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Inverse probability weighting (IPW), a well-established method to control for confounding in observational studies with binary exposures, has been extended to analyses with continuous exposures. Methods developed for continuous exposures may not apply when the exposure is quasi-continuous due to irregular exposure distributions that violate key assumptions. We used simulations and cluster-randomized clinical trial data to assess four approaches developed for continuous exposures – ordinary least squares (OLS), covariate balancing generalized propensity scores (CBGPS), non-parametric covariate balancing generalized propensity scores (npCBGPS), and quantile binning (QB) – and a novel method – a cumulative probability model (CPM) – in quasi-continuous exposure settings. We compared IPW stability, covariate balance, bias, mean squared error, and standard error estimation across 3000 simulations with six different quasi-continuous exposures, varying in skewness and granularity. In general, CBGPS and npCBGPS resulted in excellent covariate balance, and npCBGPS was the least biased but most variable. The QB and CPM approaches had the lowest mean squared error, particularly with marginally skewed exposures. We then successfully applied the IPW approaches, together with missing-data techniques, to assess how session attendance (out of 15) in a partners-based clustered intervention among pregnant couples living with HIV in Mozambique influenced postpartum contraceptive uptake.

Background Postpartum contraceptive uptake reduces short interpregnancy intervals, unintended pregnancies, and their negative sequalae: poor maternal and fetal outcomes. Healthy timing and spacing of pregnancy in people living with HIV (PLHIV) also allows time to achieve viral suppression to reduce parent-to-child HIV transmission. There is scant understanding about how couples-based interventions impact postpartum contraceptive uptake among PLHIV in sub-Saharan Africa. Methods We interviewed 38 recently pregnant people and 26 of their partners enrolled in the intervention arm of the Homens para Saúde Mais (HoPS+) [Men for Health Plus] trial to assess their perceptions of, attitudes towards, and experiences with contraceptive use. Individuals in the HoPS+ intervention arm received joint—as opposed to individual—HIV-related services during pregnancy and postpartum periods, six counseling and skills sessions, and nine sessions with a peer support couple. Our thematic analysis of the 64 in-depth interviews generated 14 deductive codes and 3 inductive codes across themes within the Information, Motivation, and Behavior Model of health behavior change. Results Participants reported accurate and inaccurate information about birth spacing and contraceptive methods. They described personal (health, economic, and religious) and social (gender norms, desired number of children) motivations for deciding whether to use contraceptives—with slightly different motivations among pregnant and non-pregnant partners. Finally, they explained the skills needed to overcome barriers to contraceptive use including how engagement in HoPS+ improved their shared decision-making skills and respect amongst partners—which facilitated postpartum contraceptive uptake. There were also several cases where non-pregnant partners unilaterally made family planning decisions despite disagreement from their partner. Conclusions These findings suggest that couples-based interventions during pregnancy and post-partum periods aimed at increasing postpartum contraceptive uptake must center pregnant partners’ desires. Specifically, pregnant partners should be allowed to titrate the level of non-pregnant partner involvement in intervention activities to avoid potentially emboldening harmful gender-based intercouple decision-making dynamics.

Approximately 15% of people with HIV in sub-Saharan Africa have comorbid depression, which impacts treatment outcomes. We describe predictors of baseline depressive symptoms in 1079 female and 1079 male participants in a cluster-randomized trial in Zambézia Province, Mozambique from November 2017 to December 2020. We modeled each partners' depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) using proportional odds models adjusted for enrollment date, age, body mass index [BMI], partner's PHQ-9 score, district, relationship status, education, occupation, WHO HIV clinical stage, and antiretroviral therapy use history. A

Mozambique introduced guidelines for integrated gender-based violence (GBV) services in 2012. In 2017, we trained providers on empathetic and supportive services to GBV survivors and introduced home-based services for survivors who are loss-to-follow up. Rate ratios of clinic visits were compared before and after intervention initiation, using exact significance tests. Data of 1,806 GBV survivors were reviewed, with a total of 2005 events. The median age was 23 years (IQR 17-30) and 89% were women. Among those reporting violence, 69% reported physical violence, 18% reported sexual violence (SV), and 12% reported psychological violence. Rates of care-seeking behavior were higher in the intervention period (rate ratio 1.31 [95%CI: 1.18-1.46])

Mentor Mothers (MM) provide peer support to pregnant and postpartum women living with HIV (PPWH) and their infants with perinatal HIV exposure (IPE) throughout the cascade of prevention of vertical transmission (PVT) services. MM were implemented in Zambézia Province, Mozambique starting in August 2017. This evaluation aimed to determine the effect of MM on PVT outcomes.A retrospective interrupted time series analysis was done using routinely collected aggregate data from 85 public health facilities providing HIV services in nine districts of Zambézia. All PPWH (and their IPE) who initiated antiretroviral therapy (ART) from August 2016 through April 2019 were included. Outcomes included the proportion per month per district of: PPWH retained in care 12 months after ART initiation, PPWH with viral suppression and IPE with HIV DNA PCR test positivity by 9 months of age. The effect of MM on outcomes was assessed using logistic regression.The odds of 12-month retention increased 1.5% per month in the pre-MM period, compared to a monthly increase of 7.6% with-MM (35-61% pre-MM, 56-72% with-MM; p0.001). The odds of being virally suppressed decreased by 0.9% per month in the pre-MM period, compared to a monthly increase of 3.9% with-MM (49-85% pre-MM, 59-80% with-MM; p0.001). The odds of DNA PCR positivity by 9 months of age decreased 8.9% per month in the pre-MM period, compared to a monthly decrease of 0.4% with-MM (0-14% pre-MM, 4-10% with-MM; p0.001). The odds of DNA PCR uptake (the proportion of IPE who received DNA PCR testing) by 9 months of age were significantly higher in the with-MM period compared to the pre-MM period (48-100% pre-MM, 87-100% with-MM; p0.001).MM services were associated with improved retention in PVT services and higher viral suppression rates among PPWH. While there was ongoing but diminishing improvement in DNA PCR positivity rates among IPE following MM implementation, this might be explained by increased uptake of HIV testing among high-risk IPE who were previously not getting tested. Additional efforts are needed to further optimize PVT outcomes, and MM should be one part of a comprehensive strategy to address this critical need.

Background The ability to understand another’s emotions and act appropriately, empathy, is an important mediator of relationship function and health intervention fidelity. We adapted the Interpersonal Reactivity Index (IRI) – an empathy scale – among seroconcordant expectant couples with HIV in the Homens para Saúde Mais (HoPS+) trial – a cluster randomized controlled trial assessing couple-based versus individual treatment on viral suppression – in Zambézia Province, Mozambique. Methods Using baseline data from 1332 HoPS+ trial participants (666 couples), an exploratory factor analysis assessed culturally relevant questions from the IRI. Because empathy is interdependent among couples, we validated the results of the exploratory factor analysis using a dyadic confirmatory factor analysis (CFA) with dyadic measurement invariance testing. Finally, we assessed the relationship between scores on our final scale and basic demographic characteristics (sex, age, education, and depression) using t-tests. Results We found two subscales: 1) a seven-item cognitive empathy subscale (Cronbach’s alpha 0.78) and 2) a six-item affective empathy subscale (Cronbach’s alpha 0.73). The dyadic CFA found acceptable model fit and metric invariance across partners (Comparative Fit Index (CFI) = 0.914, Tucker Lewis Index = 0.904, Root Mean Squared Error of Approximation = 0.056, ΔCFI = 0.011). We observed higher cognitive (p: 0.012) and affective (p: 0.049) empathy among males and higher cognitive (p: 0.031) and affective (p: 0.030) empathy among younger participants. More educated participants had higher affective empathy (p: 0.017) and depressed participants had higher cognitive empathy (p: Conclusions This scale will allow us to assess the interplay between empathy and other psychometric constructs (stigma, social support, etc.) in the HoPS+ trial and how each relates to retention in HIV, adherence to treatment, and prevention of maternal to child HIV transmission. Furthermore, this scale can be adapted for other sub-Saharan African populations, which will allow researchers to better assess HIV-related intervention efficacy. Trial registration This study is within the context of the HoPS+ trial, registered at ClinicalTrials.gov as number NCT03149237. Registered May 11, 2017.

Background As one of several countries that pledged to achieve the Millennium Development Goals (MDGs), Mozambique sought to reduce child, neonatal, and maternal mortality by two thirds by 2015. This study examines the impact of Mozambique’s efforts between 1997 and 2015, highlighting the increases in intervention coverage that contributed to saving the most lives. Methods A retrospective analysis of available household survey data was conducted using the Lives Saved Tool (LiST). Baseline mortality rates, cause-of-death distributions, and coverage of child, neonatal, and maternal interventions were entered as inputs. Changes in mortality rates, causes of death, and additional lives saved were calculated as results. Due to limited coverage data for the year 2015, we reported most results for the period 1997-2011. For 2011-2015 we reported additional lives saved for a subset of interventions. All analyses were performed at national and provincial level. Results Our modelled estimates show that increases in intervention coverage from 1997 to 2011 saved an additional 422 282 child lives (0-59 months), 85 450 neonatal lives (0-1 month), and 6528 maternal lives beyond those already being saved at baseline coverage levels in 1997. Malaria remained the leading cause of child mortality from 1997 to 2011; prematurity, asphyxia, and sepsis remained the leading causes of neonatal mortality; and hemorrhage remained the leading cause of maternal mortality. Interventions to reduce acute malnutrition and promote artemisinin-based combination therapy (ACT) for malaria were responsible for the largest number of additional child lives saved in the 1997-2011 period. Increases in coverage of delivery management were responsible for most additional newborn and maternal lives saved in both periods in Mozambique. Conclusion Mozambique has made impressive gains in reducing child mortality since 1997. Additional effort is needed to further reduce maternal and neonatal mortality in all provinces. More lives can be saved by continuing to increase coverage of existing health interventions and exploring new ways to reach underserved populations.

Background: Follow-up of HIV-exposed children for the delivery of prevention of mother-to-child transmission services and for early diagnosis and treatment of HIV infection is critical to their survival. Despite efforts, uptake of postnatal care for these children remains low in many sub-Saharan African countries. Methods: A qualitative study was conducted in three provinces in Mozambique to identify motivators and barriers to improve uptake of and retention in HIV prevention, care and treatment services for HIV-exposed and HIV-infected children. Participant recommendations were also gathered. Individual interviews (n = 79) and focus group discussions (n = 32) were conducted with parents/caregivers, grandmothers, community leaders and health care workers. Using a socioecological framework, the main themes identified were organized into multiple spheres of influence, specifically at the individual, interpersonal, institutional, community and policy levels. Results: Study participants reported factors such as seeking care outside of the conventional health system and disbelief in test results as barriers to use of HIV services. Other key barriers included fear of disclosure at the interpersonal level and poor patient flow and long waiting time at the institutional level. Key facilitators for accessing care included having hope for children's future, symptomatic illness in children, and the belief that health facilities were the appropriate places to get care. Conclusions: The results suggest that individual-level factors are critical drivers that influence the health-seeking behavior of caregivers of HIV-exposed and HIV-infected children in Mozambique. Noted strategies are to provide more information and awareness on the benefits of early pediatric testing and treatment with positive messages that incorporate success stories, to reach more pregnant women and mother-child pairs postpartum, and to provide counseling during tracing visits. Increasing uptake and retention may be achieved by improving patient flow at the institutional level at health facilities, by addressing concerns with family decision makers, and by working with community leaders to support the uptake of services for HIV-exposed children for essential preventive care.

Introduction: Prevention of acute HIV infections in pregnancy is required to achieve elimination of pediatric HIV. Identification and support for HIV negative pregnant women and their partners, particularly serodiscordant couples, are critical. A mixed method study done in Southern Mozambique estimated HIV incidence during pregnancy, associated risk factors and factors influencing partner's HIV testing. Methods: Between April 2008 and November 2011, a prospective cohort of 1230 HIV negative pregnant women was followed during pregnancy. A structured questionnaire, HIV testing, and collection of dried blood spots were done at 2-3 scheduled visits. HIV incidence rates were calculated by repeat HIV testing and risk factors assessed by Poisson regression. A qualitative study including 37 individual interviews with men, women, and nurses and 11 focus group discussions (n=94) with men, women and grandmothers explored motivators and barriers to uptake of male HIV testing. Results: HIV incidence rate was estimated at 4.28/100 women-years (95% CI: 2.33-7.16). Significant risk factors for HIV acquisition were early sexual debut (RR 3.79, 95% CI: 1.04-13.78, p=0.04) and living in Maputo Province (RR 4.35, 95% CI: 0.97-19.45, p=0.05). Nineteen percent of women reported that their partner had tested for HIV (93% knew the result with 8/213 indicating an HIV positive partner), 56% said their partner had not tested and 19% did not know their partner test status. Of the 14 seroconversions, only one reported being in a serodiscordant relationship. Fear of discrimination or stigma was reported as a key barrier to male HIV testing, while knowing the importance of getting tested and receiving care was the main motivator. Conclusions: HIV incidence during pregnancy is high in Southern Mozambique, but knowledge of partners' HIV status remains low. Knowledge of both partners' HIV status is critical for maximal effectiveness of prevention and treatment services to reach elimination of pediatric HIV/AIDS.

Only 37% of infants younger than 6 months in Mozambique are exclusively breastfed. A qualitative assessment was undertaken to identify the knowledge, beliefs, and practices around exclusive breastfeeding—specifically, those of mothers, fathers, grandmothers, and nurses—and to identify the support networks. Results show many barriers. In addition to receiving breast milk, infants receive water, traditional medicines, and porridges before 6 months of age. Many mothers had heard of the recommendation to exclusively breastfeed for 6 months. However, other family decision makers had heard less about exclusive breastfeeding, and many expressed doubts about its feasibility. Some of them expressed willingness to support exclusive breastfeeding if they were informed by health workers. Nurses know the benefits of exclusive breastfeeding and pass this information on verbally but have insufficient counseling skills. Interventions to improve exclusive breastfeeding should target family and community members and include training of health workers in counseling to resolve breastfeeding problems.

Background Prevalence of HIV in Mozambique among individuals aged 15–49 years is 11.5%. The HIV prevalence is higher in women than in men across the country, peaking at ages 25–29 years and 35–39 years, respectively. In this study, we aimed at determining the prevalence and incidence of HIV, prevalence of Hepatitis B (HBV), and prevalence of syphilis in youths. We also characterized a cohort of youths for future participation in phase I/II HIV vaccine trials. Methods The study was conducted at a youth clinic in Maputo Central Hospital from August 2009 to October 2011. Youths of both genders aged 18–24 years (n = 1380) were screened for HIV using a sequential algorithm of two immunochromatographic assays, HBV using an enzyme linked immunosorbant test, and syphilis using a treponemal immunochromatographic strip test. The HIV seronegative participants (n = 1309) were followed-up for 12 months with quarterly study visits. The clinical and behavioral data were collected using structured questionnaires. The HIV seroconversions were confirmed by a molecular assay. Results The study population was female dominant (76.8%). All participants had a formal education, with 44.6% studying for technical or higher education degrees. The mean age at sexual debut was 16.6 years (SD: ±1.74), with 85.6% reporting more than one sexual partner in life. The screening showed the prevalence of HIV, HBV, and syphilis at 5.1% (95% CI: 3.97–6.31), 12.2% (95% CI 10.5%–14.0%), and 0.36% (95% CI 0.15%–0.84%), respectively. The HIV incidence rate was found to be 1.14/100 person years (95% CI: 0.67–1.92). Retention rates were stable throughout the study being 85.1% at the last visit. Conclusion Incidence of HIV in this cohort of youths in Maputo was relatively low. Also, the prevalence of HIV and syphilis was lower than the national values in this age group. However, the HBV prevalence was higher than in previous reports in the country.

The introduction of highly active antiretroviral therapy (HAART) has changed the natural history of AIDS-associated Kaposi's sarcoma (KS). Although the use of HAART remains limited in low-resource settings, there are global initiatives to make these drugs available to several millions of HIV-infected persons. While there are multiple reports of KS regression during HAART with or without chemotherapy, there is little documentation on KS management in resource-limited settings. In this paper we review current KS treatments available worldwide and discuss the implications of the increased access to antiretrovirals for KS treatment strategies in resource-limited settings.