The Mulher Study: cervical cancer screening with primary HPV testing in Mozambique.

OBJECTIVE: To evaluate cervical cancer screening with primary human papillomavirus (HPV) testing in Mozambique, a country with one of the highest burdens of cervical cancer globally. METHODS: Women aged 30-49 years were prospectively enrolled and offered primary HPV testing using either self-collected or provider-collected specimens. Patients who tested positive for HPV underwent visual assessment for treatment using visual inspection with acetic acid to determine eligibility for thermal ablation. If ineligible, they were referred for excision with a loop electrosurgical excision procedure, for cold knife conization, or for cervical biopsy if malignancy was suspected. RESULTS: Between January 2020 and January 2023, 9014 patients underwent cervical cancer screening. Median age was 37 years (range 30-49) and 4122 women (45.7%) were patients living with HIV. Most (n=8792, 97.5%) chose self-collection. The HPV positivity rate was 31.1% overall and 39.5% among patients living with HIV. Of the 2805 HPV-positive patients, 2588 (92.3%) returned for all steps of their diagnostic work-up and treatment, including ablation (n=2383, 92.1%), loop electrosurgical excision procedure (n=169, 6.5%), and cold knife conization (n=5, 0.2%). Thirty-one patients (1.2%) were diagnosed with cancer and referred to gynecologic oncology. CONCLUSION: It is feasible to perform cervical cancer screening with primary HPV testing and follow-up in low-resource settings. Participants preferred self-collection, and the majority of screen-positive patients completed all steps of their diagnostic work-up and treatment. Our findings provide important information for further implementation and scale-up of cervical cancer screening and treatment services as part of the WHO global strategy for the elimination of cervical cancer.

Self-sampling for human papilloma virus DNA as a strategy to increase access to cervical cancer screening: patients' and providers' perspectives on facilitators and barriers to scale.

Self-sampling represents a high accuracy approach to human papilloma virus DNA (HPV-DNA) testing that allows for privacy and autonomy. As part of a larger study to evaluate cervical cancer screening in Mozambique, we explored user-driven facilitators and barriers to, and provider perspectives on, self-sampling. Our study was conducted in 4 public health facilities in 2 districts in Mozambique. Women aged 30-49 were prospectively enrolled for HPV screening and were offered provider or self-collected sampling. We used enrolment data from 9014 participants to examine characteristics of women choosing self-sampling and conducted in depth interviews with 104 women and 15 providers to understand facilitators and barriers to self-sampling. 97.5% of participants chose self-sampling over provider sampling. Participant-reported barriers included fear about technique, discomfort and inadequate training. Facilitators to self-sampling included increased privacy and having been exposed to a peer who previously self-sampled. Providers expressed concern about their limited role in the screening process with a self-sampling technique. Self-sampling for HPV is an acceptable approach to cervical cancer screening but barriers such as fear of sampling incorrectly and discomfort with their bodies remain.

L'auto-échantillonnage représente une approche de haute précision pour les tests d'ADN du virus du papillome humain (ADN-HPV) qui permet la confidentialité et l'autonomie. Dans le cadre d'une étude plus vaste visant à évaluer le dépistage du cancer du col de l'utérus au Mozambique, nous avons exploré les facilitateurs et les obstacles imposés par les utilisateurs, ainsi que les points de vue des prestataires sur l'auto-échantillonnage. Notre étude a été menée dans 4 établissements de santé publics dans 2 districts du Mozambique. Les femmes âgées de 30 à 49 ans ont été inscrites de manière prospective pour le dépistage du VPH et se sont vu proposer un prélèvement par un prestataire ou un prélèvement auto-collecté. Nous avons utilisé les données d'inscription de 9 014 participantes pour examiner les caractéristiques des femmes choisissant l'auto-échantillonnage et mené des entretiens approfondis avec 104 femmes et 15 prestataires pour comprendre les facilitateurs et les obstacles à l'auto-échantillonnage. 97,5 % des participants ont choisi l'auto-échantillonnage plutôt que l'échantillonnage par un prestataire. Les obstacles signalés par les participants comprenaient la peur concernant la technique, l'inconfort et une formation inadéquate. Les facilitateurs de l'auto-échantillonnage comprenaient une plus grande intimité et le fait d'avoir été exposé à un pair qui avait déjà effectué un auto-échantillonnage. Les prestataires ont exprimé leur inquiétude quant à leur rôle limité dans le processus de dépistage avec une technique d'auto-échantillonnage. L'auto-prélèvement pour le VPH est une approche acceptable pour le dépistage du cancer du col de l'utérus, mais des obstacles tels que la peur d'un prélèvement incorrect et l'inconfort avec leur corps demeurent.

Men who have sex with men in Mozambique: identifying a hidden population at high-risk for HIV.

The population of men who have sex with men (MSM) has been largely ignored in HIV-related policies and programming in Mozambique and there is little information about the contribution of MSM to the HIV epidemic. An integrated biological and behavioral study among MSM using respondent-driven sampling was conducted in 2011 in Maputo, Beira and Nampula/Nacala. Men who reported engaging in oral or anal sex with other men in the last 12 months answered a questionnaire and provided a blood sample for HIV testing. The prevalence of HIV was 8.2 % (Maputo, n = 496), 9.1 % (Beira, n = 584) and 3.1 % (Nampula/Nacala, n = 353). Prevalence was higher among MSM ≥ 25 vs. 18-24 years: 33.8 % vs. 2.4 % (p < 0.001), 32.1 vs. 2.8 % (p < 0.001), and 10.3 vs. 2.7 % (p < 0.06), in each city respectively. The difference in prevalence demonstrates the need to increase prevention for younger MSM at risk for HIV and ensure care and treatment for older HIV-infected MSM.

Determinants of COVID-19 vaccine acceptance in Mozambique: The role of institutional trust.

BACKGROUND: Vaccination plays an imperative role in protecting public health and preventing avoidable mortality. Yet, the reasons for vaccine hesitancy in African countries are not well understood. This study investigates the factors associated with the acceptance of COVID-19 vaccine in Mozambique, with a focus on the role of institutional trust. METHODS: The data came from the three waves of the COVID-19 Knowledge, Attitudes and Practices (KAP) survey which followed a cohort of 1,371 adults in Mozambique over six months (N = 3809). We examined vaccine acceptance based on three measurements: willingness to take vaccine, perceived vaccine efficacy, and perceived vaccine safety. We conducted multilevel regression analysis to investigate the trajectories of, and the association between institutional trust and vaccine acceptance. RESULTS: One third of the survey participants (37%) would definitely take the vaccine. Meanwhile, 31% believed the vaccine would prevent the COVID-19 infection, and 27% believed the vaccine would be safe. There was a significant decrease in COVID-19 vaccine acceptance between waves 1 and 3 of the survey. Institutional trust was consistently and strongly correlated with different measures of vaccine acceptance. There was a greater decline in vaccine acceptance in people with lower institutional trust. The positive correlation between institutional trust and vaccine acceptance was stronger in younger than older adults. Vaccine acceptance also varied by gender and marital status. CONCLUSIONS: Vaccine acceptance can be volatile even over short periods of time. Institutional trust is a central driver of vaccine acceptance and contributes to the resilience of the health system. Our study highlights the importance of health communication and building a trustful relationship between the general public and the institutions in the context of a global pandemic.

Defining Collective Priorities: Research and Learning Agendas for Family Planning Across 6 Countries.

Evidence should be the foundation for a well-designed family planning (FP) program, but existing evidence is rarely aligned with and/or synthesized to speak directly to FP programmatic needs. Based on our experience cocreating FP research and learning agendas (FP RLAs) in Côte d'Ivoire, Malawi, Mozambique, Nepal, Niger, and Uganda, we argue that FP RLAs can drive the production of coordinated research that aligns with national priorities.To cocreate FP RLAs, stakeholders across 6 countries conducted desk reviews of 349 documents and 106 key informant interviews, organized consultation meetings in each country to prioritize evidence gaps and generate research and learning questions, and, ultimately, formed 6 FP RLAs comprising 190 unique questions. We outline the process for consensus-driven development of FP RLAs and communicate the results of an analysis of the questions in each FP RLA across 4 technical areas: self-care, equity, high impact practices, and youth. Each question was categorized as a learning versus research question, the former indicating an opportunity to synthesize existing evidence and the latter to conduct new research to answer the question. Themes emerging from the data shed light on shared evidence gaps across the 6 countries. We argue that similarities and differences in the questions in each FP RLA reflect the unique implementation experience and context, as well as each country's placement on the FP S-curve. Early uses of the FP RLAs include informing the development of FP costed implementation plans and FP2030 commitments. FP RLAs have also been discussed in multiple thematic working groups. For FP stakeholders, these FP RLAs represent a consensus-based agenda that can guide the generation and synthesis of evidence to answer each country's most pressing questions, ultimately driving progress toward increasingly evidence-based programming and policy.

The effects of text reminders on the use of family planning services: evidence from a randomised controlled trial in urban Mozambique.

INTRODUCTION: Reduction of unmet need for contraception is associated with enhanced health outcomes. We conducted a randomised controlled trial in Mozambique analysing the effects of text messages encouraging use of family planning services. METHODS: This trial was conducted within a sample of women served by the Integrated Family Planning Program implemented by Population Services International, in which community health workers provide clinic referrals for family planning services. The evaluation enrolled 5370 women between 20 January and 18 December 2020 who received a referral, reported access to a mobile phone and provided consent. Women were randomly assigned to a treatment group that received a series of text message reminders encouraging them to visit a clinic or to a control arm. An intention-to-treat analysis was conducted to analyse the effect of reminders on the probability of a clinic visit and contraceptive uptake. The final analysis includes 3623 women; 1747 women were lost to follow-up. RESULTS: Women assigned to receive the text reminders are weakly more likely to visit a clinic (risk difference 2.3 percentage points, p=0.081) and to receive a contraceptive method at a clinic (2.2 percentage points, p=0.091), relative to a base rate of 48.0% and 46.9%, respectively. The effect on clinic visits is larger and statistically significant in the prespecified subsample of women enrolled prior to the COVID-19-related state of emergency (3.2 percentage points, p=0.042). CONCLUSION: Evidence from this trial suggests that text message reminders are a promising nudge that increases the probability that women receive contraception. TRIAL REGISTRATION NUMBER: AEARCTR-0005383.

Short-term effects of the COVID-19 state of emergency on contraceptive access and utilization in Mozambique.

The COVID-19 pandemic has increasingly disrupted the global delivery of preventive health care services, as a large number of governments have issued state of emergency orders halting service delivery. However, there is limited evidence on the realized effects of the pandemic and associated emergency orders on access to services in low-income country contexts to date. To address this gap, this paper analyzes administrative data on utilization of contraceptive health services by women referred via community health promoters in two large urban and peri-urban areas of Mozambique. We focus on the period immediately surrounding the national state of emergency declaration linked to the COVID-19 pandemic on March 31, 2020. Data reported for 109,129 women served by 132 unique promoters and 192 unique public health facilities is analyzed using logistic regression, interrupted time series analysis and hazard analysis. The results demonstrate that the imposition of the state of emergency is associated with a modest short-term drop in both service provision and utilization, followed by a relatively rapid rebound. We conclude that in this context, the accessibility of reproductive health services was not dramatically reduced during the first phase of the pandemic-related emergency.

The Mulher Study: cervical cancer screening with primary HPV testing in Mozambique

Objective To evaluate cervical cancer screening with primary human papillomavirus (HPV) testing in Mozambique, a country with one of the highest burdens of cervical cancer globally. Methods Women aged 30­49 years were prospectively enrolled and offered primary HPV testing using either self- collected or provider- collected specimens. Patients who tested positive for HPV underwent visual assessment for treatment using visual inspection with acetic acid to determine eligibility for thermal ablation. If ineligible, they were referred for excision with a loop electrosurgical excision procedure, for cold knife conization, or for cervical biopsy if malignancy was suspected. Results Between January 2020 and January 2023, 9014 patients underwent cervical cancer screening. Median age was 37 years (range 30­49) and 4122 women (45.7%) were patients living with HIV. Most (n=8792, 97.5%) chose self- collection. The HPV positivity rate was 31.1% overall and 39.5% among patients living with HIV. Of the 2805 HPV- positive patients, 2588 (92.3%) returned for all steps of their diagnostic work- up and treatment, including ablation (n=2383, 92.1%), loop electrosurgical excision procedure (n=169, 6.5%), and cold knife conization (n=5, 0.2%). Thirty- one patients (1.2%) were diagnosed with cancer and referred to gynecologic oncology. Conclusion It is feasible to perform cervical cancer screening with primary HPV testing and follow- up in low- resource settings. Participants preferred self- collection, and the majority of screen- positive patients completed all steps of their diagnostic work- up and treatment. Our findings provide important information for further implementation and scale- up of cervical cancer screening and treatment services as part of the WHO global strategy for the elimination of cervical cancer.

The effects of text reminders on the use of family planning services: evidence from a randomised controlled trial in urban Mozambique

Introduction: Reduction of unmet need for contraception is associated with enhanced health outcomes. We conducted a randomised controlled trial in Mozambique analysing the effects of text messages encouraging use of family planning services. Methods: This trial was conducted within a sample of women served by the Integrated Family Planning Program implemented by Population Services International, in which community health workers provide clinic referrals for family planning services. The evaluation enrolled 5370 women between 20 January and 18 December 2020 who received a referral, reported access to a mobile phone and provided consent. Women were randomly assigned to a treatment group that received a series of text message reminders encouraging them to visit a clinic or to a control arm. An intention-to-treat analysis was conducted to analyse the effect of reminders on the probability of a clinic visit and contraceptive uptake. The final analysis includes 3623 women; 1747 women were lost to follow-up. Results: Women assigned to receive the text reminders are weakly more likely to visit a clinic (risk difference 2.3 percentage points, p=0.081) and to receive a contraceptive method at a clinic (2.2 percentage points, p=0.091), relative to a base rate of 48.0% and 46.9%, respectively. The effect on clinic visits is larger and statistically significant in the prespecified subsample of women enrolled prior to the COVID-19-related state of emergency (3.2 percentage points, p=0.042). Conclusion: Evidence from this trial suggests that text message reminders are a promising nudge that increases the probability that women receive contraception.

Short-term effects of the COVID-19 state of emergency on contraceptive access and utilization in Mozambique

The COVID-19 pandemic has increasingly disrupted the global delivery of preventive health care services, as a large number of governments have issued state of emergency orders halting service delivery. However, there is limited evidence on the realized effects of the pandemic and associated emergency orders on access to services in low-income country contexts to date. To address this gap, this paper analyzes administrative data on utilization of contraceptive health services by women referred via community health promoters in two large urban and peri-urban areas of Mozambique. We focus on the period immediately surrounding the national state of emergency declaration linked to the COVID-19 pandemic on March 31, 2020. Data reported for 109,129 women served by 132 unique promoters and 192 unique public health facilities is analyzed using logistic regression, interrupted time series analysis and hazard analysis. The results demonstrate that the imposition of the state of emergency is associated with a modest short-term drop in both service provision and utilization, followed by a relatively rapid rebound. We conclude that in this context, the accessibility of reproductive health services was not dramatically reduced during the first phase of the pandemic-related emergency

Men who have sex with men in Mozambique: identifying a hidden population at high-risk for HIV

The population of men who have sex with men (MSM) has been largely ignored in HIV-related policies and programming in Mozambique and there is little information about the contribution of MSM to the HIV epidemic. An integrated biological and behavioral study among MSM using respondent-driven sampling was conducted in 2011 in Maputo, Beira and Nampula/Nacala. Men who reported engaging in oral or anal sex with other men in the last 12 months answered a questionnaire and provided a blood sample for HIV testing. The prevalence of HIV was 8.2 % (Maputo, n = 496), 9.1 % (Beira, n = 584) and 3.1 % (Nampula/Nacala, n = 353). Prevalence was higher among MSM ≥ 25 vs. 18-24 years: 33.8 % vs. 2.4 % (p < 0.001), 32.1 vs. 2.8 % (p < 0.001), and 10.3 vs. 2.7 % (p < 0.06), in each city respectively. The difference in prevalence demonstrates the need to increase prevention for younger MSM at risk for HIV and ensure care and treatment for older HIV-infected MSM.