IntroductionResidents of Zambézia Province, Mozambique live from rural subsistence farming and fishing. The 2009 provincial HIV prevalence for adults 15–49 years was 12.6%, higher among women (15.3%) than men (8.9%). We reviewed clinical data to assess outcomes for HIV-infected children on combination antiretroviral therapy (cART) in a highly resource-limited setting.MethodsWe studied rates of 2-year mortality and loss to follow-up (LTFU) for children <15 years of age initiating cART between June 2006–July 2011 in 10 rural districts. National guidelines define LTFU as >60 days following last-scheduled medication pickup. Kaplan-Meier estimates to compute mortality assumed non-informative censoring. Cumulative LTFU incidence calculations treated death as a competing risk.ResultsOf 753 children, 29.0% (95% CI: 24.5, 33.2) were confirmed dead by 2 years and 39.0% (95% CI: 34.8, 42.9) were LTFU with unknown clinical outcomes. The cohort mortality rate was 8.4% (95% CI: 6.3, 10.4) after 90 days on cART and 19.2% (95% CI: 16.0, 22.3) after 365 days. Higher hemoglobin at cART initiation was associated with being alive and on cART at 2 years (alive: 9.3 g/dL vs. dead or LTFU: 8.3–8.4 g/dL, p<0.01). Cotrimoxazole use within 90 days of ART initiation was associated with improved 2-year outcomes Treatment was initiated late (WHO stage III/IV) among 48% of the children with WHO stage recorded in their records. Marked heterogeneity in outcomes by district was noted (p<0.001).ConclusionsWe found poor clinical and programmatic outcomes among children taking cART in rural Mozambique. Expanded testing, early infant diagnosis, counseling/support services, case finding, and outreach are insufficiently implemented. Our quality improvement efforts seek to better link pregnancy and HIV services, expand coverage and timeliness of infant diagnosis and treatment, and increase follow-up and adherence.

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The role of health literacy on HIV outcomes has not been evaluated widely in Africa, in part because few appropriate literacy measures exist. We developed a 16-item scale, the HIV Literacy Test (HIV-LT) to assess literacy-related tasks needed to participate in HIV care. Items were scored as correct or incorrect; higher scores indicated higher literacy skill (range 0–100 %). We tested internal reliability (Kuder–Richardson coefficient) of the HIV-LT in a convenience sample of 319 Portuguese-speaking, HIV infected adults on antiretroviral treatment in Maputo, Mozambique. Construct validity was assessed by a hypothetical model developed a priori. The HIV-LT was reliable and valid to measure participants’ literacy skills. The mean HIV-LT score was 42 %; literacy skills applicable to HIV care were challenging for many participants. The HIV-LT could be used to assess the relationship of literacy and HIV-related outcomes in diverse settings, and evaluate interventions to improve health communication for those in HIV care.Electronic supplementary materialThe online version of this article (doi:10.1007/s10461-016-1348-3) contains supplementary material, which is available to authorized users.

Early achievements in biomedical approaches for HIV prevention included physical barriers (condoms), clean injection equipment (both for medical use and for injection drug users), blood and blood product safety, and prevention of mother to child transmission. In recent years, antiretroviral drugs to reduce risk of transmission (when the infected person takes the medicines; treatment as prevention or TasP) or reduce risk of acquisition (when the seronegative person takes them; pre-exposure prophylaxis or PrEP) have proven efficacious. Circumcision of men has also been a major tool relevant for higher prevalence regions such as sub-Saharan Africa. Well-established prevention strategies in the control of sexually transmitted diseases and tuberculosis are highly relevant for HIV (i.e., screening, linkage to care, early treatment, and contact tracing). Unfortunately, only slow progress is being made in some available HIV prevention strategies such as family planning for HIV-infected women who do not want more children and prevention mother-to-child HIV transmission. Current studies seek to integrate strategies into approaches that combine biomedical, behavioral, and structural methods to achieve prevention synergies. This review identifies the major biomedical approaches demonstrated to be efficacious that are now available. We also highlight the need for behavioral risk reduction and adherence as essential components of any biomedical approach.

Objective Early infant diagnosis (EID) is the first step in HIV care, yet 75% of HIV-exposed infants born at two hospitals in Mozambique failed to access EID. Design Before/after study. Setting Two district hospitals in rural Mozambique. Participants HIV-infected mother/HIV-exposed infant pairs (N=791). Intervention We planned two phases of improvement using quality improvement methods. In Phase 1, we enhanced referral by offering direct accompaniment of new mothers to the EID suite, increasing privacy, and opening a medical record for infants prior to post-partum discharge. In Phase 2, we added enhanced referral activity as an item on the maternity register to standardize the process of referral. Main outcome measure(s) The proportion of HIV-infected mothers who accessed EID for their infant <90 days of life. Results We tracked mother/infant pairs from June 2009 to March 2011 (Phase 0: N=144; Phase 1: N=479; Phase 2: N=168), compared study measures for mother/infant pairs across intervention phases with chi-square, estimated time-to-EID by Kaplan-Meier, and determined the likelihood of EID by Cox regression after adjusting for likely barriers to follow-up. At baseline (phase 0), 25.7% of infants accessed EID <90 days. EID improved to 32.2% after Phase 1; only 17.3% received enhanced referral. After Phase 2, 61.9% received enhanced referral and 39.9% accessed EID, a significant three-phase improvement (p=0.007). In adjusted analysis, the likelihood of EID at any time was higher in the Phase 2 group vs. Phase 0 (aHR:1.68, 95%CI:1.19-2.37, p=0.003). Conclusions Retention improved by 55% with a simple referral enhancement. Quality improvement efforts could help improve care in Mozambique and other low-resource countries.

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