Quantifying the gender gap in the HIV care cascade in southern Mozambique: We are missing the men.

BACKGROUND: HIV-infected men have higher rates of delayed diagnosis, reduced antiretroviral treatment (ART) retention and mortality than women. We aimed to assess, by gender, the first two UNAIDS 90 targets in rural southern Mozambique. METHODS: This analysis was embedded in a larger prospective cohort enrolling individuals with new HIV diagnosis between May 2014-June 2015 from clinic and home-based testing (HBT). We assessed gender differences between steps of the HIV-cascade. Adjusted HIV-community prevalence was estimated using multiple imputation (MI). RESULTS: Among 11,773 adults randomized in HBT (7084 female and 4689 male), the response rate before HIV testing was 48.7% among eligible men and 62.0% among women (p<0.001). MI did not significantly modify all-age HIV-prevalence for men but did decrease prevalence estimates in women from 36.4%to 33.0%. Estimated proportion of HIV-infected individuals aware of their status was 75.9% for men and 88.9% for women. In individuals <25 years, we observed up to 22.2% disparity in awareness of serostatus between genders. Among individuals eligible for ART, similar proportions of men and women initiated treatment (81.2% and 85.9%, respectively). Fourfold more men than womenwere in WHO stage III/IV AIDS at first clinical visit. Once on ART, men had a twofold higher 18-month loss to follow-up rate than women. CONCLUSION: The contribution of missing HIV-serostatus data differentially impacted indicators of HIV prevalence and of achievement of UNAIDS targets by age and gender and men were missing long before the second 90. Increased efforts to characterize missing men and their needs will and their needs will allow us to urgently address the barriers to men accessing care and ensure men are not left behind in the UNAIDS 90-90-90 targets achievement.

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

INTRODUCTION: Complete follow-up of human immunodeficiency virus (HIV)-exposed infants (HEI) is crucial for a successful prevention of mother-to-child HIV transmission. This study analyzed the HEI follow-up and factors associated with loss to follow-up (LTFU) in southern Mozambique. METHODS: This retrospective cohort study used the data of HEI enrolled between June 2017 and June 2018, followed-up for 18 months. The outcomes were the proportion of infants with completed follow-up and a definitive diagnosis, and the presence of clinical events. Kaplan-Meier survival analysis was used to calculate the cumulative probability of LTFU and of clinical events. Factors associated with LTFU and clinical events were analyzed using Cox regression to calculate the hazard ratio (HR) and adjusted HR (AHR), with a 95% confidence interval (CI) and a significance cutoff of p<0.05. RESULTS: 1413 infants were enrolled (49% males) at a median age of 32 days (IQR 31-41); the median follow-up time was 12 months (IQR 8.2-14.2); 1129 (80%) completed follow-up and had a definitive diagnosis, 58 (4%) were HIV-positive, 225 (16%) were LTFU; 266 (19%) presented a clinical event. Factors associated with LTFU were: age >2 months at entry (AHR, 1.58; 95% CI, 1.12-2.23), non-exclusive breastfeeding (AHR, 1.44; 95% CI, 1.01-2.06), poor cotrimoxazole adherence (AHR, 3.42; 95% CI, 1.59-7.35), and clinical events (AHR, 0.51; 95% CI, 0.34-0.77). Factors associated with clinical events were: malnutrition (AHR, 10.06; 95% CI, 5.92-17.09), non-exclusive breastfeeding (AHR, 1.98; 95% CI, 1.34-2.93), no nevirapine prophylaxis (AHR, 1.67; 95% CI, 1.18-2.36), and poor cotrimoxazole adherence (AHR, 2.62; 95% CI, 1.10-6.22). CONCLUSION: The high rate of HEI LTFU, associated with delayed linkage to postnatal care, poor prophylaxis adherence, non-exclusive breastfeeding, indicates the need to design a differentiated service delivery model that is tailored to the mothers' and infants' specific needs.

Loss to follow-up and opportunities for reengagement in HIV care in rural Mozambique: A prospective cohort study.

Patients lost to follow-up (LTFU) over the human immunodeficiency virus (HIV) cascade have poor clinical outcomes and contribute to onward HIV transmission. We assessed true care outcomes and factors associated with successful reengagement in patients LTFU in southern Mozambique.Newly diagnosed HIV-positive adults were consecutively recruited in the Manhiça District. Patients LTFU within 12 months after HIV diagnosis were visited at home from June 2015 to July 2016 and interviewed for ascertainment of outcomes and reasons for LTFU. Factors associated with reengagement in care within 90 days after the home visit were analyzed by Cox proportional hazards model.Among 1122 newly HIV-diagnosed adults, 691 (61.6%) were identified as LTFU. Of those, 557 (80.6%) were approached at their homes and 321 (57.6%) found at home. Over 50% had died or migrated, 10% had been misclassified as LTFU, and 252 (78.5%) were interviewed. Following the visit, 79 (31.3%) reengaged in care. Having registered in care and a shorter time between LTFU and visit were associated with reengagement in multivariate analyses: adjusted hazards ratio of 3.54 [95% confidence interval (CI): 1.81-6.92; P < .001] and 0.93 (95% CI: 0.87-1.00; P = .045), respectively. The most frequently reported barriers were the lack of trust in the HIV-diagnosis, the perception of being in good health, and fear of being badly treated by health personnel and differed by type of LTFU.Estimates of LTFU in rural areas of sub-Saharan Africa are likely to be overestimated in the absence of active tracing strategies. Home visits are resource-intensive but useful strategies for reengagement for at least one-third of LTFU patients when applied in the context of differentiated care for those LTFU individuals who had already enrolled in HIV care at some point.

Loss to follow-up and opportunities for reengagement in HIV care in rural Mozambique. A prospective cohort study

Patients lost to follow-up (LTFU) over the human immunodeficiency virus (HIV) cascade have poor clinical outcomes and contribute to onward HIV transmission. We assessed true care outcomes and factors associated with successful reengagement in patients LTFU in southern Mozambique. Newly diagnosed HIV-positive adults were consecutively recruited in the Manhiça District. Patients LTFU within 12 months after HIV diagnosis were visited at home from June 2015 to July 2016 and interviewed for ascertainment of outcomes and reasons for LTFU. Factors associated with reengagement in care within 90 days after the home visit were analyzed by Cox proportional hazards model. Among 1122 newly HIV-diagnosed adults, 691 (61.6%) were identified as LTFU. Of those, 557 (80.6%) were approached at their homes and 321 (57.6%) found at home. Over 50% had died or migrated, 10% had been misclassified as LTFU, and 252 (78.5%) were interviewed. Following the visit, 79 (31.3%) reengaged in care. Having registered in care and a shorter time between LTFU and visit were associated with reengagement in multivariate analyses: adjusted hazards ratio of 3.54 [95% confidence interval (CI): 1.81­ 6.92; P<.001] and 0.93 (95% CI: 0.87­1.00; P=.045), respectively. The most frequently reported barriers were the lack of trust in the HIV-diagnosis, the perception of being in good health, and fear of being badly treated by health personnel and differed by type of LTFU. Estimates of LTFU in rural areas of sub-Saharan Africa are likely to be overestimated in the absence of active tracing strategies. Home visits are resource-intensive but useful strategies for reengagement for at least one-third of LTFU patients when applied in the context of differentiated care for those LTFU individuals who had already enrolled in HIV care at some point.

High proportion of unknown HIV exposure status among children aged less than 2 years: An analytical study using the 2015 National AIDS Indicator Survey in Mozambique.

BACKGROUND: Determination of the human immunodeficiency virus (HIV) exposure status in infants and young children is required to guarantee timely diagnosis and access to appropriate care. HIV prevalence among Mozambican women aged 15-49 years is 15%, and vertical transmission rate is still high. The study investigated HIV exposure in children aged less than 2 years in Mozambique and the factors associated with unknown HIV exposure and with HIV exposure status in this population. METHODS: This was a cross-sectional analytical study using data from the 2015 Survey of Indicators on Immunization, Malaria and HIV/AIDS in Mozambique. A total of 2141 mothers (15-49 years) with children aged less than 2 years were interviewed. The dependent variables were "known HIV exposure status in a child" and "HIV-exposed child," and the explanatory variables were mother's social, demographic, economic, and reproductive health characteristics. We used binary and logistic regression, adjusted for complex sampling, to determine the association between variables. RESULTS: HIV exposure status was unknown in 27% of children (95% CI, 25.1-28.9). Mothers residing in the North (AOR, 4.41; 95% CI, 2.18-8.91), in rural area (AOR, 2.44; 95% CI, 1.33-4.35), with no education (AOR, 2.72; 95% CI, 1.38-5.36), and not having utilized any health services in the last pregnancy (AOR, 1.9; 95% CI, 1.42-2.55) were more likely to have a child with unknown HIV exposure status. Six percent of children were HIV-exposed (95% CI, 5-7). Children were less likely to be HIV-exposed if the head of the household was a male (AOR, 0.26; 95% CI, 0.08-0.86), if the mother was residing in the North (AOR, 0.41; 95% CI, 0.26-0.66) and did not utilize any health services in her last pregnancy (AOR, 0.52; 95% CI, 0.32-0.83). CONCLUSION: The high proportion of children with unknown HIV exposure status and the associated socioeconomic factors suggests that HIV retesting of eligible women throughout breastfeeding should be intensified and identifies the urgent need to reach women without prior access to health care using a multisectoral approach.

Continuum of HIV Care in Rural Mozambique: The Implications of HIV Testing Modality on Linkage and Retention.

INTRODUCTION: Context-specific improvements in the continuum of HIV care are needed to achieve the UNAIDS target of 90-90-90. This study aimed to assess the linkage to and retention in HIV care according to different testing modalities in rural southern Mozambique. METHODS: Adults newly diagnosed with HIV from voluntary counseling and testing, provider-initiated counseling and testing, and home-based HIV testing services were prospectively enrolled between 2014 and 2015 at the Manhiça District. Patients were passively followed up through chart examination. Tracing was performed at 12 months to ascertain causes of loss to follow-up. Fine and Gray competing risk analysis was performed to determine factors associated with the each step of the cascade. RESULTS: Overall linkage to care as defined by having a CD4 count at 3 months was 43.7% [95% confidence interval (CI): 40.8 to 46.6] and 25.2% of all participants initiated antiretroviral therapy. Factors associated with increased linkage in multivariable analysis included testing at voluntary counseling and testing, older age, having been previously tested for HIV, owning a cell phone, presenting with WHO clinical stages III/IV, self-reported illness-associated disability in the previous month, and later calendar month of participant recruitment. Ascertaining deaths and transfers allowed for adjustment of the rate of 12-month retention in treatment from 75.6% (95% CI: 70.2 to 80.5) to 84.2% (95% CI: 79.2 to 88.5). CONCLUSIONS: Home-based HIV testing reached a sociodemographically distinct population from that of clinic-based testing modalities but low linkage to care points to a need for facilitated linkage interventions. Distinguishing between true treatment defaulting and other causes of loss to follow-up can significantly change indicators of retention in care.

Monitoring progress towards the first UNAIDS target: understanding the impact of people living with HIV who re-test during HIV-testing campaigns in rural Mozambique.

INTRODUCTION: Awareness of HIV-infection goes beyond diagnosis, and encompasses understanding, acceptance, disclosure and initiation of the HIV-care. We aimed to characterize the HIV-positive population that underwent repeat HIV-testing without disclosing their serostatus and the impact on estimates of the first UNAIDS 90 target. METHODS: This analysis was nested in a prospective cohort established in southern Mozambique which conducted three HIV-testing modalities: voluntary counselling and testing (VCT), provider-initiated counselling and testing (PICT) and home-based testing (HBT). Participants were given the opportunity to self-report their status to lay counsellors and HIV-positive diagnoses were verified for previous enrolment in care. This study included 1955 individuals diagnosed with HIV through VCT/PICT and 11,746 participants of a HBT campaign. Those who did not report their serostatus prior to testing, and were found to have a previous HIV-diagnosis, were defined as non-disclosures. Venue-stratified descriptive analyses were performed and factors associated with non-disclosure were estimated through log-binomial regression. RESULTS: In the first round of 2500 adults randomized for HBT, 1725 were eligible for testing and 18.7% self-reported their HIV-positivity. Of those tested with a positive result, 38.9% were found to be non-disclosures. Similar prevalence of non-disclosures was found in clinical-testing modalities, 29.4% (95% CI 26.7 to 32.3) for PICT strategy and 13.0% (95% CI 10.9 to 15.3) for VCT. Prior history of missed visits (adjusted prevalence ratio (APR) 4.2, 95% CI 2.6 to 6.8), younger age (APR 2.5, 95% CI 1.4 to 4.4) and no prior history of treatment ((APR) 1.4, 95% CI 1.0 to 2.1) were significantly associated with non-disclosure as compared to patients who self-reported. When considering non-disclosures as people living with HIV (PLWHIV) aware of their HIV-status, the proportion of PLWHIV aware increased from 78.3% (95% CI 74.2 to 81.6) to 86.8% (95% CI 83.4 to 89.6). CONCLUSION: More than one-third of individuals testing HIV-positive did not disclose their previous positive HIV-diagnosis to counsellors. This proportion varied according to testing modality and age. In the absence of an efficient and non-anonymous tracking system for HIV-testers, repeat testing of non-disclosures leads to wasted resources and may distort programmatic indicators. Developing interventions that ensure appropriate psychosocial support are needed to encourage this population to disclose their status and optimize scarce resources.

Acceptability and Effectiveness of Assisted Human Immunodeficiency Virus Partner Services in Mozambique: Results From a Pilot Program in a Public, Urban Clinic.

BACKGROUND: Assisted partner services (APS) involves offering persons with human immunodeficiency virus (HIV) assistance notifying and testing their sex partners. Assisted partner services is rarely available in sub-Saharan Africa. We instituted a pilot APS program in Maputo, Mozambique. METHODS: Between June and September 2014, community health workers (CHWs) offered APS to persons with newly diagnosed HIV (index patients [IPs]). Community health workers interviewed IPs at baseline, 4 and 8 weeks. At baseline, CHWs counseled IPs to notify partners and encourage their HIV testing, but did not notify partners directly. At 4 weeks, CHWs notified partners directly. We compared 4- and 8-week outcomes to estimate the impact of APS on partner notification, HIV testing and HIV case finding. RESULTS: Community health workers offered 223 IPs APS, of whom 220 (99%) accepted; CHWs collected complete follow-up data on 206 persons; 79% were women, 74% were married, and 50% named >1 sex partner. Index patients named 262 HIV-negative partners at baseline. At 4 weeks, before APS, IPs had notified 193 partners (74%), but only 82 (31%) had HIV tested; 43 (13%) tested HIV positive. Assisted partner services resulted in the notification of 22 additional partners, testing of 83 partners and 43 new HIV diagnoses. In relative terms, APS increased partner notification, testing, and HIV case finding by 13%, 101%, and 125%. Seventy-two (35%) of 206 IPs were in ongoing HIV serodiscordant partnerships. Only 2.5 IPs needed to receive APS to identify a previously undiagnosed HIV-infected partner or an ongoing HIV serodiscordant partnership. Two (1%) IPs reported APS-related adverse events. CONCLUSIONS: Assisted partner services is acceptable to Mozambicans newly diagnosed with HIV, identifies large numbers of serodiscordant partnerships and persons with undiagnosed HIV, and poses a low risk of adverse events.