HIV-exposed infant follow-up in Mozambique: Formative research findings for the design of a cluster randomized controlled trial to improve testing and ART initiation

Abstract

Background: HIV-exposed infant diagnosis (EID) and initiation of HIV-positive infants on anti-retroviral therapy (ART) requires a well-coordinated cascade of care. Loss-to-follow-up (LTFU) can occur at multiple steps and effective EID is impeded by human resource constraints, difficulty with patient tracking, and long waiting periods. The objective of this research was to conduct formative research to guide the development of an intervention to improve the pediatric HIV care cascade in central Mozambique. The study was conducted in Manica and Sofala Provinces where the adult HIV burden is higher than the national average. The research focused on 3 large clinics in each province, along the highly populated Beira corridor. Methods: The research was initiated in 2014 over 3 months at six facilities and consisted of 1) patient flow mapping and collection of health systems data from postpartum, child-at-risk, and ART service registries, 2) measurement of clinic waiting times, and 3) patient and health worker focus groups. Results: HIV testing and ART initiation coverage for mothers tends to be high, but EID and pediatric ART initiation are hampered by lack of patient tracking, long waiting times, and inadequate counseling to navigate the care cascade. About 76% of HIV-positive infants were LTFU and did not initiate ART. Conclusions: Effective interventions to reduce LTFU in EID and improve pediatric ART initiation should focus on patient tracking, active follow-up of defaulting patients, reduction in EID turn-around times for PCR results, and initiation of ART by nurses in child-at-risk services. TRIAL REGISTRATION: Retrospectively registered, ISRCTN67747315, July 24, 2019.

Correlates of loss to follow-up and missed diagnosis among HIV-exposed infants throughout the breastfeeding period in southern Mozambique

“…This study did not evaluate socioeconomic determinants, such as lack of partner or family support, fear of stigma among others. However, these factors might have affected the early access to PNC and retention throughout the cascade, as reported by other studies conducted in Mozambique, South Africa, and Malawi [ 36 , 39 – 41 ]. Therefore, collecting such data in future studies is crucial to understand whether early linkage and completeness of follow-up are influenced by the same determinants that affect access and retention along all of the steps of the PMTCT cascade [ 20 , 40 , 42 ].…”

“…In fact, at high-volume MCH clinics, nurses or counselors may be unable to spend sufficient time for an appropriate counseling session, as shown in a study in central Mozambique where the median duration of an infant’s visit was between 5 and 11 minutes and the feedback from interviews with mothers and health workers suggested a need to improve the counseling sessions [ 36 ].…”

“…Our data suggest the possibility that either the mothers did not access ANC or they did not receive proper feeding counseling. Again, the quality of counseling sessions is crucial to convey appropriate healthcare messages, and it is critical to keep infants linked to care [ 36 ].…”

HIV-exposed infant follow-up in Mozambique: Formative research findings for the design of a cluster randomized controlled trial to improve testing and ART initiation

“…New work flow and patient flow diagrams were developed for each site. The intervention was initiated in 2015 through 2017 and outcome results of the intervention study have been presented elsewhere (29,30) .…”