Troy D. Moon

Barriers to antiretroviral therapy adherence in rural Mozambique

BackgroundHIV is treated as a chronic disease, but high lost-to-follow-up rates and poor adherence to medication result in higher mortality, morbidity, and viral mutation. Within 18 clinical sites in rural Zambézia Province, Mozambique, patient adherence to antiretroviral therapy has been sub-optimal.MethodsTo better understand barriers to adherence, we conducted 18 community and clinic focus groups in six rural districts. We interviewed 76 women and 88 men, of whom 124 were community participants (CP; 60 women, 64 men) and 40 were health care workers (HCW; 16 women, 24 men) who provide care for those living with HIV.ResultsWhile there was some consensus, both CP and HCW provided complementary insights. CP focus groups noted a lack of confidentiality and poor treatment by hospital staff (42% CP vs. 0% HCW), doubt as to the benefits of antiretroviral therapy (75% CP vs. 0% HCW), and sharing medications with family members (66% CP vs. 0%HCW). Men expressed a greater concern about poor treatment by HCW than women (83% men vs. 0% women). Health care workers blamed patient preference for traditional medicine (42% CP vs. 100% HCW) and the side effects of medication for poor adherence (8% CP vs. 83% CHW).ConclusionsPerspectives of CP and HCW likely reflect differing sociocultural and educational backgrounds. Health care workers must understand community perspectives on causes of suboptimal adherence as a first step toward effective intervention.

Rise in sexually transmitted diseases during democratization and economic crisis in Mongolia.

In 1990, democratic changes and loss of Soviet economic subsidies led to enormous social upheaval in Mongolia. The objective of this study is to map sexually transmitted disease (STD) trends in Mongolia from 1983-1995 and review human immunodeficiency virus (HIV) surveillance data since 1987. Data for syphilis show a decreasing trend from 1983-1993 with a decline in cases from 70 to 18/100,000 population, followed by a rise in cases to 32/100,000 population in 1995. Data suggest a 1.5-3.0 fold higher rate of syphilis for ages 15-24 than for any other group. Data for gonorrhoea show an upward trend in the rate of cases, from 51/100,000 population in 1983 to 142/100,000 in 1995. The majority of cases are aged 15-44. Trichomonas rates also show an upward trend in the number of cases, from 47/100,000 population in 1983 to 155/100,000 cases in 1995. Like gonorrhoea the majority of cases are in the 15-44 year age range. For children aged 0-14, the 1983-1993 rate remained below 4.5/100,000; however, in 1994 and 1995 the rate increased reaching 53 and 48/100,000 respectively. Since 1987, more than 176,000 HIV tests have been done with only one confirmed positive result. Rises in STD rates coincide with deterioration in STD services and reduced active surveillance, suggesting that these data reflect a minimum estimation of the problem. Changes in business and social circumstances may have resulted in increasing HIV and STD risk behaviour.

Transitioning HIV care and treatment programs in southern Africa to full local management

Global AIDS programs such as the US Presidents Emergency Plan for AIDS Relief (PEPFAR) face a challenging health care management transition. HIV care must evolve from vertically-organized, externally-supported efforts to sustainable, locally controlled components that are integrated into the horizontal primary health care systems of host nations. We compared four southern African nations in AIDS care, financial, literacy, and health worker capacity parameters (2005 to 2009) to contrast in their capacities to absorb the huge HIV care and prevention endeavors that are now managed with international technical and fiscal support. Botswana has a relatively high national income, a small population, and an advanced HIV/AIDS care program; it is well poised to take on management of its HIV/AIDS programs. South Africa has had a slower start, given HIV denialism philosophies of the previous government leadership. Nonetheless, South Africa has the national income, health care management, and health worker capacity to succeed in fully local management. The sheer magnitude of the burden is daunting, however, and South Africa will need continuing fiscal assistance. In contrast, Zambia and Mozambique have comparatively lower per capita incomes, many fewer health care workers per capita, and lower national literacy rates. It is improbable that fully independent management of their HIV programs is feasible on the timetable being contemplated by donors, nor is locally sustainable financing conceivable at present. A tailored nation-by-nation approach is needed for the transition to full local capacitation; donor nation policymakers must ensure that global resources and technical support are not removed prematurely.

Improving retention in the early infant diagnosis of HIV program in rural Mozambique by better service integration.

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.

Implementation of cervical cancer screening using visual inspection with acetic acid in rural Mozambique: successes and challenges using HIV care and treatment programme investments in Zambézia Province

In order to maximize the benefits of HIV care and treatment investments in sub‐Saharan Africa, programs can broaden to target other diseases amenable to screening and efficient management. We nested cervical cancer screening into family planning clinics at select sites also receiving PEPFAR support for antiretroviral therapy (ART) rollout. This was done using visual inspection with acetic acid (VIA) by maternal child health nurses. We report on achievements and obstacles in the first year of the program in rural Mozambique.

Enrolment and programmatic trends and predictors of antiretroviral therapy initiation from President's Emergency Plan for AIDS Relief (PEPFAR)-supported public HIV care and treatment sites in rural Mozambique

Summary 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.

Addressing poor retention of infants exposed to HIV: a quality improvement study in rural Mozambique

Objective:Early infant diagnosis (EID) is the first step in HIV care, yet 75% of HIV-exposed infants born at 2 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 2 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 before postpartum 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: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 &khgr;2, 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, but only 17.3% had received enhanced referral. After phase 2, 61.9% received enhanced referral and 39.9% accessed EID, a significant 3-phase improvement (P = 0.007). In adjusted analysis, the likelihood of EID at any time was higher in the phase 2 group versus phase 0 (adjusted hazard ratio: 1.68, 95% confidence interval: 1.19 to 2.37, P = 0.003).

HIV knowledge and health-seeking behavior in Zambézia Province, Mozambique

HIV prevalence rates in Zambézia Province were estimated to be 12.6% in 2009. A number of educational campaigns have been aimed at improving HIV transmission and prevention knowledge among community members in an effort to reduce infection rates. These campaigns have also encouraged people to seek health care at clinical sites, instead of employing traditional healers to cure serious illness. The impact of these programs on the rural population has not been well documented. To assess the level of knowledge about HIV transmission and prevention and health-seeking behavior, we interviewed 349 people in 2009 using free response and multiple choice questionnaires. Over half reported first seeking treatment at a government health clinic; however, the majority of participants had visited a traditional healer in the past. Knowledge regarding prevention and transmission of HIV was primarily limited to the sexual origins of infection and the protective advantages of condom use. Increased educational level and having learned about HIV from a community health worker were associated with higher HIV prevention and transmission knowledge. Traditional healers and community health-care workers were both conduits of health information to our study participants. HIV education and use of clinical services may be facilitated by partnering more closely with these groups.

Poor Clinical Outcomes for HIV Infected Children on Antiretroviral Therapy in Rural Mozambique: Need for Program Quality Improvement and Community Engagement

Introduction Residents 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. Methods We 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. Results Of 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). Conclusions We 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.

HIV/AIDS-Related Attitudes and Practices Among Traditional Healers in Zambézia Province, Mozambique

OBJECTIVES To document HIV knowledge, treatment practices, and the willingness of traditional healers to engage with the health system in Zambézia Province, Mozambique. SETTINGS/LOCATION Traditional healers offer culturally acceptable services and are more numerous in Mozambique than are allopathic providers. Late presentation of human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS) is reported among persons who have first sought care from traditional healers. DESIGN One hundred and thirty-nine (139) traditional healers were interviewed in their native languages (Chuabo or Lomwe) in Zambézia Province. Furthermore, 24 traditional healers were observed during patient encounters. Healers answered a semistructured questionnaire regarding their knowledge of HIV/AIDS, general treatment practices, attitudes toward the allopathic health system, and their beliefs in their abilities to cure AIDS. RESULTS Traditional healers were older and had less formal education than the general population. Razor cutting in order to rub herbs into blooded skin was observed, and healers reported razor cutting as a routine practice. Healers stated that they did not refer HIV patients to clinics for two principal reasons: (1) patient symptoms/signs of HIV were unrecognized, and (2) practitioners believed they could treat the illness effectively themselves. Traditional healers were far more likely to believe in a spiritual than an infectious origin of HIV disease. Prior HIV/AIDS training was not associated with better knowledge or referral practices, though 81% of healers were interested in engaging allopathic providers. CONCLUSIONS It was found that the HIV-related practices of traditional healers probably increase risk for both HIV-infected and uninfected persons through delayed care and reuse of razors. Mozambican traditional healers attribute HIV pathogenesis to spiritual, not infectious, etiologies. Healers who had received prior HIV training were no more knowledgeable, nor did they have better practices. The willingness expressed by 4 in 5 healers to engage local formal health providers in HIV/AIDS care suggests a productive way forward, though educational efforts must be effective and income concerns considered.