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.

The effect of pre-service training on post-graduation skill and knowledge retention among mid-level healthcare providers in Mozambique.

BACKGROUND: Mozambique suffers from critical shortages of healthcare workers including non-physician clinicians, Tecnicos de Medicina Geral (TMGs), who are often senior clinicians in rural health centres. The Mozambique Ministry of Health and the International Training and Education Center for Health, University of Washington, Seattle, revised the national curriculum to improve TMG clinical knowledge and skills. To evaluate the effort, data was collected at graduation and 10 months later from pre-revision (initial) and revised curriculum TMGs to determine the following: (1) Did cohorts trained in the revised curriculum score higher on measurements of clinical knowledge, physical exam procedures, and solving clinical case scenarios than those trained in the initial curriculum; (2) Did TMGs in both curricula retain their knowledge over time (from baseline to follow-up); and (3) Did skills and knowledge retention differ over time by curricula? Post-graduation and over time results are presented. METHODS: t-tests examine differences in scores between curriculum groups. Univariate and multivariate linear regression models assess curriculum-related, demographic, and workplace factors associated with scores on each of three evaluation methods at the p < 0.05 level. Paired t-tests examine within-group changes over time. ANOVA models explore differences between Health Training Institutes (HTIs). Generalized estimating equations determine whether change in scores over time differed by curricula. RESULTS: Mean scores of initial curriculum TMGs at follow-up were 52.7%, 62.6%, and 40.0% on the clinical cases, knowledge test, and physical exam, respectively. Averages were significantly higher among the revised group for clinical cases (60.2%; p < 0.001) and physical exam (47.6%; p < 0.001). HTI was influential on clinical case and physical exam scores. Between graduation and follow-up, clinical case and physical exam scores decreased significantly for initial curriculum students; clinical case scores increased significantly among revised curriculum TMGs. CONCLUSIONS: Although curriculum revision had limited effect, marginal improvements in the revised group show promise that these TMGs may have increased ability to synthesize clinical information. Weaknesses in curriculum and practicum implementation likely compromised the effect of curriculum revision. An improvement strategy that includes strengthened TMG training, greater attention to pre-service clinical practice, and post-graduation mentoring may be more advantageous than curriculum revision, alone, to improve care provided by TMGs.

HIV prevalence and risk behaviors among Mozambicans working in South African mines.

Mineworkers are considered a population at risk for HIV due to risk behaviors associated with migratory work patterns. This was the first study in Mozambique to determine the prevalence of HIV and associated demographic and risk behaviors, and assess use and access to prevention and healthcare services among Mozambicans working in South African mines. Men who had worked in a South African mine in the past 12 months were recruited between February and May 2012 using time location sampling (TLS) at the Ressano Garcia border between Mozambique and South Africa. Demographic and behavioral data were collected through a standardized questionnaire, and HIV prevalence was estimated by testing dried blood spots (DBS) with two enzyme immunoassays. In total, 432 eligible mine workers were recruited. Mean age was 43 years. Most were married or cohabitating; among them, 12.6 % had two or more wives/marital partners in Mozambique. In the 12 months preceding the survey, 24.7 % had an occasional sexual partner, and 6.6 % had at least one partner who was a female sex worker. Only one in five (18.5 %) used a condom during last sex. HIV prevalence among mineworkers was 22.3 %, and 74.6 % of those who tested positive as part of the survey did not know their status. HIV prevalence was significantly higher (p = 0.018) among those that were uncircumcised (31.2 %) than those who were circumcised (18.5 %). Multiple partners (multiple spouses, cross-border relations, and multiple occasional partnerships), inconsistent condom use, and a high proportion of infected mineworkers who do not know their HIV status increases the risk of HIV transmission in this population. Combination strategies involving the promotion of condom use, HIV testing, and male circumcision should be strengthened among mineworkers.

Mid-level healthcare personnel training: an evaluation of the revised, nationally-standardized, pre-service curriculum for clinical officers in Mozambique.

INTRODUCTION: Mozambique suffers from a critical shortage of healthcare workers. Mid-level healthcare workers, (Tecnicos de Medicina Geral (TMG)), in Mozambique require less money and time to train than physicians. From 2009-2010, the Mozambique Ministry of Health (MoH) and the International Training and Education Center for Health (I-TECH), University of Washington, Seattle, revised the TMG curriculum. To evaluate the effect of the curriculum revision, we used mixed methods to determine: 1) if TMGs meet the MoH's basic standards of clinical competency; and 2) do scores on measurements of clinical knowledge, physical exam, and clinical case scenarios differ by curriculum? METHODS: T-tests of differences in means examined differences in continuous score variables between curriculum groups. Univariate and multivariate linear regression models assess curriculum-related and demographic factors associated with assessment scores on each of the three evaluation methods at the p<0.05 level. Qualitative interviews and focus groups inform interpretation. RESULTS: We found no significant differences in sex, marital status and age between the 112 and 189 TMGs in initial and revised curriculum, respectively. Mean scores at graduation of initial curriculum TMGs were 56.7%, 63.5%, and 49.1% on the clinical cases, knowledge test, and physical exam, respectively. Scores did not differ significantly from TMGs in the revised curriculum. Results from linear regression models find that training institute was the most significant predictor of TMG scores on both the clinical cases and physical exam. CONCLUSION: TMGs trained in either curriculum may be inadequately prepared to provide quality care. Curriculum changes are a necessary, but insufficient, part of improving TMG knowledge and skills overall. A more comprehensive, multi-level approach to improving TMG training that includes post-graduation mentoring, strengthening the pre-service internship training, and greater resources for training institute faculty may result in improvements in TMG capacity and patient care over time.