained on the regimen, 156 (13.6%) switched off (majority to Dolutegravir 50mg), 22 (1.9%) had ≥ 2 anchor drug switches; 134 (11.7%) had no documented follow-up regimen. Factors associated with pDTG initiation or switch were younger age (adjusted odds ratio [AOR] = 0.71 [0.63-0.80]) and a recorded weight (AOR = 55.58 [33.88-91.18]). VLS among the 294 children with a viral load (VL) test after ≥ 5 months post-pDTG was 75.5% (n = 222/294). Pre-pDTG VLS rate among treatment-experienced children was 56.5% (n = 130/230). Factors associated with VLS were older age (AOR = 1.18 [1.03-1.34]) and previous VLS (AOR = 2.27 [1.27-4.06]). Conclusion: Most eligible children initiated pDTG per guidelines, improving post-pDTG VLS. Challenges included unexplained switches off pDTG after initiation, low VL coverage and inadequate documentation in clinic records.

Consistency of Multi-Month Antiretroviral Therapy Dispensing and Association with Viral Load Coverage among Pediatric Clients Living with HIV in Mozambique.

With the increase in uptake of multi-month antiretroviral therapy dispensing (MMD) for children, little is known about consistency of MMD receipt over time and its association with virological outcomes. This analysis aims to assess the uptake of 3-month MMD among children, consistent receipt of MMD after uptake, and clinical outcomes following transition to MMD in 16 health facilities in Gaza and Inhambane Provinces. This is a secondary analysis involving children <15 years living with HIV with clinical visits during the period from September 2019 to August 2020. Of 4383 children, 82% ever received MMD (at least one pickup of a 3-month MMD supply) during the study period but only 40% received it consistently (defined as MMD at every visit during the study period). Consistent MMD was most common among older children and children without indications of clinical instability. Overall viral load (VL) coverage was 40% (733/1851). Consistent MMD was significantly associated with lower odds of having a VL (0.78, 95% CI: 0.64-0.95). In conclusion, while receipt of a multi-month supply was common particularly during the early days of the COVID-19 pandemic, only a minority of children received consistent MMD; however, there is a need to ensure children with fewer visits still receive timely VL monitoring.

Factors associated with the use of long-lasting insecticidal nets in pregnant women and mothers with children under five years of age in Gaza province, Mozambique.

Malaria remains a major public health concern worldwide. Malaria is endemic in Mozambique, with seasonal fluctuations throughout the country. Although the number of malaria cases in Mozambique have dropped by 11% from 2020 to 2021, there are still hotspots in the country with persistent high incidence and low insecticide-treated bed net usage. The aim of this study is to evaluate the factors associated with the use of long-lasting insecticidal nets by pregnant women and women with children under 5 years old in two hotspot districts in the Gaza province, Mozambique. A descriptive, qualitative cross-sectional study was conducted between June 15th and 21st 2022. An in-depth interview process was conducted with pregnant women and mothers with children under five years old, exploring their beliefs, experiences, and perception of messages conveyed by health professionals when long-lasting insecticidal nets were being supplied. A total of 48 women participated (24 pregnant women and 24 women with children under 5 years). Most participants recognized the protective effects of long-lasting insecticidal nets in preventing malaria, and understood that women and children were high risk groups. The nets were reported to cause side effects and difficulty breathing by 100% of pregnant women, while 54.2% of mothers with children under 5 reported no side effects. The majority of women in both groups reported that their health professionals did not educate them about how to use or handle the nets properly. Only 16.7% of mothers with children under 5 received correct handling instructions. Providing clear, culturally sensitive, and practical information on the correct use of LLINs, as well as regular monitoring of their proper use, would be a great step forward for Mozambique's national malaria program.

Virologic Outcomes and ARV Switch Profiles 2 Years After National Rollout of Dolutegravir to Children Less Than 15 Years in Southern Mozambique.

BACKGROUND: Dolutegravir (DTG) was scaled up globally to optimize treatment for children living with HIV. We evaluated the rollout and virological outcomes after DTG introduction in Mozambique. METHODS: Data from children 0-14 years with visits from September 2019 to August 2021 were extracted from records in 16 facilities in 12 districts. Among children ever on DTG, we report treatment switches, defined as changes in anchor drug, regardless of changes to nucleoside reverse transcriptase inhibitor (NRTI) backbones. Among those on DTG for ≥6 months, we described viral load suppression rates by children newly initiating and switching to DTG and by the NRTI backbone at the time of the DTG switch. RESULTS: Overall, 3,347 children were ever on DTG-based treatment (median age 9.5 years; 52.8% female). Most children (3,202, 95.7%) switched to DTG from another antiretroviral regimen. During the 2-year follow-up, 9.9% never switched from DTG; 52.7% had 1 regimen change, of which 97.6% were switched to DTG. However, 37.2% of children experienced ≥2 anchor drug changes. Overall median time on DTG was 18.6 months; nearly all children ≥5 years (98.6%) were on DTG at the last visit. Viral suppression was 79.7% (63/79) for children newly initiating DTG and 85.8% (1,775/2,068) for those switching to DTG. Suppression rates were 84.8% and 85.7% among children who switched and maintained NRTI backbones, respectively. CONCLUSIONS: Viral suppression rates of ≥80% with minor variations by backbone were achieved during the 2-year DTG rollout. However, there were multiple anchor drug switches for over one-third of children, which may be attributable in part to drug stockouts. Long-term pediatric HIV management will only be successful with immediate and sustainable access to optimized child-friendly drugs and formulations.

HIV community index testing reaches proportionally more males than facility-based testing and is cost-effective: A study from Gaza province, Mozambique.

BACKGROUND: In Mozambique, 38.7% of women and 60.4% of men ages 15-59 years old living with HIV do not know their HIV status. A pilot home-based HIV counseling and testing program based on index cases in the community was implemented in eight districts in Gaza province (Mozambique). The pilot targeted the sexual partners, biological children under 14 years old living in the same household, and parents (for pediatric cases) of people living with HIV. The study aimed to estimate the cost-efficiency and effectiveness of community index testing and compare the HIV testing outputs with facility-based testing. METHODS: Community index testing costs included the following categories: human resources, HIV rapid tests, travel and transportation for supervision and home visits, training, supplies and consumables, and review and coordination meetings. Costs were estimated from a health systems perspective using a micro-costing approach. All project costs were incurred between October 2017 and September 2018 and converted to U.S. dollars ($) using the prevailing exchange rate. We estimated the cost per individual tested, per new HIV diagnosis, and per infection averted. RESULTS: A total of 91,411 individuals were tested for HIV through community index testing, of which 7,011 were newly diagnosed with HIV. Human resources (52%), purchase of HIV rapid tests (28%) and supplies (8%) were the major cost drivers. The cost per individual tested was $5.82, per new HIV diagnosis was $65.32, and per infection averted per year was $1,813. Furthermore, the community index testing approach proportionally tested more males (53%) than facility-based testing (27%). CONCLUSION: These data suggest that expansion of the community index case approach may be an effective and efficient strategy to increase the identification of previously undiagnosed HIV-positive individuals, particularly males.

Mother-to-child transmission of HIV infection and its associated factors in the district of Bilene, Gaza Province-Mozambique.

BACKGROUND: Mother-to-child transmission of HIV infection is a significant problem in Mozambique. This study aims to determine the risk factors associated with mother-to-child transmission of HIV in rural Mozambique. METHODS: Retrospective case-control study in a rural area of Bilene District, on the coast of southern Mozambique, performed from January 2017 to June 2018. The analysis considered the clinical data of HIV exposed children with definitive HIV positive results and their respective infected mothers (cases), and the data of HIV exposed children with definitive HIV negative results and their respective infected mothers (controls) registered in At Risk Child Clinics from 1st January 2017 to 30th June 2018 at the Macia and Praia de Bilene health facilities in Bilene district, Gaza province-Mozambique. RESULTS: Ninety pregnant women with HIV were involved in the study, including 30 who had transmitted the infection to their children and 60 who had not. Statistical analysis, adjusted for maternal age and gestational age at first antenatal care visit, showed that independent risk factors for transmission were gestational age at first visit (adjusted odds ratio [aOR] 1.19, 95% confidence interval [CI] 1.05-1.36), non-adherence to combination antiretroviral therapy (56.7% vs. 5%; aOR 14.12, 95% CI 3.15-63.41); a viral load of 1000 copies/mL or more (90% vs. 5%; aOR: 156, 95% CI 22.91-1,062) and female sex of the neonate (80% vs. 51.7%; aOR: 4.43, 95% CI 1.33-15.87). CONCLUSION: A high viral load and non-adherence to antiretroviral therapy are important predictors of mother-to-child HIV transmission.

HIV community index testing reaches proportionally more males than facility-based testing and is cost-effective: A study from Gaza province, Mozambique

In Mozambique, 38.7% of women and 60.4% of men ages 15­59 years old living with HIV do not know their HIV status. A pilot home-based HIV counseling and testing program based on index cases in the community was implemented in eight districts in Gaza province (Mozambique). The pilot targeted the sexual partners, biological children under 14 years old living in the same household, and parents (for pediatric cases) of people living with HIV. The study aimed to estimate the cost-efficiency and effectiveness of community index testing and compare the HIV testing outputs with facility-based testing. Methods Community index testing costs included the following categories: human resources, HIV rapid tests, travel and transportation for supervision and home visits, training, supplies and consumables, and review and coordination meetings. Costs were estimated from a health systems perspective using a micro-costing approach. All project costs were incurred between October 2017 and September 2018 and converted to U.S. dollars ($) using the prevailing exchange rate. We estimated the cost per individual tested, per new HIV diagnosis, and per infection averted. Results A total of 91,411 individuals were tested for HIV through community index testing, of which 7,011 were newly diagnosed with HIV. Human resources (52%), purchase of HIV rapid tests (28%) and supplies (8%) were the major cost drivers. The cost per individual tested was $5.82, per new HIV diagnosis was $65.32, and per infection averted per year was $1,813

Lipoarabinomannan Antigen Assay (TB-LAM) for Diagnosing Pulmonary Tuberculosis in Children with Severe Acute Malnutrition in Mozambique

Tuberculosis (TB) and malnutrition are important causes of morbidity and mortality in children in the developing world. Aims To assess the prevalence of pulmonary TB in severely malnourished children and evaluate TB detection using the urine lipoarabinomannan antigen assay (TB-LAM). Methods A retrospective analysis was conducted in all pediatric inpatients with severe acute malnutrition at a rural health center in Mozambique, from February to August 2018. All children underwent a physical examination and chest X-ray, and their nasopharyngeal aspirates and stool specimens were studied for mycobacterial culture and subjected to the Xpert MTB/RIF assay. TB-LAM tests were performed on urine. Results Of 45 included cases, 17 (37.8%) were clinically diagnosed as pulmonary TB. None of these were detected by the Xpert MTB test; 4 (8.9%) nasopharyngeal aspirates were TB-culture positive. Seventeen patients (37.8%)­all clinically diagnosed with TB­tested positive on the TB-LAM, while 23 (51.1%) were negative. In 5 (11.1%), the urine LAM was not done. Conclusion Although our sample size was small, TB was diagnosed and treated in more than a third of included children. The urine TB-LAM test showed a perfect correlation with clinical diagnosis of childhood TB. LAY SUMMARY Severe acute malnutrition makes children more vulnerable to tuberculosis (TB) infections, but it is difficult to detect TB in children because they cannot always cough up phlegm, which is used in diagnostic processes. This study aimed to find out how many severely malnourished children had TB in Gaza, Mozambique, and to test the accuracy of a less-used diagnostic test: the lipoarabinomannan assay (TB-LAM). Of the 45 severely malnourished children who were admitted to our hospital, 17 were diagnosed with TB by their doctor. The TB-LAM corroborated the clinical diagnosis in all cases, while the other tests (Xpert MTB/RIF assay) and cultures failed to detect most of them. Overall, more than a third of severely malnourished children had TB, and the TB-LAM test­a simple, point-of-care method­was a highly accurate way to diagnose them. While larger studies are needed to confirm these results, our findings suggest that the TB-LAM could vastly improve TB diagnosis in malnourished children.