Trends in HIV prevalence and risk factors among men who have sex with men in Mozambique: implications for targeted interventions and public health strategies.

BACKGROUND: Men who have sex with Men (MSM) are known to contribute to increased HIV prevalence as an integral part of key populations with high vulnerability to HIV/AIDS due to their sexual behaviours. Mozambique conducted two rounds of bio-behavioral surveys (BBS) in this population with the main objective of estimating HIV prevalence and associated risk behaviors among MSM in Mozambique. The present study aims to estimate the trend of HIV prevalence and determine the correlations of HIV infection among MSM. METHODS: A repeated cross-sectional analytical study was conducted from secondary data from the first and second rounds of BBS in Mozambique conducted in 2011 and 2020-2021 respectively. Each round used a similar methodology which allowed for comparison between the two surveys. Chi-square test and logistic regression was used to compare the HIV prevalence between the BBS rounds, identify factors associated with HIV, and assess changes in HIV prevalence across selected risk factors. RESULTS: There was a significant increase in HIV prevalence among MSM (7.1-14.9%), living in Maputo (9.3-14.7%), uncircumcised (11.7-25.1%), and those who reported two sexual partners in the last year (5.2-14.4%). In contrast, there was a decrease in prevalence among adult MSM aged between 25 and 29 years (24.7-13.9%), aged 30 years or older (45.7-27.7%), married (29.1-16.8%), with higher education (16.7-5.9%) and moderate perception of HIV risk (10.9-3.4%). Multivariable analysis showed that factors such as age, marital status, religion, sexual identity, circumcision, and the use of lubrication during anal sex are significantly associated with the risk of HIV infection. CONCLUSIONS: This study underscores the continuing need for HIV prevention and education efforts. The rise in prevalence among specific population segments and the sustained presence of risk factors emphasize the requirement for holistic strategies tailored to the unique requirements of each subgroup. Understanding trends and risk factors is crucial to guiding public health policies and designing efficacious prevention programs that aim to curtail HIV transmission while enhancing the well-being of those impacted by the condition.

Cholera and diarrheal diseases in Cuamba District, Niassa Province, Mozambique: Systematic healthcare facility-based surveillance strengthening, characteristics of suspected cholera and diarrheal patients, and incidence of diarrheal diseases.

BACKGROUND: Mozambique is one of the countries in Africa that is continuously at risk of cholera outbreaks due to poor sanitation, hygiene, and limited access to potable water in some districts. The Mozambique Cholera Prevention and Surveillance (MOCA) project was implemented in Cuamba District, Niassa Province to prevent and control cholera outbreaks through a preemptive cholera vaccination, strengthened surveillance system for cholera and diarrheal diseases, and better understanding of cholera-related healthcare seeking behavior of local populations, which may further guide the national cholera control and prevention strategies. This article presents the surveillance component of the MOCA project. METHODOLOGY/PRINCIPAL FINDINGS: A prospective healthcare facility (HCF)-based surveillance of cholera and diarrheal disease was conducted in six HCFs in the District of Cuamba from March 2019 to December 2020. A systematic surveillance procedure has been put in place with capacity building in selected sentinel HCFs and a basic microbiology laboratory established on-site. Patients presenting with suspected cholera or other diarrheal symptoms were eligible for enrollment. Clinical data and rectal swab samples were collected for laboratory confirmation of Vibrio Cholerae and other pathogens. A total of 419 eligible patients from six HCFs were enrolled. The median age was 19.8 years with a similar age distribution between sentinel sites. The majority were patients who exhibited diarrhea symptoms not suspected of cholera (88.8%; n = 410). Among those, 59.2% (210/397) were female and 59.9% (235/392) were 15 years and above. There were 2 cholera cases, coming outside of the catchment area. The incidence of diarrheal diseases ranged from 40-103 per 100,000 population. No Vibrio cholerae was isolated among surveillance catchment population and Escherichia coli spp. (82/277; 29.6%) was the most common pathogen isolated. CONCLUSION/SIGNIFICANCE: Efforts were made to strengthen the systematic surveillance of suspected cholera with standardised patient screening, enrolment, and diagnostics. The first basic microbiology laboratory in Niassa Province established in Cuamba District under the MOCA project needs to be integrated into the national network of laboratories for sustainability. No reports of laboratory confirmed cholera cases from the surveillance catchment area may be highly related to the pre-emptive oral cholera vaccine (OCV) mass vaccination campaign conducted in 2018 and the use of drugs by local populations prior to visiting the sentinel HCFs. Continued systematic cholera surveillance is needed to closely monitor the cholera endemicity and epidemics, and further evaluate the long-term impact of this vaccination. High incidence of diarrheal illnesses needs to be addressed with improved water, sanitation, and hygiene (WaSH) conditions in Cuamba District. Efforts integrated with the prioritization of prevention measures are fundamental for the control of cholera in the country.

Prevalence and correlates of hazardous alcohol drinking and drug use among female sex workers and men who have sex with men in Mozambique.

BACKGROUND: Hazardous drinking and drug consumption are associated with an increased risk of HIV due to the complex interplay of factors influencing decision-making capability, stigma and social marginalization. In this study, we explore the patterns of hazardous alcohol and drug use and correlates of risk factors among female sex workers (FSW) and men who as sex with men (MSM) in Mozambique. METHODS: We conducted a secondary data analysis of bio-behavioral surveys (BBS) among FSW and MSM using a respondent-driven sampling methodology conducted in five main urban areas of Mozambique from 2019 to 20. The survey included a standardized questionnaire, where hazardous drinking was assessed (using AUDIT-C scores ≥ 4 for men, ≥ 3 for women) and drug use in the last year (FSW). Chi-squared test was used to analyze the association between socio-demographic and behavioral variables, and multivariate logistic regression measured the impact of the associated factors. RESULTS: The prevalence of hazardous alcohol drinking was 47.1% (95% CI:44.8-49.5) for FSW and 46.5 (95% CI: 44.0-49.0) for MSM. Current drug use was reported in 13.3% of FSW. FSW engaging in hazardous alcohol drinking reported more sexual partners in the last month than those no reporting hazardous alcohol use (55.3% vs. 47,1%, p < 0.001), higher rates of self-reported STIs in the last year (62,5% vs. 48,2%, p < 0.001), physical (53.5% vs. 46.7%, p < 0.0001) and sexual violence (54.7% vs. 44.2%, p < 0.001), and HIV prevalence (55.2% vs. 44.2 p < 0.001). Among MSM with hazardous alcohol drinking, there was a higher prevalence of self-reported STIs (52.8% vs. 45.4%, p < 0.001), experiences of sexual violence (18.0% vs. 8.3%, p < 0.001), and HIV prevalence (53.0% vs. 46.3%, p < 0.001). In addition, FSW who reported illicit drug use were more likely to self-reported HIV own risk (14.2% vs. 9.7%), early start sexual activity (15.4% vs. 5.3%), self-reported STIs (17.9% vs. 10.2%), and experiences of both physical (17.4% vs. 7.0%) and sexual violence (18.6% vs. 8.9%). CONCLUSION: There is an immediate need for the introduction and integration of comprehensive substance use harm mitigation and mental health interventions into HIV prevention programs, particularly those targeting key populations in Mozambique.

People Who Inject Drugs in Mozambique: We need to normalize HIV treatment and care services in specialized community centers for people who inject drugs!

Globally, People Who Inject Drugs (PWID) have limited healthcare, treatment, and prevention services, and they frequently experience stigma and negative attitudes toward healthcare providers when accessing services. Mozambique, with a general population HIV prevalence of 12.5%, has one of the highest rates in the world, and the PWID population has the highest HIV prevalence among key populations, estimated at nearly 50%. Less than half of HIV positives who inject drugs are linked to HIV treatment and are retained in care. One of the main reasons is that HIV treatment is mainly provided in a public health facility and PWID delayed accessing healthcare since they anticipated mistreatment from multiple levels of healthcare providers. To improve the health outcomes in this group, we need to treat them where they feel comfortable and respected. In this commentary, we outline the importance of innovative approaches to enhance the management of HIV-positive PWID. As a country gets close to controlling the HIV epidemic, refocusing and targeting responses to the highest-risk groups becomes even more essential for shaping more effective HIV interventions and achieving epidemic control.

Young key populations left behind: The necessity for a targeted response in Mozambique.

INTRODUCTION: The first exposure to high-risk sexual and drug use behaviors often occurs during the period of youth (15-24 years old). These behaviors increase the risk of HIV infection, especially among young key populations (KP)-men how have sex with men (MSM), female sex workers (FSW), and people who inject drugs (PWID). We describe the characteristics of young KP participants in the first Biobehavioral Surveillance (BBS) surveys conducted in Mozambique and examine their risk behaviors compared to adult KP. METHODS: Respondent-driven sampling (RDS) methodology was used to recruit KP in three major urban areas in Mozambique. RDS-weighted pooled estimates were calculated to estimate the proportion of young KP residing in each survey city. Unweighted pooled estimates of risk behaviors were calculated for each key population group and chi-square analysis assessed differences in proportions between youth (aged less than 24 years old) and older adult KP for each population group. RESULTS: The majority of MSM and FSW participants were young 80.7% (95% CI: 71.5-89.9%) and 71.9% (95% CI: 71.9-79.5%), respectively, although not among PWID (18.2%, 95% CI: 13.2-23.2%). Young KP were single or never married, had a secondary education level or higher, and low employment rates. They reported lower perception of HIV risk (MSM: 72.3% vs 56.7%, p<0.001, FSW: 45.3% vs 24.4%, p<0.001), lower HIV testing uptake (MSM: 67.5% vs 72.3%, p<0.001; FSW: 63.2% vs 80.6%; p<0.001, PWID: 53.3% vs 31.2%; p = 0.001), greater underage sexual debut (MSM: 9.6% vs 4.8%, p<0.001; FSW: 35.2% vs 22.9%, p<0.001), and greater underage initiation of injection drug use (PWID: 31.9% vs 7.0%, p<0.001). Young KP also had lower HIV prevalence compared to older KP: MSM: 3.3% vs 27.0%, p<0.001; FSW: 17.2% vs 53.7%, p<0.001; and PWID: 6.0% vs 55.0%, p<0.001. There was no significant difference in condom use across the populations. CONCLUSION: There is an immediate need for a targeted HIV response for young KP in Mozambique so that they are not left behind. Youth must be engaged in the design and implementation of interventions to ensure that low risk behaviors are sustained as they get older to prevent HIV infection.

Who Are the Men Who Pay for Sex in Mozambique? Results from the National HIV/AIDS Indicator Survey 2015.

Mozambique has one of the highest burdens of HIV in the world, where the prevalence is estimated at 13.2% among adults aged 15-49 years. Men who pay for sex (MPS) are considered a bridging population for HIV infection. However, the characteristics of MPS in Mozambique are poorly understood. The objective of this study was to estimate the prevalence of paid sex among men 15-49 years and investigate risk factors associated with paid sex. We analyzed data collected from 4724 men, aged 15-49 years, as part of the 2015 Mozambique AIDS Indicator Survey. Chi-squared tests and logistic regression models accounting for survey design were used to assess the associations between paying for sex and demographic characteristics and the number of lifetime and recent sex partners, condom use at last sex, and self-reported sexually transmitted infection symptoms. The prevalence of paid sex in the last 12 months was 10.4% (95% CI 9.0-12.1), with Cabo Delgado province having the highest prevalence (38.8%). MPS in the last 12 months were most frequently between the ages of 20-24 years (13.5%), not in a relationship (17.8%), had a primary education (11.9%), from poor households (14.0%), had more than three sexual partners excluding their spouse in the last 12 months (44.7%), and self-reported a STI in the past 12 months (44.2%). HIV prevalence was higher among men who ever paid for sex compared with men who did not (13.1% vs. 9.4%, p = .02). Men who reported 10+ lifetime partner (aOR 7.7; 95% CI 4.5-13.0; p < .001), from Cabo Delgado (aOR 4.0; 95% CI 2.2-7.4; p < .001), who reported STI symptoms in the past 12 months (aOR 2.7; 95% CI 1.7-4.2; p < .001), and HIV positive (aOR 1.6; 95% CI 1.0-3.7; p = .05) were more likely to have paid for sex in the last 12 months. These findings present the HIV prevalence among Mozambican MPS and highlight the need for a comprehensive behavioral, structural, and biomedical approach to interventions to reduce the risks of commercial and transactional sex.

Cyclone Idai as a Trigger for Pellagra Outbreak in Nhamatanda, Mozambique: A Case-Control Study.

In mid-June 2019, 3 months after cyclone Idai landfall in Mozambique, health authorities of Nhamatanda district reported an outbreak of Pellagra. Applying a mixed-method protocol, we carried out an investigation to characterize cases of pellagra, identify the associated factors for the outbreak using a case-control study, and explore the perceived impact on food security (availability, access, and usage) before and after Idai. We collected data from 121 cases and 121 controls and conducted in-depth interviews with 69 heads of households. The cases were more likely to be female (P < 0.01) and less educated (P < 0.01) than controls. Insufficient consumption of chicken and peanut before cyclone Idai arrival were statistically associated with pellagra (P < 0.05). From interviewed households' heads, 51% were experiencing food shortages even before the cyclone hit. Cyclone Idai served as a trigger to reduce niacin consumption below the threshold that protected Nhamatanda population from pellagra and caused a ≈2,300 case (707.9/100,000 inhabitants) outbreak.

Recognizing the hidden: strengthening the HIV surveillance system among key and priority populations in Mozambique.

High quality, representative data from HIV surveillance systems that have country ownership and commitment are critical for guiding national HIV responses, especially among key and priority populations given their disproportionate role in the transmission of the virus. Between 2011 to 2013, the Mozambique Ministry of Health has conducted five Biobehavioral Surveillance Surveys among key populations (female sex workers, men who has sex with men and people who inject drugs) and priority populations (long distance truck drives and miners) as part of the national HIV surveillance system. We describe the experience of strengthening the HIV surveillance system among those populations through the implementation of these surveys in Mozambique. We document the lessons learned through the impact on coordination and collaboration; workforce development and institutional capacity building; data use and dissemination; advocacy and policy impact; financial sustainability and community impact. Key lessons learned include the importance of multisectoral collaboration, vital role of data to support key populations visibility and advocacy efforts, and institutional capacity building of government agencies and key populations organizations. Given that traditional surveillance methodologies from routine data often do not capture these hidden populations, it will be important to ensure that Biobehavioral Surveillance Surveys are an integral part of ongoing HIV surveillance activities in Mozambique.

Prevalence of HIV, viral hepatitis B/C and tuberculosis and treatment outcomes among people who use drugs: Results from the implementation of the first drop-in-center in Mozambique.

BACKGROUND: People who use drugs (PWUD) which includes both people who inject drugs (PWID) and non-injection drug users (NIDU) are marginalized, experience high levels of stigma and discrimination, and are likely to have challenges with accessing health services. Mozambique implemented the first drop-in center (DIC) for PWUD in Maputo City in 2018. This analysis aims to assess the prevalence of HIV, viral hepatitis B (HBV) and C (HCV) and tuberculosis (TB) among PWUD, and assess their linkage to care and associated correlates. METHODS: We conducted a cross-sectional retrospective analysis of routine screening data collected from the first visit at the drop-in center (DIC) during the period of May 2018 to November 2019 (18 months). Descriptive and multivariable logistic regression analysis were conducted to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of HIV, HBV, HCV and TB infections among PWID and NIDU. Cox proportional hazards models of determinants were used to estimate time from HIV diagnosis to linkage to care for PWUD. RESULTS: A total of 1,818 PWUD were screened at the DIC, of whom 92.6% were male. The median age was 27 years (range:14-63). Heroin was the most consumed drug (93.8%), and among people who used it, 15.5% injected it. Prevalence of HIV (43.9%), HCV (22.6%) and HBV (5.9%) was higher among PWID (p<0.001). Linkage to HIV care was observed in 40.5% of newly diagnosed PWID. Factors associated with shorter time to linkage to care included drug injection (aHR=1.6) and confirmed TB infection (aHR=2.9). CONCLUSION: This was the first analysis conducted on the implementation of the DIC in Mozambique and highlights the importance of targeted services for this high-risk population. Our analysis confirmed a high prevalence of HIV, HBV and HCV, and highlight the challenges with linkage to care among PWID. The expansion of DIC locations to other high-risk localities to enhance HIV testing, treatment services and linkage to care to reduce ongoing transmission of HIV, HBV, HCV and TB and improve health outcomes.

High burden of self-reported sexually transmitted infections among key populations in Mozambique: the urgent need for an integrated surveillance system.

BACKGROUND: Key populations - men who have sex with men (MSM), female sex workers (FSW) and people who inject drugs (PWID) - are at high risk for sexually transmitted infections (STI) given their sexual risk behaviours along with social, legal and structural barriers to prevention, care and treatment services. The purpose of this secondary analysis is to assess the prevalence of self-reported STIs and to describe associated risk factors among participations of the first Biological Behavioural Surveillance (BBS) in Mozambique. METHODS: Responses from the first BBS surveys conducted in 2011-2014 were aggregated across survey-cities to produce pooled estimates for each population. Aggregate weighted estimates were computed to analyse self-reported STI prevalence. Unweighted pooled estimates were used in multivariable logistic regression to identify risk factors associated with self-reported STI. RESULTS: The prevalence of self-reported STI was 11.9% (95% CI, 7.8-16.0), 33.6% (95% CI, 29.0-41.3), and 22.0% (95% CI, 17.0-27.0) among MSM, FSW and PWID, respectively. MSM who were circumcised, had HIV, reported drug use, reported receptive anal sex, and non-condom use with their last male partner had greater odds of STI self-report. STI-self report among FSW was associated with living in Beira, being married, employment aside from sex work, physical violence, sexual violence, drug use, access to comprehensive HIV prevention services, non-condom use with last client, and sexual relationship with a non-client romantic partner. Among PWID, risk factors for self-reported STI included living in Nampula/Nacala, access to HIV prevention services, and sex work. CONCLUSION: The high-burden of STIs among survey participants requires integrated HIV and STI prevention, treatment, and harm reduction services that address overlapping risk behaviours, especially injection drug use and sex work. A robust public health response requires the creation of a national STI surveillance system for better screening and diagnostic procedures within these vulnerable populations.

Prevalence and risk factors associated with HIV/hepatitis B and HIV/hepatitis C co-infections among people who inject drugs in Mozambique.

BACKGROUND: There is scare information about HIV co-infections with hepatitis B virus (HBV) and/or hepatitis C virus (HCV) among People Who Inject Drugs (PWID) in Mozambique. This information is critical to ensure the treatment necessary to decrease the progression of liver disease and the transmission of both HIV and hepatitis. We assess the prevalence of HIV, HBV and HCV co-infections as well as associated risk factors among PWID. METHODS: The first Bio-Behavioral Surveillance Survey was conducted in 2013-2014 among persons who self-reported to have ever injected drugs. Using respondent-driven sampling, PWID aged 18 years and older were recruited in two cross-sectional samples in Maputo and Nampula/Nacala, two large urban centers of Mozambique. Rapid screening of HIV, HBV (HBsAg) and HCV was performed on site. Data from participants in both cities were pooled to conduct RDS-weighted bivariate analyses with HIV/HBV and HIV/HCV co-infections as separate outcomes. Unweighted bivariate and multivariate logistic regression analyses were conducted to assess correlates of co-infection. RESULTS: Among 492 eligible PWID, 93.3% were male and median age was 32 years [IQR: 27-36]. HIV, HBV and HCV prevalence were respectively 44.9% (95% CI:37.6-52.3), 32.8% (95% CI:26.3-39.5) and 38.3 (95% CI:30.6-45.9). Co-infections of HIV/HBV, HIV/HCV and HIV/HBV/HCV were identified in 13.1% (95% CI:7.2-18.9), 29.5% (95% CI:22.2-36.8) and 9.2% (95% CI:3.7-14.7) of PWID, respectively. Older age, history of needle/syringe sharing and history of injection with used needle/syringe was associated with HIV/HBV co-infection. Living in Maputo city, have older age, history of needle/syringe sharing and history of injection with used needle/syringe was associated with HIV/HCV co-infection. CONCLUSION: There is a high burden of HBV and HCV among HIV-infected PWID in Mozambique. Our results highlight the need for targeted harm reduction interventions that include needle exchange programs and integrated services for the diagnosis and treatment of HIV, HBV and HCV to address these epidemics among PWID. Efforts should be made to strengthen ART coverage in the population as an important treatment strategy for both viruses.

Mozambique's response to cyclone Idai: how collaboration and surveillance with water, sanitation and hygiene (WASH) interventions were used to control a cholera epidemic.

Cyclone Idai, which hit Mozambique in March 2019, was one of the worst climate-related natural disasters on record in the Southern Hemisphere causing massive destruction of housing and disruption to vital infrastructure including the electrical grid, communications and water supply. Almost two million people were affected with over 600 deaths, hundreds of thousands of people displaced accompanied by rapid spread of cholera. We describe emergency measures taken by the Government of Mozambique, in collaboration with multilateral partners, to establish a real-time disease surveillance system, implement interventions recommended by a Water, Sanitation and Hygiene (WASH) taskforce and rapidly scale up a massive community vaccination program to control a cholera epidemic.

Access to and use of health and social services among people who inject drugs in two urban areas of Mozambique, 2014: qualitative results from a formative assessment.

BACKGROUND: Prior to 2014, data about health seeking behaviors or service uptake for People who inject drugs (PWID) in Mozambique did not exist. We present the results from the formative assessment component of the Biological and Behavioral Survey (BBS). METHODS: Standardized interview guides were used during key informant interviews (KII) and focus group discussions (FGD) in Maputo and Nampula/Nacala to discuss issues related to risk behaviors and access to and utilization of health and social services by PWID. The target sample size was not defined a priori, but instead KII and FGD were conducted until responses reached saturation. Data analysis was based on the principles of grounded theory related to qualitative research. RESULTS: Eighty-eight respondents, ages 15 to 60, participated in KIIs and FGDs. Participants were majority male from diverse income and education levels and included current and former PWID, non-injection drug users, health and social service providers, peer educators, and community health workers. Respondents reported that PWID engage in high-risk behaviors such as needle and syringe sharing, exchange of sex for drugs or money, and low condom use. According to participants, PWID would rather rent, share or borrow injection equipment at shooting galleries than purchase them due to stigma, fear of criminalization, transportation and purchase costs, restricted pharmacy hours, personal preference for needle sharing, and immediacy of drug need. Barriers to access and utilization of health and social services include distance, the limited availability of programs for PWID, lack of knowledge of the few programs that exist, concerns about the quality of care provided by health providers, lack of readiness as a result of addiction and perceived stigma related to the use of mental health services offering treatment to PWID. CONCLUSIONS: Mozambique urgently needs to establish specialized harm reduction programs for PWID and improve awareness of available resources. Services should be located in hot spot areas to address issues related to distance, transportation and the planning required for safe injection. Specific attention should go to the creation of PWID-focused health and social services outside of state-sponsored psychiatric treatment centers.

HIV prevalence and TB in migrant miners communities of origin in Gaza Province, Mozambique: The need for increasing awareness and knowledge.

BACKGROUND: As part of ongoing efforts to generate evidence needed on HIV and tuberculosis (TB) to inform policies and programs aimed to improve the health outcomes of migrants and communities affected by migration and mining, a preliminary investigation was conducted through a biological and behavioral (BBS) approach related to HIV and TB in two communities of origin of migrant mineworkers in Gaza Province. The main objective was to determine the prevalence of HIV and the rates of asymptomatic infection by TB, and the social and behavioral risk factors associated. METHODS: A cross-sectional survey was conducted from May to June 2017 using a simple random sampling methodology. Eligible participants were individuals who were living in the community at the time the survey was conducted, which included adult mine workers and members of their families aged 18 and above. A socio-behavioral questionnaire was administered, blood specimens were collected for HIV testing (Determine/Unigold) and sputum for TB (GeneXpert MTB/RIF) was collected. The statistical analysis was performed using the R studio software to produce means, proportion and odds ratio at 95% confidence intervals. RESULTS: A total of 1012 participants were enrolled, 75.2% were females, with a median age of 34. The overall prevalence of HIV found in the two communities was 24.2% (CI: 21.6-27.0) and was higher in the rural community (31.6%; 95% CI: 27.0-35.3). The prevalence of active TB was found to be 0.3% (n = 3) while 7.5% of the participants self-reported to have been previously diagnosed with TB at some point in their life. Only 2.8% of participants had knowledge of the basic principles of TB transmission. Condom use at last sexual intercourse with a regular partner was low among both sexes (17.3% male and 12.6% female). A considerable proportion of participants had not been aware of their HIV positive serostatus(31.1% female and 25.0% male). About 1/3 of the participants had had a history of STIs. CONCLUSION: The results of this survey confirm a high prevalence of HIV in communities of origin of migrant miners in Gaza province. Findings also demonstrated low levels of awareness/ knowledge and prevention of TB and HIV. It is important to strengthen strategies that encourage regular HIV testing and TB screening. Appropriate communication interventions on methods of transmission and prevention of HIV and TB in these communities must be intensified, as well as ensuring ongoing linkage to TB and HIV social and healthcare services.

Young people who inject drugs in Mozambique: should we emphasize them in the National Harm Reduction Plan?

Mozambique has one of the highest burdens of HIV globally, and people who inject drugs (PWID) have one of the highest HIV infection rates in Africa. After the implementation of the first Biological Behavioral Surveillance (BBS) Survey among PWID in Mozambique, the Ministry of Health started the development of a National Harm Reduction Plan. Although the findings from the BBS survey highlighted the specific needs of young PWID, the proposed Harm Reduction Plan does not explicitly focus on reducing high-risk behaviors of young PWID. We outline the importance of the inclusion of age-specific interventions focused on the needs of young PWID in Mozambique, and how a comprehensive Harm Reduction Plan can reduce the HIV epidemic in this population. There is a unique opportunity to advocate for the Harm Reduction Plan to include "youth-friendly" cost-effective and evidence-based interventions that are targeted to this important sub-group within an already vulnerable population.

High prevalence of HIV, HBsAg and anti-HCV positivity among people who injected drugs: results of the first bio-behavioral survey using respondent-driven sampling in two urban areas in Mozambique.

BACKGROUND: Few countries in sub-Saharan Africa know the magnitude of their HIV epidemic among people who inject drugs (PWID). This was the first study in Mozambique to measure prevalence of HIV, HBV, and HCV, and to assess demographic characteristics and risk behaviors in this key population. METHODS: We used respondent-driven sampling (RDS) to conduct a cross-sectional behavioral surveillance survey of PWID in two cities of Mozambique lasting six months. Participants were persons who had ever injected drugs without a prescription. Participants completed a behavioral questionnaire and provided blood specimens for HIV, hepatitis B surface antigen (HBsAg) and hepatitis C virus antibody (anti-HCV) testing. We performed RDS-adjusted analysis in R 3.2 using RDSAT 7.1 weights. RESULTS: We enrolled 353 PWID in Maputo and 139 in Nampula/Nacala; approximately 95% of participants were men. Disease prevalence in Maputo and Nampula/Nacala, respectively, was 50.1 and 19.9% for HIV, 32.1 and 36.4% for HBsAg positivity, and 44.6 and 7.0% for anti-HCV positivity. Additionally, 8% (Maputo) and 28.6% (Nampula/Nacala) of PWID reported having a genital sore or ulcer in the 12 months preceding the survey. Among PWID who injected drugs in the last month, 50.3% (Maputo) and 49.6% (Nampula/Nacala) shared a needle at least once that month. Condomless sex in the last 12 months was reported by 52.4% of PWID in Maputo and 29.1% in Nampula/Nacala. Among PWID, 31.6% (Maputo) and 41.0% (Nampula/Nacala) had never tested for HIV. In multivariable analysis, PWID who used heroin had 4.3 (Maputo; 95% confidence interval [CI]: 1.2, 18.2) and 2.3 (Nampula/Nacala; 95% CI: 1.2, 4.9) greater odds of having HIV. CONCLUSION: Unsafe sexual behaviors and injection practices are frequent among PWID in Mozambique, and likely contribute to the disproportionate burden of disease we found. Intensified efforts in prevention, care, and treatment specific for PWID have the potential to limit disease transmission.

Oral cholera vaccine coverage during a preventive door-to-door mass vaccination campaign in Nampula, Mozambique.

BACKGROUND: In addition to improving water, sanitation and hygiene (WASH) measures and optimal case management, the introduction of Oral cholera vaccine (OCV) is a complementary strategy for cholera prevention and control for vulnerable population groups. In October 2016, the Mozambique Ministry of Health implemented a mass vaccination campaign using a two-dose regimen of the Shanchol™ OCV in six high-risk neighborhoods of Nampula city, in Northern Mozambique. Overall 193,403 people were targeted by the campaign, which used a door-to-door strategy. During campaign follow-up, a population survey was conducted to assess: (1) OCV coverage; (2) frequency of adverse events following immunization; (3) vaccine acceptability and (4) reasons for non-vaccination. METHODOLOGY/PRINCIPAL FINDINGS: In the absence of a household listing and clear administrative neighborhood delimitations, we used geospatial technology to select households from satellite images and used the support of community leaders. One person per household was randomly selected for interview. In total, 636 individuals were enrolled in the survey. The overall vaccination coverage with at least one dose (including card and oral reporting) was 69.5% (95%CI: 51.2-88.2) and the two-dose coverage was 51.2% (95%CI: 37.9-64.3). The campaign was well accepted. Among the 185 non-vaccinated individuals, 83 (44.6%) did not take the vaccine because they were absent when the vaccination team visited their houses. Among the 451 vaccinated individuals, 47 (10%) reported minor and non-specific complaints, and 78 (17.3%) mentioned they did not receive any information before the campaign. CONCLUSIONS/SIGNIFICANCE: In spite of overall coverage being slightly lower than expected, the use of a mobile door-to-door strategy remains a viable option even in densely-populated urban settings. Our results suggest that campaigns can be successfully implemented and well accepted in Mozambique in non-emergency contexts in order to prevent cholera outbreaks. These findings are encouraging and complement the previous Mozambican experience related to OCV.

Clinical and epidemiological characterization of influenza virus infections in children with severe acute respiratory infection in Maputo, Mozambique: Results from the implementation of sentinel surveillance, 2014 - 2016.

In Sub-Saharan Africa, where burden, impact, and incidence of acute respiratory infections (ARI) are the highest in the world, conversely, the epidemiology of influenza-associated severe acute respiratory infections (SARI) is incompletely known. The aim of this study was to describe the clinical and epidemiological features of influenza-associated SARI in hospitalized children in Maputo city, Mozambique. Nasopharyngeal and oropharyngeal swabs were collected from children aged 0-14 years old who met the case definition for SARI in two hospitals in Maputo city after their parents or legal representative consented to participate. A structured questionnaire was used to collect clinical and demographic data. Typing and subtyping of influenza were performed by real-time PCR. From January 2014 to December 2016, a total of 2,007 eligible children were recruited, of whom 1,997 (99.5%) were screened for influenza by real-time PCR. The median age of participants was 16.9 months (IQR: 7.0-38.9 months) and 53.9% (1076/1991) were male. A total of 77 were positive for influenza, yielding a frequency of 3.9% (77/1,991), with the highest frequency being reported in the age group 1-5 years old. Cases of influenza peaked twice each year, during which, its frequency reached up to 60%-80%. Among all influenza confirmed cases, 33.7% (26/77), 35.1% (27/77) and 28.6% (22/77) were typed as influenza A/H3N2, A/H1N1pdm09, and B, respectively. This represents the first report of influenza in urban/sub urban setting in Mozambique and the first evidence of distribution of strains of influenza in the country. Our data showed that frequency of influenza was lower than reported in a rural setting in Mozambique and the frequency of seasonal (A/H1N1pdm09) and (A/H3N2) subtypes were similar in children with SARI.

Respiratory syncytial and influenza viruses in children under 2 years old with severe acute respiratory infection (SARI) in Maputo, 2015.

INTRODUCTION: Although respiratory syncytial virus (RSV) and influenza virus (influenza) infections are one of the leading causes of Severe Acute Respiratory Infections (SARI) and death in young children worldwide, little is known about the burden of these pathogens in Mozambique. MATERIAL AND METHODS: From January 2015 to January 2016, nasopharyngeal swabs from 450 children, aged ≤2 years, who had been admitted to the Pediatric Department of the Maputo Central Hospital (HCM) in Mozambique, suffering with SARI were enrolled and tested for influenza and RSV using a real-time PCR assay. RESULTS: Influenza and RSV were detected in 2.4% (11/450) and 26.7% (113/424) of the participants. Children with influenza were slightly older than those infected with RSV (10 months in influenza-infected children compared to 3 months in RSV-infected children); male children were predominant in both groups (63.6% versus 54.9% in children with influenza and RSV, respectively). There was a trend towards a higher frequency of influenza (72.7%) and RSV (93.8%) cases in the dry season. Bronchopneumonia, bronchitis and respiratory distress were the most common diagnoses at admission. Antibiotics were administered to 27,3% and 15,9% of the children with influenza and RSV, respectively. Two children, of whom, one was positive for RSV (aged 6 months) and another was positive for Influenza (aged 3 months) died; both were children of HIV seropositive mothers and had bronchopneumonia. CONCLUSIONS: Our data demonstrated that RSV, and less frequently influenza, occurs in children with SARI in urban/sub-urban settings from southern Mozambique. The occurrence of deaths in small children suspected of being HIV-infected, suggests that particular attention should be given to this vulnerable population. Our data also provide evidence of antibiotics prescription in children with respiratory viral infection, which represents an important public health problem and calls for urgent interventions.

Multi-site cholera surveillance within the African Cholera Surveillance Network shows endemicity in Mozambique, 2011-2015.

BACKGROUND: Mozambique suffers recurrent annual cholera outbreaks especially during the rainy season between October to March. The African Cholera Surveillance Network (Africhol) was implemented in Mozambique in 2011 to generate accurate detailed surveillance data to support appropriate interventions for cholera control and prevention in the country. METHODOLOGY/PRINCIPAL FINDINGS: Africhol was implemented in enhanced surveillance zones located in the provinces of Sofala (Beira), Zambézia (District Mocuba), and Cabo Delgado (Pemba City). Data were also analyzed from the three outbreak areas that experienced the greatest number of cases during the time period under observation (in the districts of Cuamba, Montepuez, and Nampula). Rectal swabs were collected from suspected cases for identification of Vibrio cholerae, as well as clinical, behavioral, and socio-demographic variables. We analyzed factors associated with confirmed, hospitalized, and fatal cholera using multivariate logistic regression models. A total of 1,863 suspected cases and 23 deaths (case fatality ratio (CFR), 1.2%) were reported from October 2011 to December 2015. Among these suspected cases, 52.2% were tested of which 23.5% were positive for Vibrio cholerae O1 Ogawa. Risk factors independently associated with the occurrence of confirmed cholera were living in Nampula city district, the year 2014, human immunodeficiency virus infection, and the primary water source for drinking. CONCLUSIONS/SIGNIFICANCE: Cholera was endemic in Mozambique during the study period with a high CFR and identifiable risk factors. The study reinforces the importance of continued cholera surveillance, including a strong laboratory component. The results enhanced our understanding of the need to target priority areas and at-risk populations for interventions including oral cholera vaccine (OCV) use, and assess the impact of prevention and control strategies. Our data were instrumental in informing integrated prevention and control efforts during major cholera outbreaks in recent years.