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Seroprevalence and Determinants of Human Immunodeficiency Virus Infection Among Women of Reproductive Age in Mozambique: A Multilevel Analysis. Infect Dis Ther 2020; 9:881-900. [PMID: 32910429 PMCID: PMC7680491 DOI: 10.1007/s40121-020-00336-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Indexed: 11/21/2022] Open
Abstract
Background Human immunodeficiency virus (HIV) has continued to be one of the foremost public health problems globally. Even as more people living with the disease can now have access to antiretroviral therapy (ART), there are still some regions in the world with high transmission rates. The objective of this study was to examine the prevalence and individual-, household- and community-level factors associated with HIV infection among women of reproductive age in Mozambique. Methods We used nationally representative cross-sectional data from the 2015 Survey of Indicators on Immunization, Malaria and HIV or Acquired Immunodeficiency Syndrome (AIDS) in Mozambique. A sample of 4726 women of reproductive age was included in this study. Prevalence was measured in percentage and the factors for HIV infection were examined using a multivariable multilevel logistic regression model. The level of significance was set at P < 0.05. Results The seroprevalence of HIV among women in Mozambique was 10.3% (95% CI 9.2%, 11.6%). Furthermore, women who had two, three and four or more total lifetime number of sex partners were 2.73, 5.61 and 3.95 times as likely to have HIV infection when compared with women with only one lifetime sex partners, respectively. In addition, women of Islam religion had 60% reduction in HIV infection when compared with Christian women (adjusted odds ratio, AOR = 0.40; 95% CI 0.16, 0.99). The individual-level model (model B) had the best model fitness with the lowest Akaike information criterion (AIC) = 500.87 and Bayesian information criterion (BIC) = 648.88. The variations in the odds of HIV infection across communities (σ2 = 9.61 × 10–8; SE = 0.55) and households (σ2 = 1.02 × 10–4; SE = 1.02) were estimated. Results from the median odds ratio (MOR = 1.00) did not show any evidence of community and household contextual factors shaping HIV infection. MOR equal to unity (1) indicated that there were no community or household variances given the ICC of 0.0%. At both community and household levels, the explained variances were each 100%. This implied total variances in HIV infection has been explained by the individual-level factors. Conclusion In this study, we found that having multiple total lifetime number of sexual partners and religion were predisposing factors for HIV infection at individual woman level. Female headship and wealth quintiles were associated with HIV infection at household level. Community illiteracy, intimate partner violence, poverty and geographical region were associated with HIV infection at community level. Therefore, multifaceted health intervention by stakeholders in the healthcare system will be useful in addressing the multilevel predisposing factors of HIV infection among Mozambican women.
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Macicame I, Bhatt N, Matavele Chissumba R, Eller LA, Viegas E, Araújo K, Nwoga C, Li Q, Milazzo M, Hills NK, Lindan C, Michael NL, Robb ML, Jani I, Polyak CS. HIV prevalence and risk behavior among male and female adults screened for enrolment into a vaccine preparedness study in Maputo, Mozambique. PLoS One 2019; 14:e0221682. [PMID: 31527868 PMCID: PMC6748437 DOI: 10.1371/journal.pone.0221682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 08/13/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Mozambique continues to have a significant burden of HIV. Developing strategies to control the HIV epidemic remains a key priority for the Mozambican public health community. The primary aim of this study was to determine HIV prevalence and risk behavior among males and females screened for a HIV vaccine preparedness study in Maputo, Mozambique. METHODS Male and female participants between 18-35 years old were recruited from the general community and from female sex worker (FSW) and lesbian, gay, bisexual, and transgender (LGBT) associations in Maputo. All participants were screened for HIV and a questionnaire was administered to each participant to assess HIV risk behavior. RESULTS A total of 1125 adults were screened for HIV infection, among whom 506 (45%) were male. Among men, 5.7% reported having had sex with men (MSM) and 12% of female participants reported having exchanged sex for money, goods or favors in the past 3 months. The overall HIV prevalence was 10.4%; 10.7% of women, and 10.1% of men were HIV infected; 41.4% of MSM were seropositive. HIV infection was associated with older age (25-35 years old) (OR: 6.13, 95% CI: 3.01, 12.5), MSM (OR: 9.07, 95% CI: 3.85, 21.4), self-perception of being at high-risk for HIV (OR: 3.99, 95% CI: 1.27, 12.5) and self-report of a history of a diagnosis of sexually transmitted infection (OR: 3.75, 95% CI: 1.57, 8.98). CONCLUSION In our cohort, HIV prevalence was much higher among MSM compared to the overall prevalence. Behavioral factors were found to be more associated with HIV prevalence than demographic factors. The study findings demonstrate the critical importance of directing services to minority communities, such as MSM, when prevention strategies are being devised for the general population.
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Affiliation(s)
- Ivalda Macicame
- Instituto Nacional de Saúde, Ministério da Saúde, Mozambique
| | - Nilesh Bhatt
- Instituto Nacional de Saúde, Ministério da Saúde, Mozambique
| | | | - Leigh Anne Eller
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
| | - Edna Viegas
- Instituto Nacional de Saúde, Ministério da Saúde, Mozambique
| | - Khelvon Araújo
- Instituto Nacional de Saúde, Ministério da Saúde, Mozambique
| | - Chiaka Nwoga
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
| | - Qun Li
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
| | - Mark Milazzo
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
| | - Nancy K. Hills
- University of California San Francisco, San Francisco, California, United States of America
| | - Christina Lindan
- University of California San Francisco, San Francisco, California, United States of America
| | - Nelson L. Michael
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
| | - Merlin L. Robb
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
| | - Ilesh Jani
- Instituto Nacional de Saúde, Ministério da Saúde, Mozambique
| | - Christina S. Polyak
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
- * E-mail:
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Dias SS, Mbofana F, Cassy SR, Dias S, Augusto GF, Agadjanian V, Martins MRO. Estimating risk factors for HIV infection among women in Mozambique using population-based survey data. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2018; 17:62-71. [PMID: 29504505 DOI: 10.2989/16085906.2017.1405824] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The use of population-based survey data together with sound statistical methods can enhance better estimation of HIV risk factors and explain variations across subgroups of the population. The distribution and determinants of HIV infection in populations must be taken into consideration. We analysed data from the HIV Prevalence and Behaviour Survey in Mozambique aiming to find risk factors associated with HIV infection among Mozambican women. The paper provides a complex survey logistic regression model to explain the variation in HIV seropositivity using demographic, socio-economic and behavioural factors. Results show that women aged 25-29 years, living in female-headed households, living in richer households and those widowed, divorced or not living with a partner have higher odds of being HIV-positive. Findings from our study provide a unique and integrated perspective on risk factors for being HIV-positive among Mozambican women and could support the implementation of programmes aiming to reduce HIV infection in Mozambique.
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Affiliation(s)
- Sara S Dias
- a EpiDoC Unit, Centro de Estudos de Doenças Crónicas da NOVA Medical School , Universidade Nova de Lisboa , Lisboa , Portugal.,f Unidade de Investigação em Saúde, Escola Superior de Saúde de Leiria , Instituto Politécnico de Leiria , Leiria , Portugal
| | | | - Sheyla R Cassy
- c Departamento de Matemática e Informática, Faculdade de Ciências , Universidade Eduardo Mondlane , Maputo , Mozambique.,g Departamento de Matemática, Faculdade de Ciências e Tecnologia , Universidade Nova de Lisboa , Caparica , Portugal
| | - Sónia Dias
- d Instituto de Higiene e Medicina Tropical , Universidade Nova de Lisboa , Lisbon , Portugal
| | - Gonçalo F Augusto
- d Instituto de Higiene e Medicina Tropical , Universidade Nova de Lisboa , Lisbon , Portugal
| | - Victor Agadjanian
- e Center of Population Dynamics , Arizona State University , Tempe , USA
| | - Maria R O Martins
- d Instituto de Higiene e Medicina Tropical , Universidade Nova de Lisboa , Lisbon , Portugal
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Brunini SM, Barros CVDL, Guimarães RA, Galdino Júnior H, Rezza G, Santos JR, da Cunha VE, Sousa JM, Ferreira PM, Barros DAC. HIV infection, high-risk behaviors and substance use in homeless men sheltered in therapeutic communities in Central Brazil. Int J STD AIDS 2018; 29:1084-1088. [PMID: 29862902 DOI: 10.1177/0956462418767188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Homeless men present high vulnerability to HIV infection, mainly due to sexual risk behaviors and substance use. The objective was to estimate the prevalence of HIV infection, risk behaviors and substance use in homeless men. A cross-sectional study was conducted in 481 homeless men recruited in four therapeutic communities in the Goiás State, Central Brazil. All were interviewed about sociodemographic characteristics, substance use, and risk behaviors. Furthermore, all were tested for HIV. Poisson regression was used to verify factors associated with HIV infection. HIV prevalence was 1.24% (95.0% CI: 0.57 to 2.69%). Previous HIV testing (adjusted prevalence ratio [APR]: 10.0; 95.0% CI: 1.86-55.8) and years of education (APR: 0.76; 95.0% CI: 0.60-0.97) were factors associated with HIV infection. Participants had high rates of hazardous alcohol use and illicit drug use. The prevalence of HIV infection among homeless men was higher than that found in the Brazilian male population and we identified a high rate of risk behaviors for HIV among the homeless men investigated. Thus, it is necessary to expand HIV prevention measures in Brazil, such as health education, condom availability, regular HIV testing and increased testing coverage in this population, and treatment for alcohol and/or illicit drug dependence/abuse.
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Affiliation(s)
- Sandra M Brunini
- 1 Faculty of Nursing, Federal University of Goiás, Goiânia, Goiás, Brazil
| | | | - Rafael Alves Guimarães
- 2 Institute of Tropical Pathology and Public Health, Federal University of Goiás, Goiânia, Goiás, Brazil
| | | | | | - Jordana Rs Santos
- 1 Faculty of Nursing, Federal University of Goiás, Goiânia, Goiás, Brazil
| | - Vanessa E da Cunha
- 1 Faculty of Nursing, Federal University of Goiás, Goiânia, Goiás, Brazil
| | - Johnatan M Sousa
- 1 Faculty of Nursing, Federal University of Goiás, Goiânia, Goiás, Brazil
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High HIV prevalence and incidence among women in Southern Mozambique: Evidence from the MDP microbicide feasibility study. PLoS One 2017; 12:e0173243. [PMID: 28350843 PMCID: PMC5369694 DOI: 10.1371/journal.pone.0173243] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 02/18/2017] [Indexed: 11/23/2022] Open
Abstract
Background The study aimed to assess the feasibility of conducting large scale HIV prevention clinical trials in Mozambique by measuring HIV prevalence and incidence among women of reproductive age. This paper describes the baseline socio-demographic characteristics of the Mozambique Microbicides Development Programme (MDP) feasibility cohort, baseline prevalence of HIV and other STIs, and HIV incidence. Methods The Mozambique MDP feasibility study was conducted from September 2007 to August 2009 in urban Mavalane and rural Manhiça, in Southern Mozambique. Sexually active, HIV negative women aged 18 years and above were recruited to attend the study clinic every 4 weeks for a total of 40 weeks. At baseline, we collected demographic and sexual behaviour data, samples to test for sexually transmitted infections (STI) and conducted HIV rapid testing. STI and HIV testing were repeated at clinical follow-up visits. We describe HIV prevalence of women at screening, the demographic, behavioural and clinical characteristics of women at enrolment, and HIV incidence during follow-up. Results We screened 793 women (369 at Mavalane and 424 at Manhiça) and enrolled 505 eligible women (254 at Mavalane and 251 at Manhiça). Overall HIV prevalence at screening was 17%; 10% at Mavalane and 22% at Manhiça. Women screened at Manhiça were twice as likely as women screened at Mavalane to be HIV positive and HIV positive status was associated with younger age (18–34), lower educational level, not using a reliable method of contraception and being Zionist compared to other Christian religions. At enrolment contraceptive use was low in both clinics at 19% in Mavalane and 21% in Manhiça, as was reported condom use at last sex act at 48% in Mavalane and 25% in Manhiça. At enrolment, 8% of women tested positive for Trichomonas vaginalis, 2% for Neisseria gonorrhoeae, 4% for Chlamydia trachomatis and 46% for bacterial vaginosis. In Manhiça, 8% of women had active syphilis at screening. HIV incidence was 4.3 per 100 person years at Mavalane and 9.2 per 100 person years at Manhiça. Conclusions We demonstrated the ability to recruit a cohort of women at risk of HIV who were willing to participate in clinical research. The high HIV incidence necessitates additional action around HIV prevention for women and offers opportunities to evaluate the impact of available prevention options, such as treatment as prevention and oral PrEP. The high HIV incidence and STI prevalence also offers opportunities to evaluate the added benefit of potential prevention options such as new formulations of oral PrEP, vaginal microbicides (also called topical PrEP), vaccines, and multi-purpose technologies for HIV, STIs and contraception.
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Hønge BL, Jespersen S, Aunsborg J, Mendes DV, Medina C, da Silva Té D, Laursen AL, Erikstrup C, Wejse C. High prevalence and excess mortality of late presenters among HIV-1, HIV-2 and HIV-1/2 dually infected patients in Guinea-Bissau - a cohort study from West Africa. Pan Afr Med J 2016; 25:40. [PMID: 28154729 PMCID: PMC5268749 DOI: 10.11604/pamj.2016.25.40.8329] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 06/06/2016] [Indexed: 01/13/2023] Open
Abstract
Introduction HIV infected individuals with late presentation (LP) and advanced disease (AD) have been associated with higher mortality, higher cost of medical management, impaired CD4 cell count increment and potentially ongoing risk of HIV transmission. Here we describe the proportion of patients with LP and AD at an HIV clinic in Guinea-Bissau, identify risk factors and evaluate the outcome of these patients. Methods We included all patients >15 years diagnosed with HIV-1 and/or HIV-2 at the outpatient HIV clinic at Hospital National Simão Mendes, during June 2005 - December 2013 in a retrospective cohort study. Patients were followed until December 2014. LP and AD was defined as a baseline CD4 cell count of 200-349 cells/µL and <200 cells/µL, respectively. Results A total of 3,720/5,562 (65.7%) patients had a CD4 cell count measured within the first 90 days of HIV diagnosis. Forty-eight percent had AD and 23% had LP. Risk factors for presentation with AD were male sex, age >30 years, Fula and Mandinga ethnicity. HIV-2 and HIV-1/2 dually infected patients had lower risk of AD compared with HIV-1 infected patients. Although antiretroviral therapy (ART) was initiated for 64.4% of patients, those with AD progression had a 3.82 times higher mortality compared to patients with non-LP. Conclusion The majority of HIV infected patients presented late. Most of the late-presenters had advanced disease and patients with advanced disease had a very high mortality. Initiatives to enroll patients in care at an earlier point are needed and should focus on risk groups.
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Affiliation(s)
- Bo Langhoff Hønge
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau; Department of Infectious Diseases, Aarhus University Hospital, Denmark; Department of Clinical Immunology, Aarhus University Hospital, Denmark
| | - Sanne Jespersen
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau; Department of Infectious Diseases, Aarhus University Hospital, Denmark
| | - Johanna Aunsborg
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau; Department of Infectious Diseases, Aarhus University Hospital, Denmark
| | | | - Candida Medina
- National HIV Programme, Ministry of Health, Bissau, Guinea-Bissau
| | | | - Alex Lund Laursen
- Department of Infectious Diseases, Aarhus University Hospital, Denmark
| | | | - Christian Wejse
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau; Department of Infectious Diseases, Aarhus University Hospital, Denmark; GloHAU, Center for Global Health, School of Public Health, Aarhus University, Denmark
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Assen A, Molla F, Wondimu A, Abrha S, Melkam W, Tadesse E, Yilma Z, Eticha T, Abrha H, Workneh BD. Late presentation for diagnosis of HIV infection among HIV positive patients in South Tigray Zone, Ethiopia. BMC Public Health 2016; 16:558. [PMID: 27405542 PMCID: PMC4942918 DOI: 10.1186/s12889-016-3263-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 07/05/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In spite of the availability and accessibility of HIV testing opportunities and efforts, people are being late to test in the course of HIV infection. Late diagnosis leads to late anti-retroviral therapy initiation which in turn results in poor treatment outcome and prognosis of the disease. The aim of this study was to determine the prevalence and predictors of late HIV diagnosis among HIV-infected patients in South Tigray Zone, Ethiopia. METHODS A facility based cross sectional study was conducted among HIV positive patients from February 1-30, 2014 in Southern Tigray, Ethiopia. Multistage sampling technique was employed to select the study participants. Data were collected by reviewing patient medical card and interviewing using structured questionnaire. Data were entered using Epi-Data version 3.1 and analyzed using SPSS version 20.0. Both bivariate and multivariate logistic regressions were modeled to evaluate the association of predictors with late diagnosis of HIV infection. RESULTS Out of 789 study participants, 68.8 % of them were late for HIV diagnosis. Feeling healthy (65.7 %), fear of stigma and discrimination (32.4 %) and using traditional treatment (1.5 %) were reported as the main reasons for late HIV diagnosis. Use of Khat [AOR = 3.27, 95 % CI (1.75, 6.13)], bed ridden functional status [AOR = 2.66, 95 % CI (1.60, 4.42)], ambulatory functional status [AOR = 1.56, 95 % CI (1.03, 2.35)] and Muslim religion [AOR = 2.26, 95 % CI (1.13, 4.49)] were significantly associated with late presentation for HIV diagnosis. CONCLUSIONS High prevalence of late HIV diagnosis was recorded in Southern Tigray Zone, Ethiopia. Public health educations and campaigns targeted at improving early diagnosis and prognosis of people living with HIV/AIDS in Southern Tigray, Northern Ethiopia should be underway.
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Affiliation(s)
- Admassu Assen
- Department of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Fantahun Molla
- Department of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Abrham Wondimu
- Department of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Solomon Abrha
- Department of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Wondim Melkam
- Department of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia.
| | - Ebisa Tadesse
- Department of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Zewdu Yilma
- Department of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Tadele Eticha
- Department of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Hagos Abrha
- Department of Internal Medicine, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Birhanu Demeke Workneh
- Department of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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Factors associated with initiation of antiretroviral therapy in the advanced stages of HIV infection in six Ethiopian HIV clinics, 2012 to 2013. J Int AIDS Soc 2016; 19:20637. [PMID: 27113335 PMCID: PMC4845592 DOI: 10.7448/ias.19.1.20637] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 01/29/2016] [Accepted: 03/15/2016] [Indexed: 12/30/2022] Open
Abstract
Introduction Most HIV-positive persons in sub-Saharan Africa initiate antiretroviral therapy (ART) with advanced infection (late ART initiation). Intervening on the drivers of late ART initiation is a critical step towards achieving the full potential of HIV treatment scale-up. This study aimed to identify modifiable factors associated with late ART initiation in Ethiopia. Methods From 2012 to 2013, Ethiopian adults (n=1180) were interviewed within two weeks of ART initiation. Interview data were merged with HIV care histories to assess correlates of late ART initiation (CD4+ count <150 cells/µL or World Health Organization Stage IV). Results The median CD4 count at enrolment in HIV care was 263 cells/µL (interquartile range (IQR): 140 to 390) and 212 cells/µL (IQR: 119 to 288) at ART initiation. Overall, 31.2% of participants initiated ART late, of whom 85.1% already had advanced HIV disease at enrolment. Factors associated with higher odds of late ART initiation included male sex (vs. non-pregnant females; adjusted odds ratio (aOR): 2.02; 95% CI: 1.50 to 2.73), high levels of psychological distress (vs. low/none, aOR: 1.96; 95% CI: 1.34 to 2.87), perceived communication barriers with providers (aOR: 2.42, 95% CI: 1.24 to 4.75), diagnosis via provider initiated testing (vs. voluntary counselling and testing, aOR: 1.47, 95% CI: 1.07 to 2.04), tuberculosis (TB) treatment prior to ART initiation (aOR: 2.16, 95% CI: 1.43 to 3.25) and a gap in care of six months or more prior to ART initiation (aOR: 2.02, 95% CI: 1.10 to 3.72). Testing because of partner illness/death (aOR: 0.64, 95% CI: 0.42 to 0.95) was associated with lower odds of late ART initiation. Conclusions Programmatic initiatives promoting earlier diagnosis, engagement in pre-ART care, and integration of TB and HIV treatments may facilitate earlier ART initiation. Men and those experiencing psychological distress may also benefit from targeted support prior to ART initiation.
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Meque I, Dubé K, Bierhuizen L, Zango A, Veldhuijzen N, Cumbe F, Feldblum PJ, van de Wijgert J. Willingness to participate in future HIV prevention trials in Beira, Mozambique. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2015; 13:393-8. [PMID: 25555105 DOI: 10.2989/16085906.2014.985239] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In preparation for trials of new HIV prevention methods, willingness to participate (WTP) was assessed in Beira, Mozambique. A total of 1 019 women participating in an HIV incidence study, and 97 men participating in a separate WTP survey, were interviewed. When comparing the answers to questions that were identical in the two studies, WTP was higher among women than men for all prevention methods. Among women, WTP was highest for trials evaluating daily oral pre-exposure prophylaxis (PrEP; 84.4% reporting very likely to participate), followed by vaccination (77.8%), daily vaginal gel use (67.7%), coital vaginal gel use (67.1%) and monthly vaginal ring use (47.7%). Among men, WTP was highest for trials evaluating vaccination (57.6%), followed by daily vaginal gel use for female sexual partners (52.5%), daily oral PrEP (49.5%), coital vaginal gel use for female sexual partners (46.4%) and monthly vaginal ring use for female sexual partners (39.4%). Among men, the most important motivators for trial participation were social benefits, whereas personal risks (most notably receiving injections and/or blood draws) were deterrents; this was not assessed in women. Other important lessons learnt are that male circumcision and antiretroviral drugs were not generally recognised as ways to prevent HIV, that having to use hormonal contraception during trial participation will likely reduce WTP, and that evening clinics are not likely to be popular. The barriers reported in this and other studies may be challenging but are not impossible to overcome.
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Affiliation(s)
- Ivete Meque
- a Universidade Católica de Moçambique/Catholic University of Mozambique (UCM), Centro de Investigação de Doenças Infecciosas/Research Center for Infectious Diseases (CIDI) , Beira , Mozambique
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González R, Augusto OJ, Munguambe K, Pierrat C, Pedro EN, Sacoor C, De Lazzari E, Aponte JJ, Macete E, Alonso PL, Menendez C, Naniche D. HIV Incidence and Spatial Clustering in a Rural Area of Southern Mozambique. PLoS One 2015; 10:e0132053. [PMID: 26147473 PMCID: PMC4493140 DOI: 10.1371/journal.pone.0132053] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 06/09/2015] [Indexed: 12/03/2022] Open
Abstract
Background Monitoring the HIV epidemic in a defined population is critical for planning treatment and preventive strategies. This is especially important in sub-Saharan Africa, which harbours the highest burden of the disease. Objective To estimate HIV incidence in adults aged 18-47 years old and to investigate spatial variations of HIV prevalence in Manhiça, a semi-rural area of southern Mozambique. Methods Two cross-sectional community-based surveys were conducted in 2010 and 2012 to determine HIV prevalence. Individual participants were randomly selected from the demographic surveillance system in place in the area and voluntary HIV counselling and testing was offered at the household level. HIV incidence was calculated using prevalence estimates from the two sero-surveys. Each participant’s household was geocoded using a global information system. The Spatial Scan Statistics programme was used to identify areas with disproportionate excess in HIV prevalence. Results A total of 1511 adults were tested. The estimated HIV prevalence in the community was 39.9% in 2010 and 39.7% in 2012. The overall HIV incidence was 3.6 new infections per 100 person-years at risk (PYAR) [95CI 1.56; 7.88], assuming stable epidemic conditions, and tended to be higher in women (4.9/100 PYAR [95CI 1.74; 11.85]) than in men (3.2/PYAR [95CI 1.36; 9.92]). One cluster with significant excess HIV prevalence was identified at the same geographic location in both surveys. This cluster had an HIV prevalence of 79.0% in 2010 and 52.3% in 2012. Conclusions The findings of these first individually-randomised community-HIV sero-surveys conducted in Mozambique reinforce the need to combine HIV incidence estimates and research on micro geographical infection patterns to guide and consolidate effective prevention strategies.
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Affiliation(s)
- Raquel González
- ISGlobal, Barcelona Ctr. Int. Heath Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique
- * E-mail:
| | | | - Khátia Munguambe
- Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique
| | - Charlotte Pierrat
- ISGlobal, Barcelona Ctr. Int. Heath Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
| | - Elpidia N. Pedro
- Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique
| | - Charfudin Sacoor
- Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique
| | - Elisa De Lazzari
- ISGlobal, Barcelona Ctr. Int. Heath Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
| | - John J. Aponte
- ISGlobal, Barcelona Ctr. Int. Heath Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique
| | - Eusébio Macete
- Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique
- Direcção Nacional de Saúde (DNS), Ministério da Saúde, Maputo, Mozambique
| | - Pedro L. Alonso
- ISGlobal, Barcelona Ctr. Int. Heath Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique
- World Health Organization (WHO), Geneva, Switzerland
| | - Clara Menendez
- ISGlobal, Barcelona Ctr. Int. Heath Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique
| | - Denise Naniche
- ISGlobal, Barcelona Ctr. Int. Heath Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique
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11
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Kumakech E, Andersson S, Wabinga H, Berggren V. Integration of HIV and cervical cancer screening perceptions and preferences of communities in Uganda. BMC WOMENS HEALTH 2015; 15:23. [PMID: 25783655 PMCID: PMC4359479 DOI: 10.1186/s12905-015-0183-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 02/24/2015] [Indexed: 11/16/2022]
Abstract
Background Despite the fact that HIV-positive women carry an increased risk of developing cervical cancer (CC) in comparison with HIV-negative women, HIV and CC screening programs in many developing countries have remained unintegrated. The objective of this study is to explore perceptions and preferences of community members in Uganda, including women, men, and village health teams, regarding the integration of HIV and CC screening services in a single-visit approach. Methods This qualitative study was conducted in three districts in Uganda. Data were collected through focus group discussions with women and village health teams, and individual interviews with men. Respondents were purposely selected from among those linked to three CC clinics in the three districts. The content analysis method was used to analyze the data. Results Three themes emerged from the data, namely appreciating the benefits of integration, worrying about the challenges of integration, and preferences for integration. The women endorsed the benefits. However, there were worries that integration would prolong the waiting time at the health facility and induce tiredness in both the healthcare providers and the women. There were also fears of being found positive for both HIV and CC and the consequences such as stress, self-isolation, and social conflicts. Participants, particularly the women, considered the challenges of screening integration to be manageable by, for example, taking a day off work to visit the hospital, delegating house chores to other family members, or taking a packed lunch on visiting the hospital. Conclusions The community members in Uganda perceive the benefits of HIV and CC screening integration to outweigh the challenges, and expect that the challenges can be minimized or managed by the women. Therefore, when considering HIV and CC screening integration, it is important to not only recognize the benefits but also take into consideration the perceived challenges and preferences of community members.
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Affiliation(s)
- Edward Kumakech
- School of Health and Medical Sciences, Örebro University, 701 82, Örebro, Sweden,
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12
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Programa Geração Biz, Mozambique: how did this adolescent health initiative grow from a pilot to a national programme, and what did it achieve? Reprod Health 2015; 12:12. [PMID: 25971669 PMCID: PMC4429477 DOI: 10.1186/1742-4755-12-12] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 01/15/2015] [Indexed: 12/02/2022] Open
Abstract
Adolescent sexual and reproductive health gained particular traction in Mozambique following the 1994 International Conference on Population and Development leading to the inception of Programa Geração Biz (PGB), a multi-sectoral initiative that was piloted starting in 1999 and fully scaled-up to all provinces by 2007. We conducted a systematic review of the literature to gather information on PGB and analyzed how it planned and managed the scale-up effort using the WHO-ExpandNet framework. PGB’s activities comprised a clear and credible innovation. Appropriate resource and user organizations further facilitated national scale-up. Challenges relating to the complex nature of the multi-sectoral approach and resistance due to norms about adolescent sexual and reproductive health hindered scaling-up in some geographic areas. The national government exhibited commitment and ownership to PGB through budgetary support and integration into multiple policies. This study adds to the documentation of successful scaling-up strategies that can provide guidance for policy makers and programme managers.
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Kumakech E, Andersson S, Wabinga H, Berggren V. Integration of HIV and cervical cancer screening perceptions of healthcare providers and policy makers in Uganda. BMC Public Health 2014; 14:810. [PMID: 25099996 PMCID: PMC4246470 DOI: 10.1186/1471-2458-14-810] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 07/10/2014] [Indexed: 11/10/2022] Open
Abstract
Background HIV-positive women have an increased risk of developing cervical cancer (CC) compared to the HIV-negative women. Despite this, HIV and CC screening programs in many developing countries have remained disintegrated. Therefore, the objective of the study was to explore perceptions of healthcare providers (HCP) and policy makers (PM) about integration of HIV and CC screening services in Uganda. Methods This was a qualitative study conducted among 16 participants comprising of 12 healthcare providers and 4 policy makers in Uganda. Data were collected through individual interviews. Participants were purposively selected from different level of health facilities with clinics for HIV and CC screening services. Content analysis method was used to analyze the data. Results Three themes emerged from the data, namely appreciating benefits of integration, worrying about the limited health system capacity and potential consequences of integration and feeling optimistic about integration under improved health system conditions. The benefits embraced the women – particularly the HIV-positive women- but also men, healthcare providers and the health system or the government. There were worries that HIV stigma and shortage of healthcare workers would affect the effective delivery of the integrated program. Conclusion Integration of HIV and CC screening can offer manifold benefits to all stakeholders in the health system, more so to the women. However, its feasibility in developing countries such as Uganda will most likely be hampered by weak and inefficient health systems. Therefore, when considering HIV and CC screening integration, it is important not to only recognize the benefits but also take into account resources requirements for addressing the existing weaknesses and inefficiencies in the health systems such as limited infrastructure, insufficient drugs and supplies, inadequate and poorly motivated healthcare workers.
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Affiliation(s)
- Edward Kumakech
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
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Feldblum PJ, Enosse S, Dubé K, Arnaldo P, Muluana C, Banze R, Nhanala A, Cunaca J, Chen PL, Robb ML, Thompson R. HIV prevalence and incidence in a cohort of women at higher risk for HIV acquisition in Chókwè, southern Mozambique. PLoS One 2014; 9:e97547. [PMID: 24842811 PMCID: PMC4026130 DOI: 10.1371/journal.pone.0097547] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 04/18/2014] [Indexed: 11/21/2022] Open
Abstract
Background Reliable HIV incidence estimates for Mozambique are limited. We conducted a prospective HIV incidence study as part of a clinical research site development initiative in Chókwè district, Gaza Province, southern Mozambique. Methods Between June 2010 and October 2012, we recruited women at sites where women at higher risk of HIV infection would likely be found. We enrolled and tested 1,429 sexually active women in the screening phase and 479 uninfected women in the prospective phase. Participants were scheduled for 12+ months follow-up, when they underwent face-to-face interviews, HIV counseling and testing, and pregnancy testing. We observed a total of 373.1 woman-years (WY) of follow-up, with mean (median) of 9.4 (9.7) women-months per participant. Results The prevalence of HIV was 29.4% (95% confidence interval [CI]: 27.0–31.8%). In multivariable logistic regression analysis, factors that remained significantly associated with prevalent HIV were: older age (OR: 0.6; 95% CI: 0.4–0.7), lower educational level (OR: 0.4; 95% CI: 0.3–0.7), and using hormonal contraception (OR: 0.6; 95% CI: 0.4–0.7) or condoms (OR: 0.5; 95% CI: 0.3–0.7). We observed an HIV incidence rate of 4.6 per 100 WY (95% CI: 2.7, 7.3). The HIV incidence was 4.8 per 100 WY (95% CI: 2.5, 8.3) in women aged 18–24 years, 4.5 per 100 WY (95% CI: 1.2, 11.4) in women aged 25–29 years and 3.2 per 100 WY (95% CI: 0.1, 18.0) in the 30–35 years stratum. None of the demographic factors or time-varying behavioral factors examined was significantly associated with incident HIV infection in bivariable analysis at p≤0.10. Conclusions We found a high HIV incidence among sexually active young women in Chókwè, Mozambique. HIV prevention programs should be strengthened in the area, with more comprehensive reproductive health services, regular HIV testing, condom promotion, and messaging about multiple sexual partners.
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Affiliation(s)
- Paul J. Feldblum
- FHI 360, Durham, North Carolina, United States of America
- * E-mail:
| | - Sónia Enosse
- Chókwè Health Research and Training Center/Centro de Investigação e Treino em Saúde de Chókwè (CITSC), National Institute of Health, Mozambique
| | - Karine Dubé
- Institute for Global Health and Infectious Diseases (IGHID), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Paulo Arnaldo
- Chókwè Health Research and Training Center/Centro de Investigação e Treino em Saúde de Chókwè (CITSC), National Institute of Health, Mozambique
| | - Chadreque Muluana
- Chókwè Health Research and Training Center/Centro de Investigação e Treino em Saúde de Chókwè (CITSC), National Institute of Health, Mozambique
| | - Reginaldo Banze
- Chókwè Health Research and Training Center/Centro de Investigação e Treino em Saúde de Chókwè (CITSC), National Institute of Health, Mozambique
| | - Aristides Nhanala
- Chókwè Health Research and Training Center/Centro de Investigação e Treino em Saúde de Chókwè (CITSC), National Institute of Health, Mozambique
| | - Joana Cunaca
- Chókwè Health Research and Training Center/Centro de Investigação e Treino em Saúde de Chókwè (CITSC), National Institute of Health, Mozambique
| | - Pai-Lien Chen
- FHI 360, Durham, North Carolina, United States of America
| | - Merlin L. Robb
- United States Military HIV Research Program (MHRP), Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF), Bethesda, Maryland, United States of America
| | - Ricardo Thompson
- Chókwè Health Research and Training Center/Centro de Investigação e Treino em Saúde de Chókwè (CITSC), National Institute of Health, Mozambique
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Meque I, Dubé K, Feldblum PJ, Clements ACA, Zango A, Cumbe F, Chen PL, Ferro JJ, van de Wijgert JH. Prevalence, incidence and determinants of herpes simplex virus type 2 infection among HIV-seronegative women at high-risk of HIV infection: a prospective study in Beira, Mozambique. PLoS One 2014; 9:e89705. [PMID: 24586973 PMCID: PMC3933639 DOI: 10.1371/journal.pone.0089705] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/22/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To estimate the prevalence, incidence and determinants of herpes simplex type 2 (HSV-2) infection, and associations between HSV-2 and incident HIV infection, among women at higher risk for HIV infection in Beira, Mozambique. METHODS Between 2009 and 2012, 411 women aged 18-35 years at higher risk of HIV acquisition (defined as having had two or more sexual partners in the month prior to study enrollment) were enrolled and followed monthly for one year. At each study visit, they were counseled, interviewed, and tested for HSV-2 and HIV antibodies. RESULTS The HSV-2 prevalence at baseline was 60.6% (95% CI: 55.7% -65.4%). Increasing age (aOR = 2.94, 95% CI: 1.74-4.97, P<0.001 and aOR = 3.39, 95% CI: 1.58-7.29, P = 0.002 for age groups of 21-24 and 25-35 years old respectively), lower educational level (aOR = 1.81, 95% CI: 1.09-3.02, P = 0.022), working full time (aOR = 8.56, 95% CI: 1.01-72.53, P = 0.049) and having practiced oral sex (aOR = 3.02, 95% CI: 1.16-7.89, P = 0.024) were strongly associated with prevalent HSV-2 infection. Thirty one participants seroconverted for HSV-2 (20.5%; 95% CI: 14.4% -27.9%) and 22 for HIV during the study period. The frequency of vaginal sex with a casual partner using a condom in the last 7 days was independently associated with incident HSV-2 infection (aOR = 1.91, 95% CI: 1.05-3.47, P = 0.034). Positive HSV-2 serology at baseline was not significantly associated with risk of subsequent HIV seroconversion. CONCLUSIONS Young women engaging in risky sexual behaviors in Beira had high prevalence and incidence of HSV-2 infection. Improved primary HSV-2 control strategies are urgently needed in Beira.
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Affiliation(s)
- Ivete Meque
- Universidade Católica de Moçambique/Catholic University of Mozambique (UCM), Centro de Investigação de Doenças Infecciosas/Center for Infectious Disease Research (CIDI), Beira, Mozambique
- * E-mail:
| | - Karine Dubé
- FHI 360, Clinical Sciences Unit, Durham, North Carolina, United States of America
- United States Military HIV Research Program (MHRP), Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF), Bethesda, Maryland, United States of America
| | - Paul J. Feldblum
- FHI 360, Clinical Sciences Unit, Durham, North Carolina, United States of America
| | - Archie C. A. Clements
- University of Queensland, Infectious Disease Epidemiology Unit, School of Population Health, Brisbane, Australia
| | - Arlinda Zango
- Universidade Católica de Moçambique/Catholic University of Mozambique (UCM), Centro de Investigação de Doenças Infecciosas/Center for Infectious Disease Research (CIDI), Beira, Mozambique
| | - Fidelina Cumbe
- Universidade Católica de Moçambique/Catholic University of Mozambique (UCM), Centro de Investigação de Doenças Infecciosas/Center for Infectious Disease Research (CIDI), Beira, Mozambique
| | - Pai Lien Chen
- FHI 360, Clinical Sciences Unit, Durham, North Carolina, United States of America
| | - Josefo J. Ferro
- Universidade Católica de Moçambique/Catholic University of Mozambique (UCM), Centro de Investigação de Doenças Infecciosas/Center for Infectious Disease Research (CIDI), Beira, Mozambique
| | - Janneke H. van de Wijgert
- Amsterdam Institute for Global Health and Development (AIGHD) and Academic Medical Center of the University of Amsterdam, Amsterdam, The Netherlands
- University of Liverpool, Institute of Infection and Global Health, Liverpool, United Kingdom
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Dubé K, Zango A, van de Wijgert J, Meque I, Ferro JJ, Cumbe F, Chen PL, Ma S, Jolles E, Fumo A, Robb ML, Feldblum PJ. HIV incidence in a cohort of women at higher risk in Beira, Mozambique: prospective study 2009-2012. PLoS One 2014; 9:e84979. [PMID: 24475035 PMCID: PMC3903474 DOI: 10.1371/journal.pone.0084979] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 11/28/2013] [Indexed: 12/03/2022] Open
Abstract
Background HIV is prevalent in Sofala Province, Mozambique. To inform future prevention research, we undertook a study in the provincial capital (Beira) to measure HIV incidence in women at higher risk of HIV and assess the feasibility of recruiting and retaining them as research participants. Methods Women age 18–35 were recruited from schools and places where women typically meet potential sexual partners. Eligibility criteria included HIV-seronegative status and self-report of at least 2 sexual partners in the last month. History of injection drug use was an exclusion criterion, but pregnancy was not. Participants were scheduled for monthly follow-up for 12 months, when they underwent face-to-face interviews, HIV counseling and testing, and pregnancy testing. Results 387 women were eligible and contributed follow-up data. Most were from 18–24 years old (median 21). Around one-third of participants (33.8%) reported at least one new sexual partner in the last month. Most women (65.5%) reported not using a modern method of contraception at baseline. Twenty-two women seroconverted for a prospective HIV incidence of 6.5 per 100 woman-years (WY; 95% confidence interval (CI): 4.1–9.9). Factors associated with HIV seroconversion in the multivariable analysis were: number of vaginal sex acts without using condoms with partners besides primary partner in the last 7 days (hazard ratio (HR) 1.7; 95% CI: 1.2–2.5) and using a form of contraception at baseline other than hormonal or condoms (vs. no method; HR 25.3; 95% CI: 2.5–253.5). The overall retention rate was 80.0% for the entire follow-up period. Conclusions We found a high HIV incidence in a cohort of young women reporting risky sexual behavior in Beira, Mozambique. HIV prevention programs should be strengthened. Regular HIV testing and condom use should be encouraged, particularly among younger women with multiple sexual partners.
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Affiliation(s)
- Karine Dubé
- FHI 360, Durham, North Carolina, United States of America
- United States Military HIV Research Program (MHRP), Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF), Bethesda, Maryland, United States of America
- * E-mail:
| | - Arlinda Zango
- Universidade Católica de Moçambique/Catholic University of Mozambique, (UCM) Centro de Investigação de Doenças Infecciosas/Research Center for Infectious Diseases (CIDI), Beira, Mozambique
| | - Janneke van de Wijgert
- Amsterdam Institute for Global Health and Development (AIGHD) and Academic Medical Center of the University of Amsterdam, Amsterdam, The Netherlands
- University of Liverpool, Institute of Infection and Global Health, Liverpool, United Kingdom
| | - Ivete Meque
- Universidade Católica de Moçambique/Catholic University of Mozambique, (UCM) Centro de Investigação de Doenças Infecciosas/Research Center for Infectious Diseases (CIDI), Beira, Mozambique
| | - Josefo J. Ferro
- Universidade Católica de Moçambique/Catholic University of Mozambique, (UCM) Centro de Investigação de Doenças Infecciosas/Research Center for Infectious Diseases (CIDI), Beira, Mozambique
| | - Fidelina Cumbe
- Universidade Católica de Moçambique/Catholic University of Mozambique, (UCM) Centro de Investigação de Doenças Infecciosas/Research Center for Infectious Diseases (CIDI), Beira, Mozambique
| | - Pai Lien Chen
- FHI 360, Durham, North Carolina, United States of America
| | - Sabrina Ma
- FHI 360, Durham, North Carolina, United States of America
| | - Erik Jolles
- FHI 360, Durham, North Carolina, United States of America
| | - Afonso Fumo
- Universidade Católica de Moçambique/Catholic University of Mozambique, (UCM) Centro de Investigação de Doenças Infecciosas/Research Center for Infectious Diseases (CIDI), Beira, Mozambique
| | - Merlin L. Robb
- United States Military HIV Research Program (MHRP), Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF), Bethesda, Maryland, United States of America
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