Objectives HIV prevalence and incidence are higher among key populations including Men who have Sex with Men (MSM) and transgender women in low and middle income countries, when compared to the general population. Despite World Health Organisation guidelines on the provision of services to key populations recommending an evidence-based, culturally relevant and rights-based approach, uptake of HIV services in many resource-limited and rights-constrained settings remains low. Mé decins Sans Frontières (MSF) has been offering health services for MSM and transgender women in Beira, Mozambique since 2014 using a peer-educator driven model, but uptake of services has not been as high as expected. This qualitative study aimed to learn more about these key populations in Beira, their experiences of accessing MSM-and transgender-friendly services and their use of face-to-face and virtual networks, including social media, for engagement with health care. Methods In-depth interviews were carried out with MSM and transgender women who were 1) enrolled in, 2) disengaged from or 3) never engaged in MSF's programme. Purposive and snowball sampling were used to recruit the different groups of interviewees. Interviews were conducted in Portuguese, transcribed and translated into English before being coded and manually analysed using a thematic network framework. Results Nine transgender women and 18 cisgender MSM participated in the study. Interviewees ranged in age from 19 to 47 years, with a median age of 29. Three main themes emerged from the data: perceptions of stigma and discrimination, experiences of the peer-educator driven model and the use of face-to-face and virtual platforms for communication and engagement,

BackgroundAntiretroviral therapy is effective in reducing rates of mother-to child transmission of HIV to low levels in resource-limited contexts but the applicability and efficacy of these programs in the field are scarcely known. In order to explore such issues, we performed a descriptive study on retrospective data from hospital records of HIV-infected pregnant women who accessed in 2007–2010 the Luanda Municipal Hospital service for prevention of mother-to-child transmission (PMTCT). The main outcome measure was infant survival and HIV transmission. Our aim was to evaluate PMTCT programme in a local hospital setting in Africa.ResultsData for 104 pregnancies and 107 infants were analysed. Sixty-eight women (65.4%) had a first visit before or during pregnancy and received combination antiretroviral treatment (ART) in pregnancy. The remaining 36 women (34.6%) presented after delivery and received no ART during pregnancy. Across a median cohort follow-up time of 73 weeks, mortality among women with and without ART in pregnancy was 4.4% and 16.7%, respectively (death hazard ratio: 0.30, 95% CI 0.07–1.20, p = 0.089). The estimated rates of HIV transmission or death in the infants over a median follow up time of 74 weeks were 8.5% with maternal ART during pregnancy and 38.9% without maternal ART during pregnancy. Following adjustment for use of oral zidovudine in the newborn and exposure to maternal milk, no ART in pregnancy remained associated with a 5-fold higher infant risk of HIV transmission or death (adjusted odds ratio: 5.13, 95% CI: 1.31–20.15, p = 0.019).ConclusionsAmong the women and infants adhering to the PMTCT programme, HIV transmission and mortality were low. However, many women presented too late for PMTCT, and about 20% of infants did not complete follow up. This suggests the need of targeted interventions that maintain the access of mothers and infants to prevention and care services for HIV.

BackgroundDespite the great morbidity and mortality that childhood bacterial meningitis (BM) is experiencing in Africa, diagnosis of BM in resource-limited contexts is still a challenge. Several algorithms and clinical predictors have been proposed to help physicians in decision-making but a lot of these markers used variables that are calculable only in well-equipped laboratories. Predictors or algorithm based on parameters that can be easily performed in basic laboratories can help significantly in BM diagnosis, even in resource-limited settings, rural hospitals or health centers.ResultsThis retrospective study examined 145 cerebral-spinal fluid (CSF) specimens from children from 2 months to 14 years. CSF specimens were divided into two groups, according to the presence or not of a clinical diagnosis of BM. For each specimen, CSF aspect, CSF white blood cells (WBC) count, CSF glucose and protein concentration were analyzed and statistical analysis were performed. CSF WBC count ≥10/µl is no more a valuable predictor of BM. CSF protein concentration ≥50 mg/dl has a better sensitivity for BM diagnosis and when used with CSF glucose concentration ≤40 mg/dl, can help to diagnose correctly almost all the BM cases. An algorithm including CSF protein concentration, glucose concentration and WBC count has been proposed to rule out BM and to correctly diagnose it.ConclusionsIn resource-limited health centers, the availability of a combination of easy-to-obtain parameters can significantly help physicians in BM diagnosis. The prompt identification of a BM case can be rapid treated or transferred to adequate structures and can modify the outcome in the patient.

Background HIV drug resistance (HIV-DR) is rising in sub-Saharan Africa in both ART-naive and ART-experienced patients. Objectives To estimate the level of acquired DR (ADR) and pre-treatment DR (PDR) across selected urban and rural sites in Southern Africa, in Mozambique. Methods We conducted two cross-sectional surveys among adult HIV patients (October 2017–18) assessing ADR and PDR. In the (ADR) survey, those on NNRTI-based first-line ART for ≥6 months were recruited (three sites). In the PDR survey, those ART-naive or experienced with ≥3 months of treatment interruption prior were enrolled (eight sites). Results Among 1113 ADR survey participants 83% were receiving tenofovir (TDF)/lamivudine (3TC)/efavirenz (EFV). The median time on ART was 4.5 years (Maputo) and 3.2 years (Tete), 8.3% (95% CI 6.2%-10.6%, Maputo) and 15.5% (Tete) had a VL ≥ 1000 copies/mL, among whom 66% and 76.4% had NNRTI+NRTI resistance, and 52.8% and 66.7% had 3TC+TDF-DR. Among those on TDF regimens, 31.1% (Maputo) and 42.2% (Tete) were still TDF susceptible, whereas 24.4% and 11.5% had TDF+zidovudine (ZDV)-DR. Among those on ZDV regimens, 25% and 54.5% had TDF+ZDV-DR. The PDR survey included 735 participants: NNRTI-PDR was 16.8% (12.0–22.6) (Maputo) and 31.2% (26.2–36.6) (Tete), with a higher proportion (≥50%) among those previously on ART affected by PDR. Conclusions In Mozambique, viral failure was driven by NNRTI and NRTI resistance, with NRTI DR affecting backbone options. NNRTI-PDR levels surpassed the WHO 10% ‘alert’ threshold. Replacing NNRTI first-line drugs is urgent, as is frequent viral load monitoring and resistance surveillance. Changing NRTI backbones when switching to second-line regimens may need reconsideration.

Background Seasonal malaria chemoprevention (SMC) is a highly effective community-based intervention to prevent malaria infections in areas where the malaria burden is high and transmission occurs mainly during the rainy season. In Africa, so far, SMC has been implemented in the Sahel region. Mozambique contributes 4% of the global malaria cases, and malaria is responsible for one-quarter of all deaths in the country. Based on recommendations in the Malaria Strategic Plan, the Malaria Consortium, in partnership with the National Malaria Control Programme in Mozambique, initiated a phased SMC implementation study in the northern province of Nampula. The first phase of this 2-year implementation study was conducted in 2020-2021 and focused on the feasibility and acceptability of SMC. The second phase will focus on demonstrating impact. This paper describes phase 2 of the implementation study. Objective Specific objectives include the following: (1) to determine the effectiveness of SMC in terms of its reduction in incidence of malaria infection among children aged 3 to 59 months; (2) to determine the chemoprevention efficacy of sulfadoxine-pyrimethamine plus amodiaquine (SP+AQ) when used for SMC in Nampula Province, Mozambique, and the extent to which efficacy is impacted by drug resistance and drug concentrations; (3) to investigate the presence and change in SP+AQ– and piperaquine-resistance markers over time as a result of SMC implementation; and (4) to understand the impact of the SMC implementation model, determining the process and acceptability outcomes for the intervention. Methods This type 2, hybrid, effectiveness-implementation study uses a convergent mixed methods approach. SMC will be implemented in four monthly cycles between December 2021 and March 2022 in four districts of Nampula Province. Phase 2 will include four components: (1) a cluster randomized controlled trial to establish confirmed malaria cases, (2) a prospective cohort to determine the chemoprevention efficacy of the antimalarials used for SMC and whether drug concentrations or resistance influence the duration of protection, (3) a resistance marker study in children aged 3 to 59 months to describe changes in resistance marker prevalence over time, and (4) a process evaluation to determine feasibility and acceptability of SMC. Results Data collection began in mid-January 2022, and data analysis is expected to be completed by October 2022. Conclusions This is the first effectiveness trial of SMC implemented in Mozambique. The findings from this trial will be crucial to policy change and program expansion to other suitable geographies outside of the Sahel. The chemoprevention efficacy cohort study is a unique opportunity to better understand SMC drug efficacy in this new SMC environment. Trial Registration ClinicalTrials.gov NCT05186363; https://clinicaltrials.gov/ct2/show/NCT05186363 International Registered Report Identifier (IRRID) DERR1-10.2196/36403

Background HIV prevalence in Mozambique is estimated to be 13.2%. Routine viral load for HIV monitoring was first implemented in the rural area of Tete in 2014. Programmatic data showed an unexpected high proportion of high viral load results, with up to 40% of patients having a viral load above 1000 copies/ml. Objectives This qualitative study aimed to explore perceptions about virological failure and viral load monitoring from the perspective of HIV positive patients on first-line antiretroviral therapy (ART) and health-care workers. Methods The study was conducted in seven rural communities in Changara-Marara district, Tete province, Mozambique. A total of 91 participants took part in in-depth interviews (IDIs) and focus group discussions (FGDs), including health-care workers (n = 18), patients on ART in individual care or Community Adherence Groups (CAGs) who experienced virological failure and virological re-suppression (n = 39) and CAG focal points (n = 34). Purposive sampling was used to select participants. Interviews and FGDs were conducted in Nhuengue and Portuguese. IDIs and FGDs were translated and transcribed before being coded and thematically analysed. Results Emergent themes showed that patients and health-care workers attributed great importance to viral load monitoring. A supressed viral load was viewed by participants as a predictor of good health and good adherence. However, some patients were confused and appeared distressed when confronted with virological failure. Viral load results were often little understood, especially when virological failure was detected despite good adherence. Inadequate explanations of causes of virological failure, delayed follow-up viral load results, repeated blood tests and lack of access to second-line ART resulted in reduced confidence in the effectiveness of ART, challenged the patient-provider relationship and disempowered patients and providers. Conclusion In this rural context undetectable viral load is recognized as a predictor of good health by people living with HIV and health-care workers. However, a lack of knowledge and health system barriers caused different responses in patients and health-care workers. Adapted counselling strategies, accelerated viral load follow-up and second-line ART initiation in patients with virological failure need to be prioritized.

BACKGROUND Seasonal malaria chemoprevention (SMC) is a highly effective community-based intervention to prevent malaria infections in areas where the malaria burden is high and transmission occurs mainly during the rainy season. In Africa, so far, SMC has been implemented in the Sahel region. Mozambique contributes 4% of global malaria cases, and malaria represents one out first four causes of death in the country. Based on recommendations in the Malaria Strategic Plan, Malaria Consortium, in partnership with the Mozambican National Malaria Control Program (NMCP), initiated a phased SMC implementation study in the northern province of Nampula. It is as a two-year implementation study, with the first phase, conducted in 2020-2021, focusing on the feasibility and acceptability of SMC and the second phase on demonstrating impact. This paper describes phase 2 of the implementation study. OBJECTIVE Thsi study aims to test the feasibility, effectiveness and chemopreventive efficacy of SMC with SPAQ in a province of Mozambique, Nampula, where malaria transmission is highly seasonal. METHODS This type 2 hybrid effectiveness-implementation study uses a convergent mixed-methods approach. SMC will be implemented in four monthly cycles between December 2021 and March 2022 in four districts of Nampula province. Phase 2 will include four components: a cluster randomized control trial (cRCT) to establish confirmed malaria cases, a prospective cohort to determine whether SPAQ provides 28 days of protection from infection, and whether drug concentrations and/or resistance influence the duration of protection, a resistance markers study in children aged 3–59 months to describe changes in resistance marker prevalence over time. Finally, a process evaluation will determine feasibility and acceptability of SMC. RESULTS Ethical approval was granted by Comité Nacional de Bioética para a Saùde (CNBS) of MoH of Mozambique (Ref: 803/CNBS/21) and by Research Ethics Committee of the Hospital Clinic of Barcelona (Ref: HCB/2021/0944). Data collection begins in mid-January 2022, and data analysis is expected to be completed by August 2022. CONCLUSIONS This is the first effectiveness trial of SMC implemented in Mozambique. The findings from this trial will be crucial to policy change and program expansion to other suitable geographies outside the Sahel. The chemoprevention efficacy cohort study is a unique opportunity to better understand SMC drug efficacy in this new SMC environment. CLINICALTRIAL The trial has been registered on clinicaltrials.gov (Ref: NCT05186363).

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