Despite seven years of investment from the President's Emergency Plan For AIDS Relief (PEPFAR), the expansion of human immunodeficiency virus (HIV)-related services continues to challenge Mozambique's health-care infrastructure, especially in the country's rural regions.In 2012, as part of a national acceleration plan for HIV care and treatment, Namacurra district employed a mobile clinic strategy to provide temporary manpower and physical space to expand services at four rural peripheral clinics. This paper describes the strategy deployed, the uptake of services and the key lessons learnt in the first 18 months of implementation.In 2012, Namacurra´s adult population was estimated to be 125,425, and of those 15,803 were estimated to be HIV infected. Although there is consistent government support of antiretroviral therapy (ART) programmes, national coverage remains low, with less than 15% of those eligible having received ART by December 2012.Between April 2012 and September 2013, Namacurra district enrolled 4832 new patients into HIV care and treatment. By using the mobile clinic strategy for ART expansion, the district was able to expand provision of ART from two to six (of a desired seven) clinics by September 2013.Mobile clinic strategies could rapidly expand HIV care and treatment in under-funded settings in ways that both build local capacity and are sustainable for local health systems. The clinics best serve as a transition to improved capacity at fixed-site services.Malgré les 7 années d'investissement du Plan d'urgence du Président des États-Unis d'Amérique pour la lutte contre le SIDA (PEPFAR), l'expansion des services de lutte contre le virus de l'immunodéficience humaine (VIH) est toujours un défi pour les infrastructures de soins de santé du Mozambique, en particulier dans les régions rurales du pays.En 2012, dans le cadre d'un plan d'accélération pour les soins et le traitement contre le VIH, le district de Namacurra a utilisé une stratégie de dispensaires mobiles pour fournir une main-d'œuvre temporaire et de l'espace physique afin d'étendre les services de lutte contre le VIH à 4 dispensaires périphériques ruraux. Cet article décrit la stratégie déployée, l'assimilation de ces services et les principaux enseignements tirés au cours des 18 premiers mois de mise en œuvre.En 2012, la population adulte de Namacurra était estimée à 125 425 personnes, et on estimait que 15 803 d'entre elles étaient infectées par le VIH. Malgré un soutien constant des programmes de traitement antirétroviral (TAR) de la part du gouvernement, la couverture nationale reste faible, avec moins de 15% des personnes éligibles ayant reçu un TAR en décembre 2012.Entre avril 2012 et septembre 2013, le district de Namacurra a inscrit 4832 nouveaux patients au programme de soins et de traitement contre le VIH. En utilisant la stratégie de dispensaires mobiles pour étendre le TAR, le district a pu développer la fourniture de TAR de 2 à 6 dispensaires (pour un nombre souhaité de 7) en septembre 2013.Les stratégies de dispensaires mobiles pourraient rapidement étendre les soins et les traitements contre le VIH dans les endroits sous-financés par des moyens qui renforcent les capacités locales et qui sont durables pour les systèmes de santé locaux. Les dispensaires servent au mieux de transition vers l'amélioration des capacités dans les services de site fixe.A pesar de los siete años de inversión del Plan de Emergencia del Presidente de los Estados Unidos de América para luchar contra el SIDA (PEPFAR), la expansión de los servicios relacionados con el virus de la inmunodeficiencia humana (VIH) continúa suponiendo un desafío para la infraestructura sanitaria de Mozambique, especialmente en las regiones rurales del país.En 2012, como parte de un plan de aceleración nacional para el cuidado y tratamiento del VIH, el distrito de Namacurra empleó una estrategia clínica móvil para suministrar mano de obra y espacio físico temporales para expandir los servicios a cuatro clínicas periféricas rurales. Este documento describe la estrategia empleada, la comprensión de servicios y las lecciones clave aprendidas en los primeros 18 meses de implementación.En 2012, la población adulta estimada de Namacurra era de 125 425 y de estas personas se estimaba que 15 803 estaban infectadas con el VIH. A pesar de haber un constante apoyo gubernamental de los programas de tratamiento antirretroviral (TAR), la cobertura nacional sigue siendo baja, menos de un 15 % de las personas seleccionadas habían recibido TAR antes de diciembre de 2012.Entre abril de 2012 y septiembre de 2013, el distrito de Namacurra inscribió a 4832 nuevos pacientes en el cuidado y tratamiento del VIH. Mediante el uso de la estrategia de la clínica móvil para la expansión de TAR, el distrito pudo expandir las provisiones de TAR de dos a seis clínicas (de las siete deseadas) antes de septiembre de 2013.Las estrategias de las clínicas móviles podrían expandir rápidamente el cuidado y tratamiento del VIH en situaciones de poca financiación de forma que crean capacidad local y sean sostenibles para los sistemas sanitarios locales. Las clínicas sirven de la mejor manera como transición a la capacidad mejorada en servicios en lugares fijos.رغم مرور سبعة أعوام من الاستثمار على خطة الرئيس الطارئة للإغاثة من مرض الإيدز (PEPFAR)، ما زال التوسع في الخدمات ذات الصلة بفيروس العوز المناعي البشري يشكل تحدياً للبنية الأساسية للرعاية الصحية في موزامبيق، لا سيما في المناطق الريفية من البلد.في عام 2012، استخدمت مقاطعة ناماكورا استراتيجية العيادات المتنقلة، كجزء من خطة التسريع الوطنية لرعاية فيروس العوز المناعي البشري وعلاجه، لتوفير القوة العاملة المؤقتة والمساحة المادية لتوسيع الخدمات في أربع عيادات ريفية. وتتناول هذه الورقة بالوصف الاستراتيجية التي تم نشرها والاستفادة من الخدمات والدروس الرئيسية المستفادة في أول 18 شهراً من التنفيذ.في عام 2012، كان عدد السكان في سن البلوغ في ناماكورا وفق التقديرات 125425 نسمة، وكان من بينهم 15803 شخصاً مصابين بعدوى فيروس العوز المناعي البشري. ورغم الدعم المتسق المقدم من الحكومة لبرامج العلاج بمضادات الفيروسات القهقرية، لا تزال التغطية الوطنية منخفضة، حيث حصل أقل من 15 % فقط من المؤهلين على العلاج بمضادات الفيروسات القهقرية بحلول كانون الأول/ ديسمبر 2012.بين نيسان/ أبريل 2012 وأيلول/ سبتمبر 2013 سجلت مقاطعة ناماكورا 4832 مريضاً جديداً في رعاية فيروس العوز المناعي البشري وعلاجه. وعن طريق استخدام استراتيجية العيادات المتنقلة لتوسيع العلاج بمضادات الفيروسات القهقرية، تمكنت المقاطعة من توسيع نطاق توفير العلاج بمضادات الفيروسات القهقرية من عيادتين إلى ست عيادات (من أصل سبع عيادات مرجوة) بحلول أيلول/ سبتمبر 2013.تتمتع استراتيجيات العيادات المتنقلة بالقدرة على توسيع نطاق رعاية فيروس العوز المناعي البشري وعلاجه على نحو سريع في المناطق منخفضة التمويل بطرق يمكنها بناء القدرة المحلية وتتمتع بالاستدامة بالنسبة للنظم الصحية المحلية. وتمثل العيادات تحولاً إلى تحسين القدرة في خدمات المواقع الثابتة.尽管获得总统防治艾滋病紧急救援计划（PEPFAR）七年的投资，莫桑比克的医疗基础设施依然面临着扩大艾滋病毒（HIV）相关服务的挑战，在该国的农村地区尤其如此。在2012年，作为全国性HIV护理和治疗加速计划的组成部分，纳玛库拉（Namacurra）地区采用移动诊所策略来提供临时人力和物理空间，以扩大四个农村外围诊所的服务。本文介绍了在开始18个月的实施过程中部署的战略、提供的服务和吸取的关键经验教训。2012年，纳玛库拉成年人口估计为125425人，其中估计有15803人受到艾滋病毒的感染。虽然始终有抗逆转录病毒疗法（ART）项目的政府支持，但是这种治疗的全国覆盖率仍然很低，到2012年12月，有资格获得这种治疗的人群中仅有不到15%的人接受了ART的治疗。在2012年4月至2013年9月，纳玛库拉地区招募了4832名新病人接受艾滋病护理和治疗。通过使用移动诊所战略进行ART扩展，该地区能够将ART治疗的提供点从两个诊所增加到2013年9月的六个（预期需要七个）。流动诊所策略可以迅速扩大资金短缺地区艾滋病的护理和治疗，其采取的方式既有利于建设本地能力，对当地卫生系统也是可持续的。这些诊所是改进固定网点服务能力的最好过渡形式。Несмотря на инвестиции, которые в течение семи лет выделялись в рамках Чрезвычайного плана Президента США по борьбе со СПИДом (PEPFAR), распространение услуг по борьбе с вирусом иммунодефицита человека (ВИЧ) продолжает оставаться проблемой для инфраструктуры здравоохранения Мозамбика, особенно в сельских регионах страны.В 2012 году в рамках Национального плана по активизации ухода и лечения ВИЧ-инфекции в районе Намакурра была использована стратегия передвижных клиник, которые предоставляли временный персонал и физическое пространство для расширения ассортимента услуг в четырех сельских периферийных клиниках. В этой статье описывается использованная стратегия, потребление услуг и главные уроки, извлеченные в ходе первых 18 месяцев реализации стратегии.В 2012 году взрослое население Намакурры оценивалось в 125 425 человек, из которых 15 803 человека, по оценкам, были инфицированы ВИЧ. Несмотря на постоянную государственную поддержку программ антиретровирусной терапии (АРТ), охват населения на национальном уровне остается низким, и менее чем 15% населения, имеющего право на АРТ, получили лечение к декабрю 2012 года.В период с апреля 2012 года по сентябрь 2013 года в районе Намакурра 4832 новых пациента были зачислены для участия в программе ухода и лечения ВИЧ. Используя стратегию передвижных клиник для расширения охвата АРТ, район смог расширить предоставление АРТ с двух до шести (из желаемых семи) клиник к сентябрю 2013 года.Стратегии передвижных клиник могут быстро расширить охват услугами ухода и лечения ВИЧ в условиях недостаточного финансирования таким путем, какой позволит нарастить местный потенциал, и являются рациональными для местных систем здравоохранения. Такие клиники являются наилучшим средством перехода к улучшенному потенциалу оказания услуг на базе стационарных учреждений.
Women First was a combined economic and social empowerment intervention implemented between 2010 and 2015 in Zambézia Province, Mozambique. The intervention was designed to reduce adolescent girls' risk of HIV and gender-based violence, improve school attendance and empower girls. However, perceptions of girls' improved respectfulness also emerged as an unanticipated effect during the programme evaluation. In this paper, we explore emic definitions of respect and girls' good behaviour and perceptions of how the intervention caused improvements in behaviour from the perspective of intervention participants, their heads of household, influential men in their lives, and community members. In depth interviews and focus group discussions were conducted at two time points in 12 rural communities where the intervention was implemented. Respondents described "good girls" as deferential and obedient; productive and willing to serve their families and communities; and sexually chaste and modestly dressed. Respondents believed the intervention had reinforced or taught these behaviours, although they were generally aligned with gender norms that were not part of the formal intervention content and sometimes contrary to the intervention's primary goals. Implications for future sexual and reproductive health programmes are discussed.
SETTING: Antenatal care (ANC) and postpartum care (PPC) clinic in Manhiça District, Mozambique.OBJECTIVE: To estimate the prevalence of TB among pregnant and post-partum women and describe the clinical characteristics of the disease in a rural area of Southern Mozambique.METHODS: We conducted a cross-sectional TB prevalence study among pregnant and post-partum women recruited from September 2016 to March 2018 at the Manhiça Health Care Center (MHC). We recruited two independent cohorts of women consecutively presenting for routine pregnancy or post-partum follow-up visits.RESULTS: A total of 1,980 women from the ANC clinic and 1,010 from the PPC clinic were enrolled. We found a TB prevalence of 505/100,000 (95% CI: 242-926) among pregnant women and 297/100,000 (95% CI: 61-865) among post-partum women. Among HIV-positive pregnant women, TB prevalence was 1,626/100,000 (95% CI: 782-2,970) and among postpartum HIV-positive women, TB prevalence was 984/100,000 (95% CI: 203-2,848).CONCLUSIONS: The burden of TB was not higher in postpartum women than in pregnant women. Most TB cases were detected in HIV-positive women. TB screening and diagnostic testing among pregnant and postpartum women attending ANC and PPC clinics in Manhiça District is acceptable and feasible.
Because AIDS is increasing in rural areas and small cities of the United States, we sought to further describe the epidemiology of HIV/AIDS in nonurban Alabama.Extensive interviews of HIV-infected residents of Alabama living outside of urban Birmingham were conducted at clinics throughout the state.Of the 417 HIV-infected persons interviewed from January 1995 through January 1997, 310 (74%) were male, 229 (55%) were white, and 179 (43%) were black. Over time, increasing proportions of HIV infections have likely been acquired in nonurban areas. Of the 417 subjects, 43 (10%) had visited an STD clinic in the past year, and 31 (7%) had smoked crack-cocaine during the past month. Of the 166 persons who had been sexually active in the past month, 59 (36%) had used alcohol before sex and 56 (34%) used condoms inconsistently. Of the 417 subjects, 161 (39%) currently had no health insurance, and 68 (16%) had lost medical insurance since becoming HIV-infected.HIV-infected persons in nonurban Alabama are likely to have practiced high-risk behavior, to have acquired HIV in nonurban settings, and to have inadequate health insurance.
Before the 2015 implementation of "Test and Start," the initiation of combination antiretroviral therapy (ART) was guided by specific CD4 cell count thresholds. As scale-up efforts progress, the prevalence of advanced HIV disease at ART initiation is expected to decline. We analyzed the temporal trends in the median CD4 cell counts among adults initiating ART and described factors associated with initiating ART with severe immunodeficiency in Zambézia Province, Mozambique. We included all HIV-positive, treatment-naive adults (age ≥ 15 years) who initiated ART at a Friends in Global Health (FGH)-supported health facility between September 2012 and September 2017. Quantile regression and multivariable logistic regression models were applied to ascertain the median change in CD4 cell count and odds of initiating ART with severe immunodeficiency, respectively. A total of 68,332 patients were included in the analyses. The median change in CD4 cell count under "Test and Start" was higher at +68 cells/mm3 (95% CI: 57.5-78.4) compared with older policies. Younger age and female sex (particularly those pregnant/lactating) were associated with higher median CD4 cell counts at ART initiation. Male sex, advanced age, WHO Stage 4 disease, and referrals to the health facility through inpatient provider-initiated testing and counseling (PITC) were associated with higher odds of initiating ART with severe immunodeficiency. Although there were reassuring trends in increasing median CD4 cell counts with ART initiation, ongoing efforts are needed that target universal HIV testing to ensure the early initiation of ART in men and older patients.
Abstract Background HIV is treated as a chronic disease, but high lost-to-follow-up rates and poor adherence to medication result in higher mortality, morbidity, and viral mutation. Within 18 clinical sites in rural Zambézia Province, Mozambique, patient adherence to antiretroviral therapy has been sub-optimal. Methods To better understand barriers to adherence, we conducted 18 community and clinic focus groups in six rural districts. We interviewed 76 women and 88 men, of whom 124 were community participants (CP; 60 women, 64 men) and 40 were health care workers (HCW; 16 women, 24 men) who provide care for those living with HIV. Results While there was some consensus, both CP and HCW provided complementary insights. CP focus groups noted a lack of confidentiality and poor treatment by hospital staff (42% CP vs. 0% HCW), doubt as to the benefits of antiretroviral therapy (75% CP vs. 0% HCW), and sharing medications with family members (66% CP vs. 0%HCW). Men expressed a greater concern about poor treatment by HCW than women (83% men vs. 0% women). Health care workers blamed patient preference for traditional medicine (42% CP vs. 100% HCW) and the side effects of medication for poor adherence (8% CP vs. 83% CHW). Conclusions Perspectives of CP and HCW likely reflect differing sociocultural and educational backgrounds. Health care workers must understand community perspectives on causes of suboptimal adherence as a first step toward effective intervention.
HIV prevalence rates in Zambézia Province were estimated to be 12.6% in 2009. A number of educational campaigns have been aimed at improving HIV transmission and prevention knowledge among community members in an effort to reduce infection rates. These campaigns have also encouraged people to seek health care at clinical sites, instead of employing traditional healers to cure serious illness. The impact of these programs on the rural population has not been well documented. To assess the level of knowledge about HIV transmission and prevention and health-seeking behavior, we interviewed 349 people in 2009 using free response and multiple choice questionnaires. Over half reported first seeking treatment at a government health clinic; however, the majority of participants had visited a traditional healer in the past. Knowledge regarding prevention and transmission of HIV was primarily limited to the sexual origins of infection and the protective advantages of condom use. Increased educational level and having learned about HIV from a community health worker were associated with higher HIV prevention and transmission knowledge. Traditional healers and community health-care workers were both conduits of health information to our study participants. HIV education and use of clinical services may be facilitated by partnering more closely with these groups.
Altered mental status (AMS) is a priority presenting sign that must be assessed in HIV-infected, febrile children, yet diagnosis is difficult in areas with limited diagnostic capacity. Malaria and bacterial meningitis have been reported as the most common causes of AMS in febrile children presenting to the hospital in sub-Saharan Africa. However, in an HIV-infected child, central nervous system manifestations are diverse.We conducted a clinical observational study of HIV-infected febrile children, aged 0-59 months, hospitalized in Mozambique and prospectively followed. Within this cohort, a nested study was designed to characterize children admitted with AMS and to assess factors associated with mortality. Univariate and multivariable analysis were performed comparing characteristics of the cohort by AMS status and evaluated demographic and clinical factors by in-hospital mortality outcome.In total, 727 children were enrolled between April 2016 and February 2019, 16% had AMS at admission. HIV-infected, febrile children, who presented with AMS and who had a diagnosis of bacteremia, had a 4-fold increased relative odds of in-hospital mortality, and children who presented with neurologic symptoms on admission had a roughly 8-fold higher odds of in-hospital mortality relative to children without presenting neurologic findings.Mozambique has a pressing need to expand local diagnostic capacity. Our results highlight the critical need for clinicians to incorporate a broader differential into their potential causes of AMS, and to develop a Ministry of Health approved diagnostic and management algorithm, which is standardly used, to manage patients for whom reliable and relevant diagnostic services are not available.
Abstract Background An estimated 2.4 million babies died within the first 28 days of life in 2020. The third leading cause of neonatal death continues to be neonatal sepsis. Sepsis-causing bacterial pathogens vary temporally and geographically and, with a rise in multidrug-resistant organisms (MDROs), pose a threat to the neonatal population. Methods This was a single-center, retrospective study of very low birth weight (VLBW) infants with late-onset sepsis (LOS) admitted to a neonatal unit in South Africa. We aimed to calculate the prevalence of multidrug-resistant (MDR) infections in this population. The data collected included demographic and clinical characteristics, length of hospital stay, risk factors for MDRO and mortality, and microbiology results. Logistic regression was used to assess the association between prespecified risk factors with MDR infections and mortality. Results Of 2570 VLBW infants admitted, 34% had LOS, of which 33% was caused by MDROs. Infection with Acinetobacter spp., Pseudomonas spp., extended-spectrum beta-lactamase Klebsiella spp., or Escherichia coli was associated with the highest mortality in the LOS cohort. Infants with congenital infections (adjusted odds ratio [aOR], 5.13; 95% CI, 1.19–22.02; P = .028) or a history of necrotizing enterocolitis (aOR, 2.17; 95% CI, 1.05–4.49; P = .037) were at significantly higher risk for MDR infections. Conclusions More than one-third of LOS cases in VLBW infants were caused by MDROs in this study. MDR infections cause substantial neonatal mortality. Antimicrobial stewardship programs, infection control protocols, and ongoing surveillance are needed to prevent further emergence and spread of MDR infections worldwide.
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