Background A key challenge inhibiting the timely initiation of pediatric antiretroviral treatment is the loss to follow-up of mothers and their infants between the time of mothers' HIV diagnoses in pregnancy and return after delivery for early infant diagnosis (EID) of HIV. We sought to identify barriers to follow-up of HIV-exposed infants in rural Zambézia Province, Mozambique. Methods We determined follow-up rates for early infant diagnosis and age at first test in a retrospective cohort of 443 HIV-infected mothers and their infants. Multivariable logistic regression models were used to identify factors associated with successful follow-up. Results Of the 443 mother-infant pairs, 217 (49%) mothers enrolled in the adult HIV care clinic, and only 110 (25%) infants were brought for early infant diagnosis. The predictors of follow-up for EID were larger household size (OR=1.30; 95% CI, 1.09-1.53), independent maternal source of income (OR=10.8; 95% CI, 3.42-34.0), greater distance from the hospital (OR=2.14; 95% CI, 1.01-4.51) and maternal receipt of ART (OR=3.15; 95% CI, 1.02-9.73). The median age at first test among 105 infants was 5 months (interquartile range 2 to 7); 16% of the tested infants were infected. Conclusions Three of four HIV-infected women in rural Mozambique did not bring their children for early infant HIV diagnosis. Maternal receipt of ART has favorable implications for maternal health that will increase the likelihood of early infant diagnosis. We are working with local health authorities to improve the linkage of HIV-infected women to HIV care to maximize early infant diagnosis and care.

BackgroundA legacy of colonial rule coupled with a devastating 16-year civil war through 1992 left Mozambique economically impoverished just as the human immunodeficiency virus (HIV) epidemic swept over southern Africa in the late 1980s. The crumbling Mozambican health care system was wholly inadequate to support the need for new chronic disease services for people with the acquired immunodeficiency syndrome (AIDS).MethodsTo review the unique challenges faced by Mozambique as they have attempted to stem the HIV epidemic, we undertook a systematic literature review through multiple search engines (PubMed, Google Scholar™, SSRN, AnthropologyPlus, AnthroSource) using Mozambique as a required keyword. We searched for any articles that included the required keyword as well as the terms 'HIV' and/or 'AIDS', 'prevalence', 'behaviors', 'knowledge', 'attitudes', 'perceptions', 'prevention', 'gender', drugs, alcohol, and/or 'health care infrastructure'.ResultsUNAIDS 2008 prevalence estimates ranked Mozambique as the 8th most HIV-afflicted nation globally. In 2007, measured HIV prevalence in 36 antenatal clinic sites ranged from 3% to 35%; the national estimate of was 16%. Evidence suggests that the Mozambican HIV epidemic is characterized by a preponderance of heterosexual infections, among the world's most severe health worker shortages, relatively poor knowledge of HIV/AIDS in the general population, and lagging access to HIV preventive and therapeutic services compared to counterpart nations in southern Africa. Poor education systems, high levels of poverty and gender inequality further exacerbate HIV incidence.ConclusionsRecommendations to reduce HIV incidence and AIDS mortality rates in Mozambique include: health system strengthening, rural outreach to increase testing and linkage to care, education about risk reduction and drug adherence, and partnerships with traditional healers and midwives to effect a lessening of stigma.

Low mother/infant retention has impeded early infant diagnosis of HIV in rural Mozambique. We enhanced the referral process for postpartum HIV-infected women by offering direct accompaniment to the location of exposed infant testing before discharge. Retrospective record review for 395 women/infants (September 2009 to June 2010) found enhanced referral was associated with higher odds of follow-up (adjusted odds ratio = 3.18, 95% confidence interval: 1.76 to 5.73, P < 0.001); and among those followed-up, earlier infant testing (median follow-up: 33 days vs. 59 days, P = 0.01) compared with women receiving standard referral. This simple intervention demonstrates benefits gleaned from attention to system improvement through service integration without increasing staff.

Many countries in sub-Saharan Africa have made antiretroviral therapy (ART) available in urban settings, but the progress of treatment expansion into rural Africa has been slower. We analysed routine data for patients enrolled in a rural HIV treatment programme in Zambézia Province, Mozambique (1 June 2006 through 30 March 2009). There were 12,218 patients who were ≥15 years old enrolled (69% women). Median age was 25 years for women and 31 years for men. Older age and higher level of education were strongly predictive of ART initiation (P < 0.001). Patients with a CD4+ count of 350 cells/μL versus 50 cells/μL were less likely to begin ART (odds ratio [OR]: 0.19, 95% confidence interval [CI]: 0.16-0.23). In rural sub-Saharan Africa, HIV testing, linkage to care, logistics for ART initiation and fears among some patients to take ART require specialized planning to maximize successes. Sustainability will require improved health manpower, infrastructure, stable funding, continuous drug supplies, patient record systems and, most importantly, community engagement.