Partner-Based HIV Treatment for Seroconcordant Couples Attending Antenatal and Postnatal Care in Rural Mozambique: A Cluster Randomized Controlled Trial.

INTRODUCTION: There is evidence that a supportive male partner facilitates maternal HIV testing during pregnancy, increases maternal antiretroviral therapy initiation and adherence, and increases HIV-free infant survival. Most male partner engagement clinical strategies have focused on increasing uptake of couple-based HIV testing and counseling. We delivered a couple-based care and treatment intervention to improve antiretroviral therapy adherence in expectant couples living with HIV. METHODS: We implemented a cluster randomized controlled trial for seroconcordant couples living with HIV, comparing retention (using a patient's medication possession ratio) in HIV care for a couple-based care and treatment intervention vs. standard of care services in rural Mozambique. The intervention included couple-based treatment, couple-based education and skills building, and couple-peer educator support. RESULTS: We recruited 1080 couples to participate in the study. Using a linear mixed effect model with a random effect for clinic, the intervention had no impact on the medication possession ratio among women at 12 months. However, the intervention increased men's medication ratio by 8.77%. Our unadjusted logistic regression model found the odds of an infant seroconverting in the intervention group was 30% less than in the control group, but the results were not statistically significant. DISCUSSION: Our study found no difference in maternal outcomes by study arm, but our intervention resulted in an improved medication possession ratio among male partners. We provide a community/clinic-based treatment framework that can improve outcomes among male partners. Further work needs to be done to improve social support for pregnant women and to facilitate prevention of vertical transmission to infants among couples living with HIV.

Development of an adjustable patient-specific rigid guide to improve the accuracy of external ventricular catheter placement.

OBJECTIVE: The most common method for external ventricular drain (EVD) placement is the freehand approach, which has reported inaccuracy rates of 12.3%-44.9%, especially in the case of altered ventricular anatomy. Current assistive devices require added time or equipment or do not account for shifted ventricles. To improve the accuracy of emergent EVD placement in the setting of altered ventricular anatomy, the authors designed a patient-specific EVD (PS-EVD) guide. METHODS: The PS-EVD guide has a tripod base and a series of differently angled inserts that lock in place at multiple rotational positions, allowing for numerous insertion angles. For testing, the authors designed a 3D-printed phantom skull with a gelatin brain analog containing ventricles simulating normal and altered ventricular anatomy. Low-resolution CT scans of the phantom were used to calculate the insertion angle in relation to the standard perpendicular entry. The corresponding insert at the correct rotational position within the base unit was positioned over the entry point on the phantom, and the catheter was inserted. Accuracy was evaluated with repeat CT scans. RESULTS: With normal ventricular anatomy, as well as abnormally shifted ventricles, proper use of the PS-EVD guide led to accurate catheter insertion into the ventricle in trials, as confirmed on coronal and sagittal CT images, including cases in which a perpendicular trajectory, such as with the Ghajar guide, was insufficient. CONCLUSIONS: The PS-EVD guide allows consistent and accurate EVD placement in phantom skulls with both normal and altered ventricular anatomy. Further trials comparing this device to the freehand approach are required.

Dear Program Director: An Evaluation of Implicit Bias in Letters of Recommendation for Neurosurgery Residency.

BACKGROUND AND OBJECTIVES: Despite comprising half of medical students, women represent only 29.6% of neurosurgery applicants and 17% of residents, suggesting a "leak" in the career pipeline for women neurosurgeons. Surveys persistently show that neurosurgery programs identify United States Medical Licensing Examination (USMLE®) Step 1 score and letters of recommendation (LORs) as the most important factors in selecting applicants to interview. A previous study in neurosurgery found no differences in LORs. However, multiple studies in other specialties have demonstrated implicit gender bias in LORs, which may influence resident selection. Our objective is to evaluate neurosurgery residency LORs for evidence of implicit gender bias. METHODS: Retrospective analysis of LORs for interviewed neurosurgery applicants at a single institution during the 2014 to 2020 National Residency Matching Program (NRMP®) match cycles. Letters were evaluated using Linguistic Inquiry & Word Count (LIWC) software (Pennebaker Conglomerates), and additional applicant data were obtained from candidate applications. LIWC (Pennebaker Conglomerates) output data included custom dictionary categories and terms that were analyzed using Prism 10 and Rstudio. RESULTS: Two hundred eighteen applications were reviewed for a total of 827 letters. LIWC (Pennebaker Conglomerates) analysis showed significant differences in word count (331 vs 297, difference = 34, 95% CI: 9-61, P = .008). LORs for applicants who were men were more likely to mention Alpha Omega Alpha Honor Medical Society (1.17 vs 0.778, difference = 0.4, 95% CI: 0.13-0.67, P = .023). USMLE® Step 1 scores were significantly lower for women (241 vs 247, difference = 6, 95% CI: 2-10, P = .004). There was no significant difference between letters for men and women for all categories evaluated in the linguistic evaluation. CONCLUSION: LORs are vital to the neurosurgical residency application process. The data exhibit some differences between the men and women applicants but few differences in their LORs, consistent with the results of the previous neurosurgical study.

Time spent at health facility is a key driver of patient satisfaction, but did not influence retention to HIV care: A serial cross-sectional study in Mozambique.

INTRODUCTION: Patient satisfaction with clinical services can have an effect on retention in HIV care and adherence to antiretroviral therapy. This study assessed patient satisfaction and its association with retention and viral suppression in Zambézia Province, Mozambique. METHODS: Monthly exit interviews with persons living with HIV were completed from August 2017-January 2019 in 20 health facilities; clinical data were extracted from medical records. Regression analyses assessed the effect of satisfaction scores on retention and viral suppression, adjusting for age, sex, education, civil status, time on treatment, and site. Satisfaction scores were correlated with time spent at health facilities using generalized linear regression models. RESULTS: Data from 4388 patients were analyzed. Overall median satisfaction score was 75% (IQR 53%-84%); median time spent at facilities (from arrival until completion of clinical services) was 2h54min (IQR 1h48min-4h). Overall satisfaction score was not associated with higher odds of retention or viral suppression, but association was seen between satisfaction regarding attention given to patient and respect and higher odds of viral suppression. Patient satisfaction was negatively associated with time spent in facility (Spearman's correlation -0.63). Increased time spent at facility (from 1 to 3 hours) was not associated with lower retention in care (OR 0.72 [95%CI:0.52-1.01] and 0.83 [95%CI: 0.63-1.09] at 6- and 12-months, respectively), nor with a lower odds of viral suppression (OR 0.96 [95%CI: 0.71-1.32]). CONCLUSIONS: Strategies to reduce patient wait times at the health facility warrant continued prioritization. Differentiated models of care have helped considerably, but novel approaches are still needed to further decongest crowded health facilities. In addition, a good client-provider communication and positive attitude can improve patient satisfaction with health services, with an overall improved retention.

Healthcare Providers' Perspectives on a Novel Couple-Based HIV Treatment Intervention: A Qualitative Assessment of the Facilitators, Barriers, and Proposed Improvements to Implementation in Zambézia Province, Mozambique.

Mozambique has one of the world's highest HIV/AIDS burdens. Despite significant investment in HIV care and treatment, pregnant and lactating women's retention in care remains suboptimal. One reason for poor maternal retention is lack of male partner support. We tested an interventional couple-based HIV care and treatment, including joint clinical appointments and couple-based educational and support sessions provided by a health counselor and peer educators, respectively. Healthcare providers delivering care for seroconcordant individuals were interviewed regarding their perspectives on facilitators and barriers to the couple-based intervention implementation. Analysis of interview responses was done using MAXQDA. Results pertaining to providers' perspectives on implementation and intervention characteristics were organized, interpreted, and contextualized using the Consolidated Framework for Implementation Research (CFIR 2.0), while providers' suggestions for improvements were coded and organized apart from CFIR. Providers felt the intervention was largely compatible with the local culture, and offered a significant advantage over standard individual-based care by facilitating patient follow-up and reducing wait times by prioritizing couples for services. They also believed it facilitated HIV treatment access through the provision of couple-based counseling that encouraged supportive behaviors towards retention. However, providers reported insufficient privacy to deliver couple-based care at some health facilities and concerns that women in difficult relationships may struggle to meaningfully participate. They suggested providing sessions in alternate clinic settings and offering a limited number of women-only visits. The facilitators and barriers described here contribute to informing the design and implementation of future couple-based interventions to improve HIV care for seroconcordant expectant couples.

Healthcare providers' perspectives on a novel couple-based HIV treatment intervention: A qualitative assessment of the facilitators, barriers, and proposed improvements to implementation in zambézia province, mozambique

Mozambique has one of the world's highest HIV/AIDS burdens. Despite significant investment in HIV care and treatment, pregnant and lactating women's retention in care remains suboptimal. One reason for poor maternal retention is lack of male partner support. We tested an interventional couple-based HIV care and treatment, including joint clinical appointments and couple-based educational and support sessions provided by a health counselor and peer educators, respectively. Healthcare providers delivering care for seroconcordant individuals were interviewed regarding their perspectives on facilitators and barriers to the couple-based intervention implementation. Analysis of interview responses was done using MAXQDA. Results pertaining to providers' perspectives on implementation and intervention characteristics were organized, interpreted, and contextualized using the Consolidated Framework for Implementation Research (CFIR 2.0), while providers' suggestions for improvements were coded and organized apart from CFIR. Providers felt the intervention was largely compatible with the local culture, and offered a significant advantage over standard individual-based care by facilitating patient follow-up and reducing wait times by prioritizing couples for services. They also believed it facilitated HIV treatment access through the provision of couple-based counseling that encouraged supportive behaviors towards retention. However, providers reported insufficient privacy to deliver couple-based care at some health facilities and concerns that women in difficult relationships may struggle to meaningfully participate. They suggested providing sessions in alternate clinic settings and offering a limited number of women-only visits. The facilitators and barriers described here contribute to informing the design and implementation of future couple-based interventions to improve HIV care for seroconcordant expectant couples.

Migraine Treatment and Healthcare Resource Utilization in Alberta, Canada.

BACKGROUND: Migraine poses a significant burden worldwide; however, there is limited evidence as to the burden in Canada. This study examined the treatment patterns, healthcare resource use (HRU), and costs among newly diagnosed or recurrent patients with migraine in Alberta, Canada, from the time of diagnosis or recurrence. METHODS: This retrospective observational study utilized administrative health data from Alberta, Canada. Patients were included in the Total Migraine Cohort if they had: (1) ≥1 International Classification of Diseases diagnostic code for migraine; or (2) ≥1 prescription dispense(s) for triptans from April 1, 2012, to March 31, 2018, with no previous diagnosis or dispensation code from April 1, 2010, to April 1, 2012. RESULTS: The mean age of the cohort (n = 199,931) was 40.0 years and 72.3% were women. The most common comorbidity was depression (19.7%). In each medication class examined, less than one-third of the cohort was prescribed triptans and fewer than one-fifth was prescribed a preventive. Among patients with ≥1 dispense, the mean rate of opioid prescriptions was 4.61 per patient-year, compared to 2.28 triptan prescriptions per patient-year. Migraine-related HRU accounted for 3%-10% of all use. CONCLUSION: Comorbidities and high all-cause HRU were observed among newly diagnosed or recurrent patients with migraine. There is an underutilization of acute and preventive medications in the management of migraine. The high rate of opioid use reinforces the suboptimal management of migraine in Alberta. Migraine management may improve by educating healthcare professionals to optimize treatment strategies.

Burden of Episodic Migraine, Chronic Migraine, and Medication Overuse Headache in Alberta.

OBJECTIVE: To describe demographic and clinical characteristics, healthcare resource use, costs, and treatment patterns in three migraine cohorts. METHODS: This retrospective observational study using administrative data examined patients with episodic migraine (EM), chronic migraine (CM) (without medication overuse headache [MOH]), and medication overuse headache in Alberta, Canada. Migraine patients were identified between 2012 and 2018 based on ≥ 1 diagnostic codes or triptan prescription. Patients with CM were defined using parameter estimates of a logistic regression model, and MOH was defined as patients with an average of ≥ 15 supply days covered of acute medications. EM was defined as patients without CM or MOH. Study outcomes were summarized using descriptive statistics. RESULTS: Patients with EM (n = 144,574), CM (n = 27,283), and MOH (n = 11,485) were included. Higher rates of healthcare use and costs were observed for CM (mean [SD] all-cause cost: ($12,693 [40,664]) and MOH ($16,611.5 [$38,748]) versus episodic migraine ($4,251 [$40,637]). Across all cohorts, opioids were the most dispensed acute medication (range across cohorts: 31.7%-89.8%), while antidepressants and anticonvulsants were the most dispensed preventive medication. Preventative medication classes were used by a minority of patients in each cohort, except anticonvulsants, where 50% of medication overuse patients had a dispensation. CONCLUSIONS: Patients with CM and MOH have a greater burden of illness compared to patients with EM. The overutilization of acute medication, particularly opioids, and the underutilization of preventive medications highlight an unmet need to more effectively manage migraine.

Favorable Impact of Community Adherence Support Groups on Retention in Care and Viral Suppression Rates Among Persons with HIV Receiving Antiretroviral Therapy in Mozambique

The community adherence support group (CASG) was one of the first differentiated service delivery (DSD) models introduced in Mozambique. This study assessed the impact of this model on retention in care, loss to follow-up (LTFU), and viral suppression among antiretroviral therapy (ART)-treated adults in Mozambique. A retrospective cohort study included CASG-eligible adults enrolled between April 2012 and October 2017 at 123 health facilities in Zambézia Province. Propensity score matching (1:1 ratio) was used to allocate CASG members and those who never enrolled in a CASG. Logistic regressions were performed to estimate the impact of CASG membership on 6- and 12-month retention and viral load (VL) suppression. Cox proportional regression was used to model differences in LTFU. Data from 26,858 patients were included. The median age at CASG eligibility was 32 years and 75% were female, with 84% residing in rural areas. A total of 93% and 90% of CASG members were retained in care at 6 and 12 months, respectively, while 77% and 66% non-CASG members were retained during the same periods. The odds of being retained in care at 6 and 12 months were significantly higher among patients receiving ART through CASG support (adjusted odds ratio [aOR] = 4.19 [95% confidence interval; CI: 3.79-4.63], p < .001, and aOR = 4.43 [95% CI: 4.01-4.90], p < .001, respectively). Among 7,674 patients with available VL measurements, the odds of being virally suppressed were higher among CASG members (aOR = 1.14 [95% CI: 1.02-1.28], p < .001). Non-CASG members had a significantly higher likelihood of being LTFU (adjusted hazard ratio = 3.45 [95% CI: 3.20-3.73], p < .001). While Mozambique rapidly scales up multi-month drug dispensation as the preferred DSD model, this study emphasizes the continued importance of CASG as an efficacious DSD alternative, especially among patients residing in rural areas, where CASG acceptability is higher.

Middle meningeal artery embolization in the management of chronic subdural hematoma in medically complex pediatric neurosurgical patients: technical note.

Middle meningeal artery (MMA) embolization has gained acceptance as a treatment for chronic subdural hematoma (cSDH) in adult patients but has not been well described in pediatric patients. Standard cSDH treatment has historically consisted of burr hole drainage with or without subdural drain placement. However, due to the high rate of recurrence and frequency of comorbidities within this population, as both pediatric and adult patients with cSDH frequently have concurrent cardiac disease and a need for anticoagulant therapies, MMA embolization has increasingly demonstrated its value as both an adjunctive and primary treatment. In this report, the authors present 3 cases of successful MMA embolization in medically complex children at a single institution. MMA embolization was used as a primary treatment modality and as an adjunctive therapy in the acute setting following surgical hematoma evacuation. Two patients were receiving anticoagulation treatment requiring reversal. Technical considerations specific to the pediatric population as well as those common to both the pediatric and adult populations are addressed. Further work is needed to define the optimal indications and outcomes for MMA embolization in children with cSDH.

Sickle cell disease in Ontario, Canada: an epidemiologic profile based on health administrative data.

BACKGROUND: The number of patients with sickle cell disease in Ontario, Canada, is unknown. In the absence of a formal registry, we performed a study to determine an approximate census via analysis of health administrative databases. METHODS: We identified Ontario patients with a diagnosis of sickle cell disease through queries of the Discharge Abstract Database, National Ambulatory Care Reporting System and Newborn Screening Ontario database. The period of inquiry was Apr. 1, 2007, through Mar. 31, 2017. We identified repeat interactions by the same patient by cross-referencing provincial health insurance plan numbers. RESULTS: We documented health care system interactions for 3418 unique patients (1912 [55.9%] female, median age at the time of identification 24 yr). Over the 10-year study period, patients visited the emergency department a median of 2 (interquartile range [IQR] 1-7) times and an average of 6.69 (standard deviation [SD] 26.71) times, and were admitted to hospital a median of 1 (IQR 1-5) time and an average of 4.38 (SD 8.53) times for treatment related to sickle cell disease. A total of 229 patients (6.7%) died during the study period, with an average age at death of 55 years. Even without accounting for the effects of immigration, the rate of natural increase slowed slightly over the study period owing to a decrease in the annual number of affected births. INTERPRETATION: The estimated prevalence of patients with sickle cell disease in Ontario in 2007/08-2016/17 was 1 in 4200, and affected patients' need for hospital-based care was substantial, although highly variable. Similar queries of health administrative databases may be feasible in other Canadian provinces.

Trends in major adverse cardiac events and healthcare utilization during the COVID-19 pandemic in Alberta, Canada.

Background: Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality in Canada. The COVID-19 pandemic altered the usual care of ambulatory and acute cardiac patients. This study aimed to describe ASCVD-related clinical outcomes and healthcare resource utilization (HCRU) patterns during the coronavirus disease 2019 (COVID-19) pandemic in Alberta, Canada, relative to the three preceding years. Methods: A repeated cross-sectional study design was conducted over three-month periods using administrative health data between March 15, 2017, and March 14, 2021. ASCVD-related clinical outcomes included major adverse cardiovascular events (MACE) endpoints. HCRU was assessed through general practitioner and other healthcare professional visits (including telehealth claims) for ASCVD events, emergency department visits, ASCVD diagnostic imaging tests, laboratory tests, and hospital length of stay. Results: Relative to the control year period (March to June 2019) ASCVD-related events (i.e., hospitalizations, emergency department (ED) visits and physician office visits) declined by 23% during the three-months COVID-19 period (March to June 2020). Acute declines were not sustained following June 2020. In contrast, in-patient mortality rates involving a primary MACE endpoint increased from March to June 2020 COVID-19 period. Conclusions: This study demonstrates the COVID-19 pandemic and corresponding public health restrictions impacted ASCVD-related care. While many clinical outcomes returned to pre-pandemic levels at the end of the observation period, our results suggest that patients' HCRU declined, which could lead to further CV events and mortality. Understanding the impact of COVID-19 restrictions on ASCVD-related care may help improve healthcare resiliency.

Gender differences in cardiothoracic surgery letters of recommendation.

OBJECTIVE: To investigate whether or not gender influences letters of recommendation for cardiothoracic surgery fellowship. METHODS: From applications to an Accreditation Council Graduate Medical Education cardiothoracic surgery fellowship program between 2016 and 2021, applicant and author characteristics were examined with descriptive statistics, analysis of variance, and Pearson χ2 tests. Linguistic software was used to assess communication differences in letters of recommendation, stratified by author and applicant gender. An additional higher-level analysis was then performed using a generalized estimating equations model to examine linguistic differences among author-applicant gender pairs. RESULTS: Seven hundred thirty-nine recommendation letters extracted from 196 individual applications were analyzed; 90% (n = 665) of authors were men and 55.8% (n = 412) of authors were cardiothoracic surgeons. Compared with women authors, authors who are men wrote more authentic (P = .01) and informal (P = .03) recommendation letters. When writing for women applicants, authors who are men were more likely to display their own leadership and status (P = .03) and discuss women applicants' social affiliations (P = .01), like occupation of applicant's father or husband. Women authors wrote longer letters (P = .03) and discussed applicants' work (P = .01) more often than authors who are men. They also mentioned leisure activities (P = .03) more often when writing for women applicants. CONCLUSIONS: Our work identifies gender-specific differences in letters of recommendation. Women applicants may be disadvantaged because their recommendation letters are significantly more likely to focus on their social ties, leisure activities, and the status of the letter writer. Author and reviewer awareness of gender-biased use of language will aid in improvements to the candidate selection process.

Attitudes and perceptions towards postpartum contraceptive use among seroconcordant partners with HIV in rural Mozambique: a qualitative study.

BACKGROUND: Postpartum contraceptive uptake reduces short interpregnancy intervals, unintended pregnancies, and their negative sequalae: poor maternal and fetal outcomes. Healthy timing and spacing of pregnancy in people living with HIV (PLHIV) also allows time to achieve viral suppression to reduce parent-to-child HIV transmission. There is scant understanding about how couples-based interventions impact postpartum contraceptive uptake among PLHIV in sub-Saharan Africa. METHODS: We interviewed 38 recently pregnant people and 26 of their partners enrolled in the intervention arm of the Homens para Saúde Mais (HoPS+) [Men for Health Plus] trial to assess their perceptions of, attitudes towards, and experiences with contraceptive use. Individuals in the HoPS+ intervention arm received joint-as opposed to individual-HIV-related services during pregnancy and postpartum periods, six counseling and skills sessions, and nine sessions with a peer support couple. Our thematic analysis of the 64 in-depth interviews generated 14 deductive codes and 3 inductive codes across themes within the Information, Motivation, and Behavior Model of health behavior change. RESULTS: Participants reported accurate and inaccurate information about birth spacing and contraceptive methods. They described personal (health, economic, and religious) and social (gender norms, desired number of children) motivations for deciding whether to use contraceptives-with slightly different motivations among pregnant and non-pregnant partners. Finally, they explained the skills needed to overcome barriers to contraceptive use including how engagement in HoPS+ improved their shared decision-making skills and respect amongst partners-which facilitated postpartum contraceptive uptake. There were also several cases where non-pregnant partners unilaterally made family planning decisions despite disagreement from their partner. CONCLUSIONS: These findings suggest that couples-based interventions during pregnancy and post-partum periods aimed at increasing postpartum contraceptive uptake must center pregnant partners' desires. Specifically, pregnant partners should be allowed to titrate the level of non-pregnant partner involvement in intervention activities to avoid potentially emboldening harmful gender-based intercouple decision-making dynamics.

Attitudes and perceptions towards postpartum contraceptive use among seroconcordant partners with HIV in rural Mozambique: a qualitative study

Background Postpartum contraceptive uptake reduces short interpregnancy intervals, unintended pregnancies, and their negative sequalae: poor maternal and fetal outcomes. Healthy timing and spacing of pregnancy in people living with HIV (PLHIV) also allows time to achieve viral suppression to reduce parent-to-child HIV transmission. There is scant understanding about how couples-based interventions impact postpartum contraceptive uptake among PLHIV in sub-Saharan Africa. Methods We interviewed 38 recently pregnant people and 26 of their partners enrolled in the intervention arm of the Homens para Saúde Mais (HoPS+) [Men for Health Plus] trial to assess their perceptions of, attitudes towards, and experiences with contraceptive use. Individuals in the HoPS+intervention arm received joint­as opposed to individual­HIV-related services during pregnancy and postpartum periods, six counseling and skills sessions, and nine sessions with a peer support couple. Our thematic analysis of the 64 in-depth interviews generated 14 deductive codes and 3 inductive codes across themes within the Information, Motivation, and Behavior Model of health behavior change. Results Participants reported accurate and inaccurate information about birth spacing and contraceptive methods. They described personal (health, economic, and religious) and social (gender norms, desired number of children) motivations for deciding whether to use contraceptives­with slightly diferent motivations among pregnant and non-pregnant partners. Finally, they explained the skills needed to overcome barriers to contraceptive use including how engagement in HoPS+improved their shared decision-making skills and respect amongst partners­which facilitated postpartum contraceptive uptake. There were also several cases where non-pregnant partners unilaterally made family planning decisions despite disagreement from their partner. Conclusions These fndings suggest that couples-based interventions during pregnancy and post-partum periods aimed at increasing postpartum contraceptive uptake must center pregnant partners' desires. Specifcally, pregnant partners should be allowed to titrate the level of non-pregnant partner involvement in intervention activities to avoid potentially emboldening harmful gender-based intercouple decision-making dynamics.

Favorable Impact of Community Adherence Support Groups on Retention in Care and Viral Suppression Rates Among Persons with HIV Receiving Antiretroviral Therapy in Mozambique.

The community adherence support group (CASG) was one of the first differentiated service delivery (DSD) models introduced in Mozambique. This study assessed the impact of this model on retention in care, loss to follow-up (LTFU), and viral suppression among antiretroviral therapy (ART)-treated adults in Mozambique. A retrospective cohort study included CASG-eligible adults enrolled between April 2012 and October 2017 at 123 health facilities in Zambézia Province. Propensity score matching (1:1 ratio) was used to allocate CASG members and those who never enrolled in a CASG. Logistic regressions were performed to estimate the impact of CASG membership on 6- and 12-month retention and viral load (VL) suppression. Cox proportional regression was used to model differences in LTFU. Data from 26,858 patients were included. The median age at CASG eligibility was 32 years and 75% were female, with 84% residing in rural areas. A total of 93% and 90% of CASG members were retained in care at 6 and 12 months, respectively, while 77% and 66% non-CASG members were retained during the same periods. The odds of being retained in care at 6 and 12 months were significantly higher among patients receiving ART through CASG support (adjusted odds ratio [aOR] = 4.19 [95% confidence interval; CI: 3.79-4.63], p < .001, and aOR = 4.43 [95% CI: 4.01-4.90], p < .001, respectively). Among 7,674 patients with available VL measurements, the odds of being virally suppressed were higher among CASG members (aOR = 1.14 [95% CI: 1.02-1.28], p < .001). Non-CASG members had a significantly higher likelihood of being LTFU (adjusted hazard ratio = 3.45 [95% CI: 3.20-3.73], p < .001). While Mozambique rapidly scales up multi-month drug dispensation as the preferred DSD model, this study emphasizes the continued importance of CASG as an efficacious DSD alternative, especially among patients residing in rural areas, where CASG acceptability is higher.

Health care services for survivors of gender-based violence: a community and clinic-based intervention in Zambézia province, Mozambique

Moçambique introduziu directrizes para serviços integrados de violência baseada no género (VBG) em 2012. Em 2017, formámos prestadores de serviços em serviços empáticos e de apoio aos sobreviventes da VBG e introduzimos serviços domiciliários para sobreviventes que não têm acompanhamento. As proporções de taxas de visitas clínicas foram comparadas antes e depois do início da intervenção, utilizando testes de significância exata. Foram revistos dados de 1.806 sobreviventes da VBG, com um total de 2.005 eventos. A idade mediana foi de 23 anos (IQR 17-30) e 89% eram mulheres. Entre aqueles que relataram violência, 69% relataram violência física, 18% relataram violência sexual (VS) e 12% relataram violência psicológica. As taxas de comportamento de procura de cuidados foram maiores no período de intervenção (razão de taxas 1,31 [IC95%: 1,18-1,46]); p < 0,01. Entre aqueles elegíveis para profilaxia pós-exposição (PEP), 94% iniciaram a PEP. A adesão ao novo teste de HIV melhorou em pontos percentuais em 34% (14% para 48%), 34% (8% para 42%) e 26% (5% para 31%) em 1, 3 e 6 meses, respectivamente . A intervenção levou a um aumento na taxa de sobreviventes de VBG que procuram serviços de saúde e melhorou as taxas de cuidados de acompanhamento entre os sobreviventes de VS que iniciaram a PEP. O reforço do aconselhamento sobre adesão à PEP continua a ser crucial para melhorar os serviços de VBG.

Health care services for survivors of gender-based violence: a community and clinic-based intervention in Zambézia province, Mozambique.

Mozambique introduced guidelines for integrated gender-based violence (GBV) services in 2012. In 2017, we trained providers on empathetic and supportive services to GBV survivors and introduced home-based services for survivors who are loss-to-follow up. Rate ratios of clinic visits were compared before and after intervention initiation, using exact significance tests. Data of 1,806 GBV survivors were reviewed, with a total of 2005 events. The median age was 23 years (IQR 17-30) and 89% were women. Among those reporting violence, 69% reported physical violence, 18% reported sexual violence (SV), and 12% reported psychological violence. Rates of care-seeking behavior were higher in the intervention period (rate ratio 1.31 [95%CI: 1.18-1.46]); p < 0.01. Among those eligible for post-exposure prophylaxis (PEP), 94% initiated PEP. Uptake of HIV retesting improved in percentage points by 34% (14% to 48%), 34% (8% to 42%) and 26% (5% to 31%) at 1-, 3- and 6-months, respectively. The intervention led to an increase in the rate of GBV survivors seeking health care services, and improved rates of follow-up care among SV survivors initiating PEP. Strengthening of PEP adherence counseling remains crucial for improving GBV services.

Correlated depressive symptoms within seroconcordant, expectant partners living with HIV in Zambézia Province, Mozambique: a cross-sectional study.

Approximately 15% of people with HIV in sub-Saharan Africa have comorbid depression, which impacts treatment outcomes. We describe predictors of baseline depressive symptoms in 1079 female and 1079 male participants in a cluster-randomized trial in Zambézia Province, Mozambique from November 2017 to December 2020. We modeled each partners' depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) using proportional odds models adjusted for enrollment date, age, body mass index [BMI], partner's PHQ-9 score, district, relationship status, education, occupation, WHO HIV clinical stage, and antiretroviral therapy use history. A post hoc analysis assessed covariate-adjusted rank correlation between partner depressive symptoms. Females were younger than males (median 23 vs. 28 years) and more likely to report no education (20.7% vs. 7.9%). Approximately 10% screened positive for depression (PHQ-9 score ≥ 10). Partner depressive symptoms were predictive of higher participant PHQ-9 scores. A male partner PHQ-9 score of 10 (versus 5) increased the odds that the female partner would have a higher PHQ-9 score (adjusted odds ratio: 7.25, 95% Confidence Interval [CI]: 5.43-9.67). Partner PHQ-9 scores were highly correlated after covariate adjustment (Spearman's rho 0.65, 95% CI 0.57-0.72). Interventions aimed to reduce depressive symptoms and improve HIV-related outcomes during pregnancy should address both partners' depressive symptoms.