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

Low engagement in HIV services and progress through the treatment cascade among key populations living with HIV in Mozambique : alarming gaps in knowledge of status

Background: Mozambique has a generalized HIV epidemic of 13.5% among the general population. Early modeling exercises in Mozambique estimate that key populations (KP), defined as men who have sex with men (MSM), female sex workers (FSW), and people who inject drugs (PWID), along with their partners account for about one third of all new infections. There is limited data describing the engagement of KP living with HIV in testing, care and treatment services. Methods: We conducted a secondary data analysis of HIV-positive participants in the first Bio-behavioral Surveillance (BBS) surveys in Mozambique conducted 2011–2014 in order to assess service uptake and progress though the HIV treatment cascade among MSM, FSW, and PWID. Unweighted pooled estimates were calculated for each key population group. Results: Among HIV-positive MSM, 63.2% of participants had ever received an HIV test, 8.8% were aware of their status, 6.1% reported having been linked to care, while 3.5% initiated ART and were currently on treatment. Of the HIV-infected FSW participants, 76.5% reported a previous HIV test and 22.4% were previously aware of their status. Linkage to care was reported by 20.1%, while 12.7% reported having initiated ART and 11.8% reported being on treatment at the time of the survey. Among HIV-infected PWID participants, 79.9% had previously received an HIV test, 63.2% were aware of their HIV status, and 49.0% reported being linked to care for their HIV infection. ART initiation was reported by 42.7% of participants, while 29.4% were on ART at the time of the survey. Conclusion: Among the three high risk populations in Mozambique, losses occurred throughout critical areas of service uptake with the most alarming breakpoint occurring at knowledge of HIV status. Special attention should be given to increasing HIV testing and linkage to ART treatment. Future surveys will provide the opportunity to monitor improvements across the cascade in line with global targets and should include viral load testing to guarantee a more complete picture of the treatment cascade

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\u3c0.001, FSW: 45.3% vs 24.4%, p\u3c0.001), lower HIV testing uptake (MSM: 67.5% vs 72.3%, p\u3c0.001; FSW: 63.2% vs 80.6%; p\u3c0.001, PWID: 53.3% vs 31.2%; p = 0.001), greater underage sexual debut (MSM: 9.6% vs 4.8%, p\u3c0.001; FSW: 35.2% vs 22.9%, p\u3c0.001), and greater underage initiation of injection drug use (PWID: 31.9% vs 7.0%, p\u3c0.001). Young KP also had lower HIV prevalence compared to older KP: MSM: 3.3% vs 27.0%, p\u3c0.001; FSW: 17.2% vs 53.7%, p\u3c0.001; and PWID: 6.0% vs 55.0%, p\u3c0.001. 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

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 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

Factors influencing risky sexual behaviour among Mozambican miners : a socio-epidemiological contribution for HIV prevention framework in Mozambique

Background: Information dealing with social and behavioural risk factors as well as their mechanisms among Mozambican migrants working in South African mines remains undocumented. This study aims to understand the various factors influencing HIV-related risk behaviours and the resulting HIV positive status of Mozambican miners employed by South African mines. This analysis was undertaken in order to inform a broader and more effective HIV preventive framework in Mozambique. Method: This study relied upon data sourced from the first Integrated Biological and Behavioural Survey among Mozambican miners earning their living in South African mines. It employs quantitative techniques using standard statistical tools to substantiate the laid-down objectives. The primary technique applied in this paper is the multivariable statistical method used in the formulation and application of a proximate determinants framework. Results: The odds of reporting one sexual partner were roughly three times higher for miners working as perforators as opposed to other types of occupation. As well, the odds of condom use - always or sometimes - for miners in the 31-40 age group were three times higher than the odds of condom use in the 51+ age group. Miners with lower education levels were less likely to use condoms. The odds of being HIV positive when the miner reports use of alcohol or drugs (sometimes/always) is 0.32 times lower than the odds for those reporting never use of alcohol or drugs. And finally, the odds of HIV positive status for those using condoms were 2.16 times that of miners who never used condoms, controlling for biological and other proximate determinants. Conclusion: In Mozambique, behavioural theory emphasising personal behavioural changes is the main strategy to combat HIV among miners. Our findings suggest there is a need to change thinking processes about how to influence safer sexual behaviour. This is viewed to be the result of a person's individual decision, due to of the complexity of social and contextual factors that may also influence sexual behaviours. This only stresses the need for HIV prevention strategies to exclusively transcend individual factors while considering the broader social and contextual phenomena influencing HIV risk among Mozambican miners

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

BackgroundPrior 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).MethodsStandardized 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.ResultsEighty-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.ConclusionsMozambique 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

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

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

HIV surveillance among key populations in Mozambique : opportunities for enhanced prevention, care and treatment

Key populations (KP) – men who have sex with men (MSM), female sex workers (FSW) and people who inject drugs (PWID) – are disproportionally affected by HIV given their sexual risk and drug use behaviors. In Mozambique, they are estimated to account for 11% of new infections. The National Strategic Plan identifies these three population groups, along with incarcerated persons, as a key priority population that must receive specialized focus within the HIV Response. Understanding their population size, health status and health seeking behaviors will create the environment necessary to ensure decreased risk of HIV transmission. The first Biobehavioral Surveillance Surveys among KP in Mozambique were conducted from 2011- 2014; they remain the only comprehensive data available about KPs in the country. This doctoral thesis seeks to examine the size of key populations, STI prevalence, and health seeking behaviors in order to provide evidence for targeted interventions and surveillance activities. Objective 1 seeks to determine the size of the key populations in Mozambique in order to ensure that the response to the HIV epidemic in the country can be adequately planned, prioritized and monitored. Objective 2 examine the risk factors related to the access and use of prevention and treatment services by FSW, MSM and PWID in Mozambique, specifically among young members of these key population groups. Objective 3 explores lessons learned in the planning, implementation, analysis, and dissemination of the first round Bio-Behavioral Surveillance Surveys in Mozambique. The results of this doctoral research show that key population size estimates in Mozambique are consistent with the literature although there is a need to continue to implement population size and mapping activities to refine the estimates. In addition, key populations generally have lower health status and engage in more risk behaviors than the general population. Their low engagement in the HIV testing and treatment cascades warrants urgent attention, especially in the promotion of HIV testing. Finally, young key populations must be supported with adopting healthy behaviors to ensure optimal health status into adulthood. Understanding the population size, health status and health seeking behaviors of key populations is essential in order to strengthen the HIV Response for this high-risk population in Mozambique.Hoog-risico groepen (‘Key populations) met inbegrip van- mannen die seks hebben met mannen (MSM), vrouwelijke sekswerkers (FSW) en mensen die drugs injecteren (PWID) - worden onevenredig zwaar getroffen door hiv, gezien hun seksuele risico's of hun drugsgebruik. In Mozambique zijn zij naar schatting verantwoordelijk voor 11% van de nieuwe infecties. Het Nationaal Strategisch Plan identificeert deze drie bevolkingsgroepen, samen met gedetineerden, als een belangrijke prioritaire populatie die binnen de hiv-respons speciale aandacht moet krijgen. Inzicht in hun bevolkingsgrootte, gezondheidsstatus en in hun toegang tot de gezondheidszorg zal de omgeving creëren die nodig is om het risico op hiv-overdracht te verminderen. De eerste nationale onderzoeken onder deze risicogroepen in Mozambique werden uitgevoerd van 2011-2014; deze blijven de enige beschikbare uitgebreide gegevens over risicogroepen in het land. Dit doctoraatsproefschrift beoogt de omvang van deze risicogroepen, de prevalentie van soa's en het zoekgedrag naar gezondheidszorg te onderzoeken om zo bewijs te leveren voor gerichte interventies en surveillance-activiteiten. Doelstelling 1 beoogt de omvang van de belangrijkste risicogroepen in Mozambique te bepalen om ervoor te zorgen dat de respons op de hiv-epidemie in het land adequaat kan worden gepland, geprioriteerd en gecontroleerd. Doelstelling 2 onderzoekt de risicofactoren die verband houden met de toegang tot, en het gebruik van, preventie- en behandelingsdiensten door FSW, MSM en PWID in Mozambique, met name onder jonge leden van deze belangrijke bevolkingsgroepen. Ten slotte verkent Doelstelling 3 de lessen die zijn geleerd bij de planning, implementatie, analyse en verspreiding van de eerste ronde van de nationale onderzoeken in risicogroepen in Mozambique. De resultaten laten zien dat de schattingen van de grootte van deze risicogroepen in Mozambique consistent zijn met de literatuur, hoewel er behoefte is aan meer recentere en nauwkeurige schattingen van de populatiegrootte. Bovendien hebben risicogroepen over het algemeen een lagere gezondheidsstatus en vertonen ze meer risicogedrag dan de algemene bevolking, wat resulteert in een hogere hiv- en soa-prevalentie. Hun geringe betrokkenheid bij de verschillende zorgaspecten van preventie en -behandeling verdient dringende aandacht. Jonge leden van de risicogroepen moeten met name worden ondersteund bij het aannemen van gezond gedrag om een optimale gezondheidsstatus tot op volwassen leeftijd te waarborgen. Ten slotte levert de uitvoering van deze nationale studies waardevolle informatie op over de hiv-epidemie onder sleutelgroepen, maar draagt zij ook bij tot de versterking van het algemene hivsurveillancesysteem in het land door de ontwikkeling van personele middelen, een betere afstemming tussen de belanghebbenden en de invoering van beleidslijnen en richtsnoeren voor een betere dienstverlening aan risicogroepen