HIV Incidence and Spatial Clustering in a Rural Area of Southern Mozambique

Spatial Co-Clustering of Tuberculosis and HIV in Ethiopia

Background: Tuberculosis (TB) and HIV are epidemiologically associated, and their co-dynamics suggest that the two diseases are directly related at the population level and within the host. However, there is no or little information on the joint spatial patterns of the two diseases in Ethiopia. The main objective of the current study was to assess the spatial co-clustering of TB and HIV cases simultaneously in Ethiopia at the district level. Methods: District-level aggregated data collected from the national Health Management Information System (HMIS) for the years 2015 to 2018 on the number of TB cases enrolled in directly observed therapy, short course (DOTS) who were tested for HIV and the number of HIV patients enrolled in HIV care who were screened for TB during their last visit to health care facilities were used in this study. The univariate and bivariate global and local Moran’s I indices were applied to assess the spatial clustering of TB and HIV separately and jointly. Results: The results of this study show that the two diseases were significantly (p-value <0.001) spatially autocorrelated at the district level with minimum and maximum global Moran’s I values of 0.407 and 0.432 for TB, 0.102 and 0.247 for HIV, and 0.152 and 0.251 for joint TB/HIV. The district-level TB/HIV spatial co-clustering patterns in Ethiopia in most cases overlapped with the hot spots of TB and HIV. The TB/HIV hot-spot clusters may appear due to the observed high TB and HIV prevalence rates in the hot-spot districts. Our results also show that there were low-low TB/HIV co-clusters or cold spots in most of the Afar and Somali regions, which consistently appeared for the period 2015−2018. This may be due to very low notifications of both diseases in the regions. Conclusions: This study expanded knowledge about TB and HIV co-clustering in Ethiopia at the district level. The findings provide information to health policymakers in the country to plan geographically targeted and integrated interventions to jointly control TB and HIV.

Impact of rotavirus vaccination on diarrheal hospitalizations in children younger than 5 years of age in a rural southern Mozambique

BACKGROUND

Rotavirus vaccine(Rotarix®) was introduced in Mozambique through its Expanded Program of Immunization in September 2015. We assessed the impact of rotavirus vaccination on childhood gastroenteritis-associated hospitalizations post-vaccine introduction in a high HIV prevalence rural setting of southern Mozambique.

METHODS

We reviewed and compared the trend of hospitalizations (prevalence) and incidence rates of acute gastroenteritis (AGE), and rotavirus associated-diarrhea (laboratory confirmed rotavirus) in pre- (January 2008-August 2015) and post-rotavirus vaccine introduction periods (September 2015-December 2020), among children <5 years of age admitted to Manhiça District Hospital.

RESULTS

From January 2008 to December 2020, rotavirus vaccination was found to contribute to the decline of the prevalence of AGE from 19% (95% CI: 18.14-20.44) prior to the vaccine introduction to 10% (95% CI: 8.89-11.48) in the post-introduction period, preventing 40% (95 % IE: 38-42) and 84% (95 % IE: 80-87) of the expected AGE and laboratory confirmed rotavirus cases, respectively, among infants. Similarly, the overall incidence of rotavirus was 11.8-fold lower in the post-vaccine introduction period (0.4/1000 child-years-at-risk [CYAR]; 95% CI: 0.3-0.6) compared with the pre-vaccination period (4.7/1000 CYAR; 95% CI: 4.2-5.1) with the highest reduction being observed among infants (16.8-fold lower from the 15.1/1000 CYAR in the pre-vaccine to 0.9/1000 CYAR in the post-vaccine eras).

CONCLUSIONS

We documented a significant reduction in all-cause diarrhea hospitalizations and rotavirus positivity after vaccine introduction demonstrating the beneficial impact of rotavirus vaccination in a highly vulnerable population.

Costs and cost-effectiveness of HIV counselling and testing modalities in Southern Mozambique

Objective

Despite the high HIV associated burden, Mozambique lacks data on HIV counselling and testing (HCT) costs. To help guide national HIV/AIDS programs, we estimated the cost per test for voluntary counselling and testing (VCT) from the patient’s perspective and the costs per person tested and per HIV-positive individual linked to care to the healthcare provider for VCT, provider-initiated counselling and testing (PICT) and home-based testing (HBT). We also assessed the cost-effectiveness of these strategies for linking patients to care.

Methods

Data from a cohort study conducted in the Manhiça District were used to derive costs and linkage-to-care outcomes of the three HCT strategies. A decision tree was used to model HCT costs according to the likelihood of HCT linking individuals to care and to obtain the incremental cost-effectiveness ratios (ICERs) of PICT and HBT with VCT as the comparator. Sensitivity analyses were performed to assess robustness of base-case findings.

Findings

Based on costs and valuations in 2015, average and median VCT costs to the patient per individual tested were US$1.34 and US$1.08, respectively. Costs per individual tested were greatest for HBT (US$11.07), followed by VCT (US$7.79), and PICT (US$7.14). The costs per HIV-positive individual linked to care followed a similar trend. PICT was not cost-effective in comparison with VCT at a willingness-to-accept threshold of US$4.53, but only marginally given a corresponding base-case ICER of US$4.15, while HBT was dominated, with higher costs and lower impact than VCT. Base-case results for the comparison between PICT and VCT presented great uncertainty, whereas findings for HBT were robust.

Conclusion

PICT and VCT are likely equally cost-effective in Manhiça. We recommend that VCT be offered as the predominant HCT strategy in Mozambique, but expansion of PICT could be considered in limited-resource areas. HBT without facilitated linkage or reduced costs is unlikely to be cost-effective.

Mapping geographic clusters of new HIV diagnoses to inform granular-level interventions for HIV epidemic control in western Kenya

BACKGROUND

As countries make progress towards HIV epidemic control, there is increasing need to identify finer geographic areas to target HIV interventions. We mapped geographic clusters of new HIV diagnoses, and described factors associated with HIV-positive diagnosis, in order to inform targeting of HIV interventions to finer geographic areas and sub-populations.

METHODS

We analyzed data for clients aged > 15 years who received home-based HIV testing as part of a routine public health program between May 2016 and July 2017 in Siaya County, western Kenya. Geospatial analysis using Kulldorff's spatial scan statistic was used to detect geographic clusters (radius < 5 kilometers) of new HIV diagnoses. Factors associated with new HIV diagnosis were assessed in a spatially-integrated Bayesian hierarchical model.

RESULTS

Of 268,153 clients with HIV test results, 2906 (1.1%) were diagnosed HIV-positive. We found spatial variation in the distribution of new HIV diagnoses, and identified nine clusters in which the number of new HIV diagnoses was significantly (1.56 to 2.64 times) higher than expected. Sub-populations with significantly higher HIV-positive yield identified in the multivariable spatially-integrated Bayesian model included: clients aged 20-24 years [adjusted relative risk (aRR) 3.45, 95% Bayesian Credible Intervals (CI) 2.85-4.20], 25-35 years (aRR 4.76, 95% CI 3.92-5.81) and > 35 years (aRR 2.44, 95% CI 1.99-3.00); those in polygamous marriage (aRR 1.84, 95% CI 1.55-2.16), or separated/divorced (aRR 3.36, 95% CI 2.72-4.08); and clients who reported having never been tested for HIV (aRR 2.35, 95% CI 2.02-2.72), or having been tested > 12 months ago (aRR 1.53, 95% CI 1.41-1.66).

CONCLUSION

Our study used routine public health program data to identify granular geographic clusters of higher new HIV diagnoses, and sub-populations with higher HIV-positive yield in the setting of a generalized HIV epidemic. In order to target HIV testing and prevention interventions to finer granular geographic areas for maximal epidemiologic impact, integrating geospatial analysis into routine public health programs can be useful.

Diagnostic performance of the Abbott RealTime MTB assay for tuberculosis diagnosis in people living with HIV

Strengthening tuberculosis diagnosis is an international priority and the advocacy for multi-disease testing devices raises the possibility of improving laboratory efficiency. However, the advantages of centralized platforms might not translate into real improvements under operational conditions. This study aimed to evaluate the field use of the Abbott RealTime MTB (RT-MTB) and Xpert MTB/RIF assays, in a large cohort of HIV-positive and TB presumptive cases in Southern Mozambique. Over a 6-month period, 255 HIV-positive TB presumptive cases were consecutively recruited in the high TB/HIV burden district of Manhiça. The diagnostic performance of both assays was evaluated against two different reference standards: a microbiological gold standard (MGS) and a composite reference standard (CRS). Results from the primary analysis (MGS) showed improved sensitivity (Se) and reduced specificity (Sp) for the Abbott RT-MTB assay compared to the Xpert MTB/RIF (RT-MTB Se: 0.92 (95% CI: 0.75;0.99) vs Xpert Se: 0.73 (95% CI: 0.52;0.88) p value = 0.06; RT-MTB Sp: 0.80 (0.72;0.86) vs Xpert Sp: 0.96 (0.92;0.99) p value < 0.001). The lower specificity may be due to cross-reactivity with non-tuberculous mycobacteria (NTMs), the detection of non-viable MTBC, or the identification of true TB cases missed by the gold standard.

Improved detection and management of advanced HIV disease through a community adult TB-contact tracing intervention with same-day provision of the WHO-recommended package of care including ART initiation in a rural district of Mozambique

INTRODUCTION

AIDS-mortality remains unacceptably high in sub-Saharan Africa, largely driven by advanced HIV disease (AHD). We nested a study in an existing tuberculosis (TB) contact-tracing intervention (Xpatial-TB). The aim was to assess the burden of AHD among high-risk people living with HIV (PLHIV) identified and to evaluate the provision of the WHO-recommended package of care to this population.

METHODS

All PLHIV ≥14 years old identified between June and December 2018 in Manhiça District by Xpatial-TB were offered to participate in the study if ART naïve or had suboptimal ART adherence. Consenting individuals were screened for AHD. Patients with AHD (CD4 < 200 cells/μL or WHO stage 3 or 4) were offered a package of interventions in a single visit, including testing for cryptococcal antigen (CrAg) and TB-lipoarabinomannan (TB-LAM), prophylaxis and treatment for opportunistic infections, adherence support or accelerated ART initiation. We collected information on follow-up visits carried out under routine programmatic conditions for six months.

RESULTS

A total of 2881 adults were identified in the Xpatial TB-contact intervention. Overall, 23% (673/2881) were HIV positive, including 351 TB index (64.2%) and 322 TB contacts (13.8%). Overall, 159/673 PLHIV (24%) were ART naïve or had suboptimal ART adherence, of whom 155 (97%, 124 TB index and 31 TB-contacts) consented to the study and were screened for AHD. Seventy percent of TB index-patients (87/124) and 16% of TB contacts (5/31) had CD4 < 200 cells/µL. Four (13%) of the TB contacts had TB, giving an overall AHD prevalence among TB contacts of 29% (9/31). Serum-CrAg was positive in 4.6% (4/87) of TB-index patients and in zero TB contacts. All ART naïve TB contacts without TB initiated ART within 48 hours of HIV diagnosis. Among TB cases, ART timing was tailored to the presence of TB and cryptococcosis. Six-month mortality was 21% among TB-index cases and zero in TB contacts.

CONCLUSIONS

A TB contact-tracing outreach intervention identified undiagnosed HIV and AHD in TB patients and their contacts, undiagnosed cryptococcosis among TB patients, and resulted in an adequate provision of the WHO-recommended package of care in this rural Mozambican population. Same-day and accelerated ART initiation was feasible and safe in this population including among those with AHD.

Predictive Value of Time-Space Clusters for HIV Transmission in Washington State, 2017-2019

BACKGROUND

Pillar 4 of the United States' End the HIV Epidemic plan is to respond quickly to HIV outbreaks, but the utility of CDC's tool for identifying HIV outbreaks through time-space cluster detection has not been evaluated. The objective of this evaluation is to quantify the ability of the CDC time-space cluster criterion to predict future HIV diagnoses and to compare it to a space-time permutation statistic implemented in SaTScan software.

SETTING

Washington State from 2017 to 2019.

METHODS

We applied both cluster criteria to incident HIV cases in Washington State to identify clusters. Using a repeated-measures Poisson model, we calculated a rate ratio comparing the 6 months after cluster detection with a baseline rate from 24 to 12 months before the cluster was detected. We also compared the demographics of cases within clusters with all other incident cases.

RESULTS

The CDC criteria identified 17 clusters containing 192 cases in the 6 months after cluster detection, corresponding to a rate ratio of 1.25 (95% confidence interval: 0.95 to 1.65) relative to baseline. The time-space permutation statistic identified 5 clusters containing 25 cases with a rate ratio of 2.27 (95% confidence interval: 1.28 to 4.03). Individuals in clusters identified by the new criteria were more likely to be of Hispanic origin (61% vs 20%) and in rural areas (51% vs 12%).

CONCLUSIONS

The space-time permutation cluster analysis is a promising tool for identification of clusters with the largest growth potential for whom interruption may prove most beneficial.

Patterns of mobility and its impact on retention in care among people living with HIV in the Manhiça District, Mozambique

Introduction

Retention in HIV care is a challenge in Mozambique. Mozambique´s southern provinces have the highest mobility levels of the country. Mobility may result in poorer response to HIV care and treatment initiatives.

Methods

We conducted a cross-sectional survey to explore the impact of mobility on retention for HIV-positive adults on ART presenting to the clinic in December 2017 and January 2018. Survey data were linked to participant clinical records from the HIV care and treatment program. This study took place in Manhiça District, southern Mozambique. We enrolled self-identified migrants (moved outside of Manhiça District ≤12 months prior to survey) and non-migrants, matched by age and sex.

Results

390 HIV-positive adults were included. We found frequent movement: 45% of migrants reported leaving the district 3–5 times over the past 12 months, usually for extended stays. South Africa was the most common destination (71%). Overall, 30% of participants had at least one delay (15–60 days) in ART pick-up and 11% were delayed >60 days, though no significant difference was seen between mobile and non-mobile cohorts. Few migrants accessed care while traveling.

Conclusion

Our population of mobile and non-mobile participants showed frequent lapses in ART pick-up. Mobility could be for extended time periods and HIV care frequently did not continue at the destination. Studies are needed to evaluate the impact of Mozambique´s approach of providing 3-months ART among mobile populations and barriers to care while traveling, as is better education on how and where to access care when traveling.

Rotavirus disease burden pre-vaccine introduction in young children in Rural Southern Mozambique, an area of high HIV prevalence

BACKGROUND

Rotavirus vaccines have been adopted in African countries since 2009, including Mozambique (2015). Disease burden data are needed to evaluate the impact of rotavirus vaccine. We report the burden of rotavirus-associated diarrhea in Mozambique from the Global Enteric Multicenter Study (GEMS) before vaccine introduction.

METHODS

A case-control study (GEMS), was conducted in Manhiça district, recruiting children aged 0-59 months with moderate-to-severe diarrhea (MSD) and less-severe-diarrhea (LSD) between December 2007 and November 2012; including 1-3 matched (age, sex and neighborhood) healthy community controls. Clinical and epidemiological data and stool samples (for laboratory investigation) were collected. Association of rotavirus with MSD or LSD was determined by conditional logistic regression and adjusted attributable fractions (AF) calculated, and risk factors for rotavirus diarrhea assessed.

RESULTS

Overall 915 cases and 1,977 controls for MSD, and 431 cases and 430 controls for LSD were enrolled. Rotavirus positivity was 44% (217/495) for cases and 15% (160/1046) of controls, with AF = 34.9% (95% CI: 32.85-37.06) and adjusted Odds Ratio (aOR) of 6.4 p< 0.0001 in infants with MSD compared to 30% (46/155) in cases and 14% (22/154) in controls yielding AF = 18.7%, (95% CI: 12.02-25.39) and aOR = 2.8, p = 0.0011 in infants with LSD. The proportion of children with rotavirus was 32% (21/66) among HIV-positive children and 23% (128/566) among HIV-negative ones for MSD. Presence of animals in the compound (OR = 1.9; p = 0.0151) and giving stored water to the child (OR = 2.0, p = 0.0483) were risk factors for MSD; while animals in the compound (OR = 2.37, p = 0.007); not having routine access to water on a daily basis (OR = 1.53, p = 0.015) and washing hands before cooking (OR = 1.76, p = 0.0197) were risk factors for LSD.

CONCLUSION

The implementation of vaccination against rotavirus may likely result in a significant reduction of rotavirus-associated diarrhea, suggesting the need for monitoring of vaccine impact.

Adolescent, Pregnant, and HIV-Infected: Risk of Adverse Pregnancy and Perinatal Outcomes in Young Women from Southern Mozambique

Sub-Saharan Africa concentrates the burden of HIV and the highest adolescent fertility rates. However, there is limited information about the impact of the interaction between adolescence and HIV infection on maternal health in the region. Data collected prospectively from three clinical trials conducted between 2003 and 2014 were analysed to evaluate the association between age, HIV infection, and their interaction, with the risk of maternal morbidity and adverse pregnancy and perinatal outcomes in women from southern Mozambique. Logistic regression and negative binomial models were used. A total of 2352 women were included in the analyses; 31% were adolescents (≤19 years) and 29% HIV-infected women. The effect of age on maternal morbidity and pregnancy and perinatal adverse outcomes was not modified by HIV status. Adolescence was associated with an increased incidence of hospital admissions (IRR 0.55, 95%CI 0.37–0.80 for women 20–24 years; IRR 0.60, 95%CI 0.42–0.85 for women >25 years compared to adolescents; p-value < 0.01) and outpatient visits (IRR 0.86, 95%CI 0.71–1.04; IRR 0.76, 95%CI 0.63–0.92; p-value = 0.02), and an increased likelihood of having a small-for-gestational age newborn (OR 0.50, 95%CI 0.38–0.65; OR 0.43, 95%CI 0.34–0.56; p-value < 0.001), a low birthweight (OR 0.40, 95%CI 0.27–0.59; OR 0.37, 95%CI 0.26–0.53; p-value <0.001) and a premature birth (OR 0.42, 95%CI 0.24–0.72; OR 0.51, 95%CI 0.32–0.82; p-value < 0.01). Adolescence was associated with an increased risk of poor morbidity, pregnancy and perinatal outcomes, irrespective of HIV infection. In addition to provision of a specific maternity care package for this vulnerable group interventions are imperative to prevent adolescent pregnancy.

Community acceptability to antimalarial mass drug administrations in Magude district, Southern Mozambique: A mixed methods study

Background

This study aimed to capture the acceptability prior to, during and after the implementation of the first year of MDA rounds conducted under the Magude project, a malaria elimination project in southern Mozambique.

Methods

This was a mixed-methods study, consisting of focus group discussions (FGDs) prior to the implementation of MDA rounds (September 2015), non-participant observations (NPOs) conducted during the MDA rounds (November 2015 –beginning of February 2016), and semi-structured interviews (SSIs) after the second round (end of February 2016). Community leaders, women in reproductive age, general members of the community, traditional healers and health professionals were recruited to capture the opinions of all representing key members of the community. A generic outline of nodes and codes was designed to analyze FGDs and SSI separately. Qualitative and quantitative NPO information was analyzed following a content analysis approach.

Findings

222 participants took part in the FGDs (n = 154), and SSIs (n = 68); and 318 household visits during the MDA underwent NPOs. The community engagement campaign emerged throughout the study stages as a crucial factor for the acceptability of MDAs. Acceptability was also fostered by the community’s general will to cooperate in any government-led activity that would reduce malaria burden, the appropriate behavior and knowledge of field workers, or the fact that the intervention was available free of charge to all. Absenteeism of heads of households was identified as the main barrier for the success of the campaign. The most commonly reported factors that negatively affected acceptability were the fear of adverse events, rumors of deaths, being unable to drink alcohol while taking DHAp, or the fear to take DHAp while in anti-retroviral treatment. Pregnancy testing and malaria testing were generally well accepted by the community.

Conclusion

Magude’s community generally accepted the first and second antimalarial MDA rounds, and the procedures associated to the intervention. Future implementation of antimalarial MDAs in southern Mozambique should focus on locally adapted strategies that engage the community to minimize absenteeism and refusals to the intervention.

Brief Report: HIV Incidence Among Older Adults in a Rural South African Setting: 2010-2015

In South Africa, evidence shows high HIV prevalence in older populations, with sexual behavior consistent with high HIV acquisition and transmission risk. However, there is a dearth of evidence on older people's HIV incidence.

Mortality and risk of tuberculosis among people living with HIV in whom TB was initially ruled out

Tuberculosis (TB) misdiagnosis remains a public health concern, especially among people living with HIV (PLHIV), given the high mortality associated with missed TB diagnoses. The main objective of this study was to describe the all-cause mortality, TB incidence rates and their associated risk factors in a cohort of PLHIV with presumptive TB in whom TB was initially ruled out. We retrospectively followed a cohort of PLHIV with presumptive TB over a 2 year-period in a rural district in Southern Mozambique. During the study period 382 PLHIV were followed-up. Mortality rate was 6.8/100 person-years (PYs) (95% CI 5.2-9.2) and TB incidence rate was 5.4/100 PYs (95% CI 3.9-7.5). Thirty-six percent of deaths and 43% of TB incident cases occurred in the first 12 months of the follow up. Mortality and TB incidence rates in the 2-year period after TB was initially ruled out was very high. The TB diagnostic work-up and linkage to HIV care should be strengthened to decrease TB burden and all-cause mortality among PLHIV with presumptive TB.

Spatial analysis of factors associated with HIV infection in Malawi: indicators for effective prevention

BACKGROUND

The objective of this study was to model the predictors of HIV prevalence in Malawi through a complex sample logistic regression and spatial mapping approach using the national Demographic and Health Survey datasets.

METHODS

We conducted a secondary data analysis using the 2015-2016 Malawi Demographic and Health Survey and AIDS Indicator Survey. The analysis was performed in three stages while incorporating population survey sampling weights to: i) interpolate HIV data, ii) identify the spatial clusters with the high prevalence of HIV infection, and iii) perform a multivariate complex sample logistic regression.

RESULTS

In all, 14,779 participants were included in the analysis with an overall HIV prevalence of 9% (7.0% in males and 10.8% in females). The highest prevalence was found in the southern region of Malawi (13.2%), and the spatial interpolation revealed that the HIV epidemic is worse at the south-eastern part of Malawi. The districts in the high HIV prevalent zone of Malawi are Thyolo, Zomba, Mulanje, Phalombe and Blantyre. In central and northern region, the district HIV prevalence map identified Lilongwe in the central region and Karonga in the northern region as districts that equally deserve attention. People residing in urban areas had a 2.2 times greater risk of being HIV-positive compared to their counterparts in the rural areas (AOR = 2.16; 95%CI = 1.57-2.97). Other independent predictors of HIV prevalence were gender, age, marital status, number of lifetime sexual partners, extramarital partners, the region of residence, condom use, history of STI in the last 12 months, and household wealth index. Disaggregated analysis showed in-depth sociodemographic regional variations in HIV prevalence.

CONCLUSION

These findings identify high-risk populations and regions to be targeted for Pre-Exposure Prophylaxis (PrEP) campaigns, HIV testing, treatment and education to decrease incidence, morbidity, and mortality related to HIV infection in Malawi.

Antibody responses to the RTS,S/AS01E vaccine and Plasmodium falciparum antigens after a booster dose within the phase 3 trial in Mozambique

The RTS,S/AS01_E vaccine has shown consistent but partial vaccine efficacy in a pediatric phase 3 clinical trial using a 3-dose immunization schedule. A fourth-dose 18 months after the primary vaccination was shown to restore the waning efficacy. However, only total IgG against the immunodominant malaria vaccine epitope has been analyzed following the booster. To better characterize the magnitude, nature, and longevity of the immune response to the booster, we measured levels of total IgM, IgG, and IgG_1-4 subclasses against three constructs of the circumsporozoite protein (CSP) and the hepatitis B surface antigen (HBsAg, also present in RTS,S) by quantitative suspension array technology in 50 subjects in the phase 3 trial in Manhiça, Mozambique. To explore the impact of vaccination on naturally acquired immune responses, we measured antibodies to P. falciparum antigens not included in RTS,S. We found increased IgG, IgG1, IgG3 and IgG4, but not IgG2 nor IgM, levels against vaccine antigens 1 month after the fourth dose. Overall, antibody responses to the booster dose were lower than the initial peak response to primary immunization and children had higher IgG and IgG1 levels than infants. Higher anti-Rh5 IgG and IgG_1-4 levels were detected after the booster dose, suggesting that RTS,S partial protection could increase some blood stage antibody responses. Our work shows that the response to the RTS,S/AS01_E booster dose is different from the primary vaccine immune response and highlights the dynamic changes in subclass antibody patterns upon the vaccine booster and with acquisition of adaptive immunity to malaria.

Predictors of high HIV+ prevalence in Mozambique: A complex samples logistic regression modeling and spatial mapping approaches

Introduction

The burden of HIV infection in southern Africa is a public health concern with an increasing number of new infections. This study sought to investigate the predictors of HIV prevalence in Mozambique through a complex samples logistic regression and spatial mapping approach using nationally representative data.

Methods

We conducted a secondary data analysis using the 2015 Mozambique Demographic and Health Survey and AIDS Indicator Survey. The analysis performed in four stages while incorporating population survey sampling weights did the following: i) created a complex sample plan file in SPSS, ii) performed the weighted estimate of HIV prevalence, iii) performed complex sample chi-square test of independence, and then iv) performed complex sample logistic regression modeling.

Results

Out of 11,270 participants, 1,469 (13.0%) tested positive for HIV. The prevalence of HIV infection was higher in females (15.1%) than males (10.2%). We found that urban dwellers were more likely to be HIV-positive compared to rural dwellers (AOR: 1.70; CI: 1.27, 2.27). We observed provincial variations in HIV prevalence, with Maputo Cidade (17.4%), Maputo Provincia (22.6%), Gaza (25.2%) recording higher prevalence above the national estimate. Other independent predictors of HIV infection in Mozambique included age, education level, marital status, total lifetime sexual partners, and having had an STI in the last 12 months.

Conclusions

The study revealed associations between high-risk sexual behavior and HIV infection. Results from our spatial mapping approach can help health policy makers to better allocate resources for cost-effective HIV/AIDS interventions. Pre-Exposure Prophylaxis (PrEP) campaigns among high-risk groups should be pursued to lower the reservoir of HIV among high-risk groups.

Adolescent motherhood in Mozambique. Consequences for pregnant women and newborns

Introduction

In sub-Saharan Mozambique, high adolescent fertility rates are a significant public health problem. Understanding the consequences of teenage pregnancies facilitates effective strategies for improving the quality of care of both mother and the newborn.

Aims

To identify the factors associated with adolescent motherhood in Tete (Mozambique).

Methods

This was a cross-sectional study including 821 pregnant women (255 teenagers) admitted to the general maternity ward of the Provincial Hospital between March and October 2016. The survey included clinical data of the mother and newborn.

Results

The overall prevalence of adolescent deliveries was 31.8% (95% CI 27.9% - 34.2%). Multivariate analysis showed that independent factors associated with teenage motherhood were: number of pregnancies (OR 0.066; 95% CI 0.040–0.110), pregnancy follow-up (OR 0.29; CI 0.173–0.488) and previous abortions (OR 4.419; 95% CI 1.931–10.112). When the age of the mother was analysed as a continuous variable, positively associated factors were body mass index, arterial hypertension, HIV infection, previous abortions, pregnancy follow-up, and the weight of the newborn. Negatively associated factors were episiotomy and respiratory distress in the newborn.

Conclusion

Teenage motherhood is a serious public health problem in Mozambique. Intensive sexual and reproductive health planning for adolescents is needed.

Demographic and health community-based surveys to inform a malaria elimination project in Magude district, southern Mozambique

OBJECTIVES

A Demographic and Health Platform was established in Magude in 2015, prior to the deployment of a project aiming to evaluate the feasibility of malaria elimination in southern Mozambique, named the Magude project. This platform aimed to inform the design, implementation and evaluation of the Magude project, through the identification of households and population; and the collection of demographic, health and malaria information.

SETTING

Magude is a rural district of southern Mozambique which borders South Africa. It has nine peripheral health facilities and one referral health centre with an inpatient ward.

INTERVENTION

A baseline census enumerated and geolocated all the households, and their resident and non-resident members, collecting demographic and socio-economic information, and data on the coverage and usage of malaria control tools. Inpatient and outpatient data during the 5 years (2010 to 2014) before the survey were obtained from the district health authorities. The demographic platform was updated in 2016.

RESULTS

The baseline census conducted in 2015 reported 48 448 (92.1%) residents and 4133 (7.9%) non-residents, and 10 965 households. Magude's population is predominantly young, half of the population has no formal education and the main economic activities are agriculture and fishing. Houses are mainly built with traditional non-durable materials and have poor sanitation facilities. Between 2010 and 2014, malaria was the most common cause of all-age inpatient discharges (representing 20% to 40% of all discharges), followed by HIV (12% to 22%) and anaemia (12% to 15%). In early 2015, all-age bed-net usage was between 21.8% and 27.1% and the reported coverage of indoor residual spraying varied across the district between 30.7% and 79%.

CONCLUSION

This study revealed that Magude has limited socio-economic conditions, poor access to healthcare services and low coverage of malaria vector control interventions. Thus, Magude represented an area where it is most pressing to demonstrate the feasibility of malaria elimination.

TRIAL REGISTRATION NUMBER

NCT02914145; Pre-results.

The characteristics of spatial-temporal distribution and cluster of tuberculosis in Yunnan Province, China, 2005-2018

BACKGROUND

Tuberculosis (TB) makes a big challenge to public health, especially in high TB burden counties of China and Greater Mekong Subregion (GMS). The aim of this study was to identify the spatial-temporal dynamic process and high-risk region of notified pulmonary tuberculosis (PTB), sputum smear-positive tuberculosis (SSP-TB) and sputum smear-negative tuberculosis (SSN-TB) cases in Yunnan, the south-western of China between years of 2005 to 2018. Meanwhile, to evaluate the similarity of prevalence pattern for TB among GMS.

METHODS

Data for notified PTB were extracted from the China Information System for Disease Control and Prevention (CISDCP) correspond to population information in 129 counties of Yunnan between 2005 to 2018. Seasonally adjusted time series defined the trend cycle and seasonality of PTB prevalence. Kulldorff's space-time scan statistics was applied to identify temporal, spatial and spatial-temporal PTB prevalence clusters at county-level of Yunnan. Pearson correlation coefficient and hierarchical clustering were applied to define the similarity of TB prevalence among borders with GMS.

RESULT

There were a total of 381,855 notified PTB cases in Yunnan, and the average prevalence was 59.1 per 100,000 population between 2005 to 2018. A declined long-term trend with seasonality of a peak in spring and a trough in winter for PTB was observed. Spatial-temporal scan statistics detected the significant clusters of PTB prevalence, the most likely cluster concentrated in the northeastern angle of Yunnan between 2011 to 2015 (RR = 2.6, P < 0.01), though the most recent cluster for PTB and spatial cluster for SSP-TB was in borders with GMS. There were six potential TB prevalence patterns among GMS.

CONCLUSION

This study detected aggregated time interval and regions for PTB, SSP-TB, and SSN-TB at county-level of Yunnan province. Similarity prevalence pattern was found in borders and GMS. The localized prevention strategy should focus on cross-boundary transmission and SSN-TB control.

Demographic characteristics and spatial clusters of recent HIV-1 infections among newly diagnosed HIV-1 cases in Yunnan, China, 2015

BACKGROUND

The characteristics of recent HIV infections can provide the information about the dynamics of HIV transmission. Yunnan is one of the provinces hardest-hit by HIV-1 in China. To further understand the characteristics of the HIV-1 epidemic in Yunnan, we analyzed the prevalence of recent HIV-1 infections among newly diagnosed cases, identified the associated factors and explored the spatial distribution of recent HIV-1 infections.

METHODS

Residual plasma samples from HIV-1 diagnostic tests were preserved. The associated information was collected from China HIV/AIDS case reporting system. Recent HIV-1 infections were estimated by combining the information about disease progression and BED- capture enzyme immunoassay (CEIA). The proportions of recent HIV-1 infections among newly diagnosed cases stratified by demographic characteristics were analyzed. The spatial clusters of recent HIV-1 infections were investigated by spatial scan statistics.

RESULTS

Among 6119 HIV/AIDS cases were newly reported between January 2015 and June 2015 in Yunnan Province, 9.3% (570/6119) were estimated as recent infections. Female, aged below 25 years and homosexual contact were more associated with the higher proportion of recent HIV-1 infections. Among the different demographic sub-groups, men who have sex with men (MSM) aged < 25 years and ≥ 50 years had a higher chance of being diagnosed as recent infections, heterosexually infected men aged ≥25 years had a lower chance of being diagnosed as recent infections. In the sub-groups with different screening approaches, the highest proportion of recent infections (16.1%) was found among women diagnosed by testing during pregnancy and childbirth. In the sub-groups with different contact histories, the higher proportion of recent infections was found among the female cases having commercial heterosexual contacts (16.4%) and MSM (19.7%). The statistically significant spatial clusters of recent infections attributed to heterosexual contact, homosexual contact and intravenous drug injection were identified, respectively.

CONCLUSIONS

The investigation of recent HIV infections among newly diagnosed cases supplements the routine HIV surveillance, and reveals the characteristics of ongoing HIV transmission. Our finding identified the potential sub-populations and geographic areas in need of services or improved interventions.

Tipping the balance towards long-term retention in the HIV care cascade: A mixed methods study in southern Mozambique

Background

The implementation of quality HIV control programs is crucial for the achievement of the UNAIDS 90-90-90 targets and to motivate people living with HIV (PLWHIV) to link and remain in HIV-care. The aim of this mixed method cross-sectional study was to estimate the linkage and long-term retention in care of PLWHIV and to identify factors potentially interfering along the HIV-care continuum in southern Mozambique.

Methods

A home-based semi-structured interview was conducted in 2015 to explore barriers and facilitators to the HIV-care cascade among individuals that had been newly HIV-diagnosed in community testing campaigns in 2010 or 2012. Linkage and long-term retention were estimated retrospectively through client self-reports and clinical records. Cohen's Kappa coefficient was calculated to measure the agreement between participant self-reported and documented cascade outcomes.

Results

Among the 112 interviewed participants, 24 (21.4%) did not disclose their HIV-positive serostatus to the interviewer. While 84 (75.0%) self-reported having enrolled in care, only 69 (61.6%) reported still being in-care 3–5 years after diagnosis of which 17.4% reported having disengaged and re-engaged. An important factor affecting optimal continuum in HIV-care was the impact of the fear-based authoritarian relationship between the health system and the patient that could act as both driver and barrier.

Conclusion

Special attention should be given to quantify and understand repeated cycles of patient disengagement and re-engagement in HIV-care. Strategies to improve the relationship between the health system and patients are still needed in order to optimally engage PLWHIV for long-term periods.

Spatial clusters of HIV-1 genotypes in a recently infected population in Yunnan, China

Background

As a gateway for HIV-1 in China, Yunnan has experienced dramatic changes in HIV-1 epidemics, during which HIV-1 genotypes have become complex. To track dynamic changes in HIV-1 genotypes, an HIV-1 molecular epidemiological study was implemented in the recently infected population in Yunnan.

Methods

From 6,357 HIV-1-positive samples diagnosed during the first half of 2015 in Yunnan, 586 samples were identified as recent infections with BED-capture enzyme immunoassay (CEIA) and were subjected to phylogenetic analyses. Spatial scanning analyses for the main HIV-1 genotypes were also performed.

Results

Among the 439 specimens successfully genotyped, more than ten genotypes were detected, including CRF08_BC (45.3%), CRF07_BC (19.4%), unique recombinant forms (URFs) (18.2%), CRF01_AE (11.4%), subtype C (2.1%), CRF85_BC (1.1%), CRF55_01B (0.9%), subtype B (0.5%), CRF64_BC (0.5%), CRF59_01B (0.2%), CRF83_cpx (0.2%) and CRF87_cpx (0.2%). Females, Chinese, heterosexual contact and intravenous drug injection were significantly associated with CRF08_BC infection; homosexual contact was significantly associated with CRF01_AE and CRF07_BC infection; males and non-Chinese had a higher risk of URF infection than females. Among all HIV-1 genotypes, the geographic coverage of CRF08_BC was the largest. For CRF08_BC, CRF07_BC, URFs and CRF01_AE, spatial clusters were detected. The two CRF08_BC clusters and one URF cluster were associated with heterosexual transmission, and two of CRF01_AE clusters were associated with homosexual transmission. Transmitted drug resistance (TDR)-associated mutations were detected in 2.4% of individuals.

Conclusions

The diversity of HIV-1 genotypes increased in recent infections because of a long-term HIV-1 epidemic in Yunnan. The predominant HIV-1 strains showed distinct demographic characteristics and formed spatial clusters. These findings improved our understanding of the evolution of HIV-1 in Yunnan and provided information for further HIV-1 control and prevention.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4276-9) contains supplementary material, which is available to authorized users.

Geographic Information Systems, spatial analysis, and HIV in Africa: A scoping review

INTRODUCTION

Geographic Information Systems (GIS) and spatial analysis are emerging tools for global health, but it is unclear to what extent they have been applied to HIV research in Africa. To help inform researchers and program implementers, this scoping review documents the range and depth of published HIV-related GIS and spatial analysis research studies conducted in Africa.

METHODS

A systematic literature search for articles related to GIS and spatial analysis was conducted through PubMed, EMBASE, and Web of Science databases. Using pre-specified inclusion criteria, articles were screened and key data were abstracted. Grounded, inductive analysis was conducted to organize studies into meaningful thematic areas.

RESULTS AND DISCUSSION

The search returned 773 unique articles, of which 65 were included in the final review. 15 different countries were represented. Over half of the included studies were published after 2014. Articles were categorized into the following non-mutually exclusive themes: (a) HIV geography, (b) HIV risk factors, and (c) HIV service implementation. Studies demonstrated a broad range of GIS and spatial analysis applications including characterizing geographic distribution of HIV, evaluating risk factors for HIV, and assessing and improving access to HIV care services.

CONCLUSIONS

GIS and spatial analysis have been widely applied to HIV-related research in Africa. The current literature reveals a diversity of themes and methodologies and a relatively young, but rapidly growing, evidence base.

Risk factors for death among children 0-59 months of age with moderate-to-severe diarrhea in Manhiça district, southern Mozambique

Background

Despite major improvements in child survival rates, the number of deaths due to diarrhea remains unacceptably high. We aimed to describe diarrhea-associated mortality and evaluate risk factors for death among Mozambican children with moderate-to-severe diarrhea (MSD).

Methods

Between December 2007 and November 2012, children under-five with MSD were enrolled in Manhiça district, as part of the Global Enteric Multicenter study (GEMS). Clinical, epidemiological, and socio-demographic characteristics were collected. Anthropometric measurements were performed and stool samples collected upon recruitment. A follow-up visit ~ 60 days post-enrolment was conducted and verbal autopsies performed in all death cases.

Results

Of the 916 MSD-cases analyzed; 90% (821/916) completed 60 days follow-up and 69 patients died. The case fatality rate at follow-up was 8% (69/821), and the mortality rate 10.2 (95%CI: 7.75–13.59) deaths per 1000 persons-week at risk. Nearly half of the deaths 48% (33/69) among study participants clustered within 2 weeks of the onset of diarrhea.

Typical enteropathogenic Escherichia coli (typical EPEC) and Cryptosporidium were the two pathogens associated to an increased risk of death in the univariate analysis with (HR = 4.16, p = 0.0461) and (H = 2.84, p = 0.0001) respectively. Conversely, Rotavirus infection was associated to a decreased risk of death (HR = 0.52, p = 0.0198).

According to the multivariate analysis, risk factors for death included co-morbidities such as malnutrition (HR = 4.13, p <  0.0001), pneumonia/lower respiratory infection (HR = 3.51, p <  0.0001) or invasive bacterial disease (IBD) (HR = 6.80, p = 0.0009), presenting on arrival with lethargy or overt unconsciousness (HR = 1.73, p = 0.0302) or wrinkled skin (HR = 1.71, p = 0.0393), and cryptosporidium infection (HR = 2.14, p = 0.0038).

When restricting the analysis to those with available HIV results (n = 191, 22% of the total study sample), HIV was shown to be a significant risk factor for death (HR = 5.05, p = 0.0009).

Verbal autopsies were conducted in 100% of study deaths, and highlighted diarrhea as the main underlying cause of death 39%, (27/69); followed by HIV/AIDS related deaths 29.0% (20/69) and sepsis 11.6% (8/69).

Conclusion

Preventive strategies targeting Cryptosporidium, malnutrition and early identification and treatment of associated co-morbidities could contribute to the prevention of the majority of diarrhea associated deaths in Mozambican children.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3948-9) contains supplementary material, which is available to authorized users.

Postdischarge Mortality Prediction in Sub-Saharan Africa

BACKGROUND

Although the burden of postdischarge mortality (PDM) in low-income settings appears to be significant, no clear recommendations have been proposed in relation to follow-up care after hospitalization. We aimed to determine the burden of pediatric PDM and develop predictive models to identify children who are at risk for dying after discharge.

METHODS

Deaths after hospital discharge among children aged <15 years in the last 17 years were reviewed in an area under demographic and morbidity surveillance in Southern Mozambique. We determined PDM over time (up to 90 days) and derived predictive models of PDM using easily collected variables on admission.

RESULTS

Overall PDM was high (3.6%), with half of the deaths occurring in the first 30 days. One primary predictive model for all ages included young age, moderate or severe malnutrition, a history of diarrhea, clinical pneumonia symptoms, prostration, bacteremia, having a positive HIV status, the rainy season, and transfer or absconding, with an area under the curve of 0.79 (0.75-0.82) at day 90 after discharge. Alternative models for all ages including simplified clinical predictors had a similar performance. A model specific to infants <3 months old was used to identify as predictors being a neonate, having a low weight-for-age z score, having breathing difficulties, having hypothermia or fever, having oral candidiasis, and having a history of absconding or transfer to another hospital, with an area under the curve of 0.76 (0.72-0.91) at day 90 of follow-up.

CONCLUSIONS

Death after discharge is an important although poorly recognized contributor to child mortality. A simple predictive algorithm based on easily recognizable variables could readily be used to identify most infants and children who are at a high risk of dying after discharge.

The role of HIV infection in the etiology and epidemiology of diarrheal disease among children aged 0-59 months in Manhiça District, Rural Mozambique

•

HIV prevalence was higher among cases with moderate-to-severe diarrhea (MSD) than controls.

•

Mortality was higher among HIV-infected children with diarrhea than HIV-uninfected ones.

•

HIV-infected children were more likely to have MSD.

•

Cryptosporidium was the most common pathogen in HIV-infected children with MSD.

•

Escherichia coli producing heat-stable toxin (enterotoxigenic Escherichia coli, any sequence type) was the most common pathogen in HIV-infected children with less severe diarrhea.

Background

Diarrhea is an important health problem among HIV-infected patients. This study evaluated the role of HIV in the epidemiology, etiology, and severity of diarrheal disease among children.

Methods

The Global Enteric Multicenter Study enrolled children with moderate-to-severe diarrhea (MSD) and less-severe diarrhea (LSD) between December 2007 and November 2012. One to three controls for MSD cases and one per LSD case were enrolled and matched by age, sex, and neighborhood. All children were tested for HIV. Clinical data, anthropometric data, and stool samples were collected. Follow-up was performed at 60 days.

Results

Two hundred and fourteen MSD cases and 418 controls, together with 349 LSD cases and 214 controls were tested. HIV prevalence was 25% among MSD cases (4% for matched controls) and 6% among LSD cases (6% among matched controls). HIV-infected children were more likely to have MSD (odds ratio 5.6, p < 0.0001).

Mortality rates were higher among HIV-infected children than among the uninfected (34 vs. 5 per 1000 child-weeks at risk; p = 0.0039). Cryptosporidium, Giardia, and enteroaggregative Escherichia coli (aatA only) were more prevalent among HIV-infected MSD cases than among uninfected ones.

Conclusion

HIV is an important risk factor for MSD. The high mortality rate implies that children with MSD should be screened for HIV and managed accordingly.

HIV drug resistance patterns in pregnant women using next generation sequence in Mozambique

Background

Few data on HIV resistance in pregnancy are available from Mozambique, one of the countries with the highest HIV toll worldwide. Understanding the patterns of HIV drug resistance in pregnant women might help in tailoring optimal regimens for prevention of mother to child transmission of HIV (pMTCT) and antenatal care.

Objectives

To describe the frequency and characteristics of HIV drug resistance mutations (HIVDRM) in pregnant women with virological failure at delivery, despite pMTCT or antiretroviral therapy (ART).

Methods

Samples from HIV-infected pregnant women from a rural area in southern Mozambique were analysed. Only women with HIV-1 RNA >400c/mL at delivery were included in the analysis. HIVDRM were determined using MiSeq® (detection threshold 1%) at the first antenatal care (ANC) visit and at the time of delivery.

Results

Ninety and 60 samples were available at the first ANC visit and delivery, respectively. At first ANC, 97% of the women had HIV-1 RNA>400c/mL, 39% had CD4+ counts <350 c/mm³ and 30% were previously not on ART. Thirteen women (14%) had at least one HIVDRM of whom 70% were not on previous ART. Eight women (13%) had at least one HIVDRM at delivery. Out of 37 women with data available from the two time points, 8 (21%) developed at least one new HIVDRM during pMTCT or ART. Twenty seven per cent (53/191), 32% (44/138) and 100% (5/5) of the mutations that were present at enrolment, delivery and that emerged during pregnancy, respectively, were minority mutations (frequency <20%).

Conclusions

Even with ultrasensitive HIV-1 genotyping, less than 20% of women with detectable viremia at delivery had HIVDRM before initiating pMTCT or ART. This suggests that factors other than pre-existing resistance, such as lack of adherence or interruptions of the ANC chain, are also relevant to explain lack of virological suppression at the time of delivery in women receiving antiretrovirals drugs during pregnancy.

Monitoring progress towards the first UNAIDS target: understanding the impact of people living with HIV who re-test during HIV-testing campaigns in rural Mozambique

INTRODUCTION

Awareness of HIV-infection goes beyond diagnosis, and encompasses understanding, acceptance, disclosure and initiation of the HIV-care. We aimed to characterize the HIV-positive population that underwent repeat HIV-testing without disclosing their serostatus and the impact on estimates of the first UNAIDS 90 target.

METHODS

This analysis was nested in a prospective cohort established in southern Mozambique which conducted three HIV-testing modalities: voluntary counselling and testing (VCT), provider-initiated counselling and testing (PICT) and home-based testing (HBT). Participants were given the opportunity to self-report their status to lay counsellors and HIV-positive diagnoses were verified for previous enrolment in care. This study included 1955 individuals diagnosed with HIV through VCT/PICT and 11,746 participants of a HBT campaign. Those who did not report their serostatus prior to testing, and were found to have a previous HIV-diagnosis, were defined as non-disclosures. Venue-stratified descriptive analyses were performed and factors associated with non-disclosure were estimated through log-binomial regression.

RESULTS

In the first round of 2500 adults randomized for HBT, 1725 were eligible for testing and 18.7% self-reported their HIV-positivity. Of those tested with a positive result, 38.9% were found to be non-disclosures. Similar prevalence of non-disclosures was found in clinical-testing modalities, 29.4% (95% CI 26.7 to 32.3) for PICT strategy and 13.0% (95% CI 10.9 to 15.3) for VCT. Prior history of missed visits (adjusted prevalence ratio (APR) 4.2, 95% CI 2.6 to 6.8), younger age (APR 2.5, 95% CI 1.4 to 4.4) and no prior history of treatment ((APR) 1.4, 95% CI 1.0 to 2.1) were significantly associated with non-disclosure as compared to patients who self-reported. When considering non-disclosures as people living with HIV (PLWHIV) aware of their HIV-status, the proportion of PLWHIV aware increased from 78.3% (95% CI 74.2 to 81.6) to 86.8% (95% CI 83.4 to 89.6).

CONCLUSION

More than one-third of individuals testing HIV-positive did not disclose their previous positive HIV-diagnosis to counsellors. This proportion varied according to testing modality and age. In the absence of an efficient and non-anonymous tracking system for HIV-testers, repeat testing of non-disclosures leads to wasted resources and may distort programmatic indicators. Developing interventions that ensure appropriate psychosocial support are needed to encourage this population to disclose their status and optimize scarce resources.

Health and socio-demographic profile of women of reproductive age in rural communities of southern Mozambique

Reliable statistics on maternal morbidity and mortality are scarce in low and middle-income countries, especially in rural areas. This is the case in Mozambique where many births happen at home. Furthermore, a sizeable number of facility births have inadequate registration. Such information is crucial for developing effective national and global health policies for maternal and child health. The aim of this study was to generate reliable baseline socio-demographic information on women of reproductive age as well as to establish a demographic surveillance platform to support the planning and implementation of the Community Level Intervention for Pre-eclampsia (CLIP) study, a cluster randomized controlled trial. This study represents a census of all women of reproductive age (12–49 years) in twelve rural communities in Maputo and Gaza provinces of Mozambique. The data were collected through electronic forms implemented in Open Data Kit (ODK) (an app for android based tablets) and household and individual characteristics. Verbal autopsies were conducted on all reported maternal deaths to determine the underlying cause of death. Between March and October 2014, 50,493 households and 80,483 women of reproductive age (mean age 26.9 years) were surveyed. A total of 14,617 pregnancies were reported in the twelve months prior to the census, resulting in 9,029 completed pregnancies. Of completed pregnancies, 8,796 resulted in live births, 466 resulted in stillbirths and 288 resulted in miscarriages. The remaining pregnancies had not yet been completed during the time of the survey (5,588 pregnancies). The age specific fertility indicates that highest rate (188 live births per 1,000 women) occurs in the age 20–24 years old. The estimated stillbirth rate was 50.3/1,000 live and stillbirths; neonatal mortality rate was 13.3/1,000 live births and maternal mortality ratio was 204.6/100,000 live births. The most common direct cause of maternal death was eclampsia and tuberculosis was the most common indirect cause of death. This study found that fertility rate is high at age 20–24 years old. Pregnancy in the advanced age (>35 years of age) in this study was associated with higher poor outcomes such as miscarriage and stillbirth. The study also found high stillbirth rate indicating a need for increased attention to maternal health in southern Mozambique. Tuberculosis and HIV/AIDS are prominent indirect causes of maternal death, while eclampsia represents the number one direct obstetric cause of maternal deaths in these communities. Additional efforts to promote safe motherhood and improve child survival are crucial in these communities.

Health system reforms in five sub-Saharan African countries that experienced major armed conflicts (wars) during 1990-2015: a literature review

BACKGROUND

Sub-Saharan Africa (SSA) has had more major armed conflicts (wars) in the past two decades - including 13 wars during 1990-2015 - than any other part of the world, and this has had an adverse effect on health systems in the region.

OBJECTIVE

To understand the best health system practices in five SSA countries that experienced wars during 1990-2015, and yet managed to achieve a maternal mortality reduction - equal to or greater than 50% during the same period - according to the Maternal Mortality Estimation Inter-Agency Group (MMEIG). Maternal mortality is a death of a woman during pregnancy, or within 42 days after childbirth - measured as maternal mortality ratio (MMR) per 100,000 live births.

DESIGN

We conducted a selective literature review based on a framework that drew upon the World Health Organisation's (WHO) six health system building blocks. We searched seven databases, Google Scholar as well as conducting a manual search of sources in articles' reference lists - restricting our search to articles published in English. We searched for terms related to maternal healthcare, the WHO six health system building blocks, and names of the five countries.

RESULTS

Our study showed three general health system reforms across all five countries that could explain MMR reduction: health systems decentralisation, the innovation related to the WHO workforce health system building block such as training of community healthcare workers, and governments-financing reforms.

CONCLUSION

Restoring health systems after disasters is an urgent concern, especially in countries that have experienced wars. Our findings provide insight from five war-affected SSA countries which could inform policy. However, since few studies have been conducted concerning this topic, our findings require further research to inform policy, and to help countries rebuild and maintain their health systems resilience.

Market for Artemether-Lumefantrine to treat childhood malaria in a district of southern Mozambique

Malaria is one of the leading causes of death in sub-Saharan Africa. Artemisinin-based combination therapies are used as first-line treatment drugs, but their market is far from competitive. Market failures include limited availability, low quality, lack of information, and high costs of access. We estimated the theoretical demand for one of the most common artemisinin-based combination therapies, artemether-lumefantrine (AL), and its determinants among caregivers of children with malaria seeking care at public health facilities, thus, entitled to receive drugs for free, in southern Mozambique (year 2012). The predicted theoretical demand was contrasted with international and local private market AL prices. Respondents stated high willingness to pay but lower ability to pay (ATP), which was defined as the theoretical demand. The ATP was on average of 0.94 USD for the treatment of a malaria episode. This implied an average gap of 1.04 USD between average local private prices and theoretical demand. Predicted ATP decreased by 14% for every additional malaria episode that the child had suffered during the malaria season. The market price was unaffordable for a large share of our sample, highlighting an unequal welfare distribution between suppliers and potential consumers, as well as issues of inequity in the private delivery of AL.

Maternal HIV infection is an important health determinant in non-HIV-infected infants

OBJECTIVE

To assess morbidity and mortality in HIV-exposed uninfected (HEU) children to help guiding appropriate clinical care and effective preventive interventions.

DESIGN

This is a longitudinal study comparing two cohorts of children; one born to HIV-infected women and the other born to HIV-uninfected women.

METHODS

We have analyzed prospectively obtained information on nutritional status, morbidity and mortality from 966 HEU and 909 HIV-unexposed infants followed up until their first 18 months of life at a referral health facility in southern Mozambique. Determinants for adverse health outcomes in HEU children were also assessed using multivariate logistic regression.

RESULTS

Increased incidence of hospital admissions (P = 0.0015), shorter survival in the first 18 months of life (P = 0.0510) and moderate and severe malnutrition (P = 0.0006 and 0.0014, respectively) were observed among HEU children compared with HIV-unexposed children. Incidence of outpatient attendance in HEU children was associated with being men, older age and the mother being on antiretroviral treatment. Among HEU children, those who were never breastfed, or who were weaned or were partially breastfed, had an increased incidence of hospital admissions compared with children who were exclusively breastfed.

CONCLUSION

Maternal HIV infection has important health consequences in non-HIV-infected children. As the prevalence of HIV-infected pregnant women is maintained and the proportion of HIV-infected children declines because of the scale-up of antiretroviral treatment during pregnancy and breastfeeding, more focus should be given to the health needs of HEU children to ensure that the post-2015 sustainable development goals are met.

High HIV prevalence and incidence among women in Southern Mozambique: Evidence from the MDP microbicide feasibility study

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.

Association between HIV infection and socio-economic status: evidence from a semirural area of southern Mozambique

OBJECTIVES

To analyse the association between socio-economic status (SES) and HIV in Manhiça, a district of Southern Mozambique with one of the highest HIV prevalences in the world.

METHODS

Data were gathered from two cross-sectional surveys performed in 2010 and 2012 among 1511 adults and from the household census of the district's population. Fractional polynomial logit models were used to analyse the association between HIV and SES, controlling for age and sex and taking into account the nonlinearity of covariates. The inequality of the distribution of HIV infection with regard to SES was computed through a concentration index.

RESULTS

Fourth and fifth wealth quintiles, the least poor, were associated with a reduced probability of HIV infection compared to the first quintile (OR = 0.595, P-value = 0.009 and OR = 0.474, P-value < 0.001, respectively). Probability of HIV infection peaked at 36 years and then fell, and was always higher for women regardless of age and SES. HIV infection was unequally distributed across the SES strata.

CONCLUSIONS

Despite the high HIV prevalence across the entire population of Manhiça, the poorest are at greatest risk of being HIV infected. While women have a higher probability of being HIV positive than men, both sexes showed the same infection reduction at higher levels of SES. HIV interventions in the area should particularly focus on the poorest and on women without neglecting anyone else, as the HIV risk is high for everyone.

Congenital and perinatally-acquired infections in resource-constrained settings

INTRODUCTION

Congenital and perinatal infections are a leading cause of neonatal and infant morbidity and mortality. Maternal screening, vaccines or treatment where available, constitute effective prevention strategies to reduce the burden of these diseases. Data on the burden of congenital and perinatal infections are very limited for low and middle-income regions.

AREAS COVERED

This review aims to summarize the burden of congenital and perinatal infections and the main challenges for their control in resource-limited settings. Articles were identified through the main electronic databases and cover the period 1971-2016. Expert commentary: Estimates from low and middle-income countries indicate that the burden of congenital infections may be higher in these regions than in industrialized countries. As preventive and curative strategies are available to tackle some of these infections, efforts at the international and national levels must be made to implement those and thus reduce their burden in resource-limited countries.

Characterization of Vaginal Escherichia coli Isolated from Pregnant Women in Two Different African Sites

The relevance of vaginal colonization of pregnant women by Escherichia coli is poorly understood, despite these strains sharing a similar virulence profile with other extraintestinal pathogenic E. coli producing severe obstetric and neonatal infections. We characterized the epidemiology, antimicrobial susceptibility and virulence profiles of 84 vaginal E. coli isolates from pregnant women from Rabat (Morocco) and Manhiça (Mozambique), two very distinct epidemiological settings. Low levels of antimicrobial resistance were observed to all drugs tested, except for trimethoprim-sulfamethoxazole in Manhiça, where this drug is extensively used as prophylaxis for opportunistic HIV infections. The most prevalent virulence factors were related to iron acquisition systems. Phylogroup A was the most common in Rabat, while phylogroups E and non-typeable were the most frequent in Manhiça. Regardless of the apparently "low virulence" of these isolates, the frequency of infections is higher and the outcomes more devastating in constrained-resources conditions, especially among pregnant women and newborns.

Spatial analysis of HIV infection and associated individual characteristics in Burundi: indications for effective prevention

Background

Adequate resource allocation is critical in the battle against HIV/AIDS, especially in Africa. The determination of the location and nature of HIV services to implement must comply with the geographic, social and behavioral characteristics of patients. We therefore investigated the spatial heterogeneity of HIV prevalence in Burundi and then assessed the association of social and behavioral characteristics with HIV infection accounting for the spatial heterogeneity.

Methods

We used data from the 2010 Demographic and Health Survey. We analyzed these data with a geostatistical approach (which takes into account spatial autocorrelation) by i) interpolating HIV data using the kernel density estimation, ii) identifying the spatial clusters with high and low HIV prevalence using the Kulldorff spatial scan statistics, and then iii) performing a multivariate spatial logistic regression.

Results

Overall HIV prevalence was 1.4 %. The interpolated data showed the great spatial heterogeneity of HIV prevalence (from 0 to 10 %), independently of administrative boundaries. A cluster with high HIV prevalence was found in the capital city and adjacent areas (3.9 %; relative risk 3.7, p < 0.001) whereas a cluster with low prevalence straddled two southern provinces (0 %; p = 0.02). By multivariate spatial analysis, HIV infection was significantly associated with the female sex (posterior odds ratio [POR] 1.36, 95 % credible interval [CrI] 1.13-1.64), an older age (POR 1.97, 95 % CrI 1.26-3.08), the level of education (POR 1.50, 95 % CrI 1.22-1.84), the marital status (POR 1.86, 95 % CrI 1.23-2.80), a higher wealth index (POR 2.11, 95 % CrI 1.77-2.51), the sexual activity (POR 1.76, 95 % CrI 1.04-2.96), and a history of sexually transmitted infection (POR 2.03, 95 % CrI 1.56-2.64).

Conclusions

Our study, which shows where and towards which populations HIV resources should be allocated, could help national health policy makers develop an effective HIV intervention in Burundi. Our findings support the strategy of the Joint United Nations Programme on HIV/AIDS (UNAIDS) for country-specific, in-depth analyses of HIV epidemics to tailor national prevention responses.

Post-ART Symptoms Were Not the Problem: A Qualitative Study on Adherence to ART in HIV-Infected Patients in a Mozambican Rural Hospital

Objective

The objective of this qualitative study was to explore how clinical symptoms may affect adherence to antiretroviral therapy (ART) in HIV patients, and to explore factors, perceptions and attitudes related to adherence to therapy.

Design

A qualitative study was carried out in the context of the prospective cohort study “Evaluation of Immune Reconstitution Following Initiation of Highly Active Antiretroviral Treatment in Manhiça, Mozambique”. In-depth Interviews were conducted twice in a sub-sample of the study cohort (51 participants), at six-month intervals.

Results

Most participants (73%) knew that AIDS is a chronic disease and that ART does not cure it. Nine participants (18%) were non-adherent at some point and two (4%) abandoned ART. All participants but five reported having symptoms after starting ART, mainly attributed to pills needing time to act and body’s reaction to the treatment. In spite of the perceived severity of the symptoms, only two people reported they discontinued the treatment due to symptoms. Almost all participants reported feeling comfortable with the HIV clinic organization and procedures, but afraid of staff being hostile if they did not follow the rules or if the health worker visited their home. Family was one of the most important source of support according participants. Almost all participants with children said that a decisive factor to follow the treatment was the desire to be able to look after them.

Conclusions

Experiencing symptoms after starting treatment was not a barrier to adherence to ART. Factors related to adherence included control measures set up by the health facility (exhaustive follow up, support, information) and family and community support. Indirect ART-related expenses did jeopardise adherence.