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Self-sampling represents a high accuracy approach to human papilloma virus DNA (HPV-DNA) testing that allows for privacy and autonomy. As part of a larger study to evaluate cervical cancer screening in Mozambique, we explored user-driven facilitators and barriers to, and provider perspectives on, self-sampling. Our study was conducted in 4 public health facilities in 2 districts in Mozambique. Women aged 30-49 were prospectively enrolled for HPV screening and were offered provider or self-collected sampling. We used enrolment data from 9014 participants to examine characteristics of women choosing self-sampling and conducted in depth interviews with 104 women and 15 providers to understand facilitators and barriers to self-sampling. 97.5% of participants chose self-sampling over provider sampling. Participant-reported barriers included fear about technique, discomfort and inadequate training. Facilitators to self-sampling included increased privacy and having been exposed to a peer who previously self-sampled. Providers expressed concern about their limited role in the screening process with a self-sampling technique. Self-sampling for HPV is an acceptable approach to cervical cancer screening but barriers such as fear of sampling incorrectly and discomfort with their bodies remain., Competing Interests: The Authors declared no conflict of interest, (African Journal of Reproductive Health © 2023.)

Objective: To evaluate cervical cancer screening with primary human papillomavirus (HPV) testing in Mozambique, a country with one of the highest burdens of cervical cancer globally., Methods: Women aged 30-49 years were prospectively enrolled and offered primary HPV testing using either self-collected or provider-collected specimens. Patients who tested positive for HPV underwent visual assessment for treatment using visual inspection with acetic acid to determine eligibility for thermal ablation. If ineligible, they were referred for excision with a loop electrosurgical excision procedure, for cold knife conization, or for cervical biopsy if malignancy was suspected., Results: Between January 2020 and January 2023, 9014 patients underwent cervical cancer screening. Median age was 37 years (range 30-49) and 4122 women (45.7%) were patients living with HIV. Most (n=8792, 97.5%) chose self-collection. The HPV positivity rate was 31.1% overall and 39.5% among patients living with HIV. Of the 2805 HPV-positive patients, 2588 (92.3%) returned for all steps of their diagnostic work-up and treatment, including ablation (n=2383, 92.1%), loop electrosurgical excision procedure (n=169, 6.5%), and cold knife conization (n=5, 0.2%). Thirty-one patients (1.2%) were diagnosed with cancer and referred to gynecologic oncology., Conclusion: It is feasible to perform cervical cancer screening with primary HPV testing and follow-up in low-resource settings. Participants preferred self-collection, and the majority of screen-positive patients completed all steps of their diagnostic work-up and treatment. Our findings provide important information for further implementation and scale-up of cervical cancer screening and treatment services as part of the WHO global strategy for the elimination of cervical cancer., Competing Interests: Competing interests: Cepheid loaned the study team GeneXpert machines for the project and provided the HPV testing cartridges at a reduced rate. The authors declare no competing interests., (© IGCS and ESGO 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Evidence should be the foundation for a well-designed family planning (FP) program, but existing evidence is rarely aligned with and/or synthesized to speak directly to FP programmatic needs. Based on our experience cocreating FP research and learning agendas (FP RLAs) in Côte d'Ivoire, Malawi, Mozambique, Nepal, Niger, and Uganda, we argue that FP RLAs can drive the production of coordinated research that aligns with national priorities.To cocreate FP RLAs, stakeholders across 6 countries conducted desk reviews of 349 documents and 106 key informant interviews, organized consultation meetings in each country to prioritize evidence gaps and generate research and learning questions, and, ultimately, formed 6 FP RLAs comprising 190 unique questions. We outline the process for consensus-driven development of FP RLAs and communicate the results of an analysis of the questions in each FP RLA across 4 technical areas: self-care, equity, high impact practices, and youth. Each question was categorized as a learning versus research question, the former indicating an opportunity to synthesize existing evidence and the latter to conduct new research to answer the question. Themes emerging from the data shed light on shared evidence gaps across the 6 countries. We argue that similarities and differences in the questions in each FP RLA reflect the unique implementation experience and context, as well as each country's placement on the FP S-curve. Early uses of the FP RLAs include informing the development of FP costed implementation plans and FP2030 commitments. FP RLAs have also been discussed in multiple thematic working groups. For FP stakeholders, these FP RLAs represent a consensus-based agenda that can guide the generation and synthesis of evidence to answer each country's most pressing questions, ultimately driving progress toward increasingly evidence-based programming and policy., (© Brittingham et al.)

Background: Vaccination plays an imperative role in protecting public health and preventing avoidable mortality. Yet, the reasons for vaccine hesitancy in African countries are not well understood. This study investigates the factors associated with the acceptance of COVID-19 vaccine in Mozambique, with a focus on the role of institutional trust., Methods: The data came from the three waves of the COVID-19 Knowledge, Attitudes and Practices (KAP) survey which followed a cohort of 1,371 adults in Mozambique over six months (N = 3809). We examined vaccine acceptance based on three measurements: willingness to take vaccine, perceived vaccine efficacy, and perceived vaccine safety. We conducted multilevel regression analysis to investigate the trajectories of, and the association between institutional trust and vaccine acceptance., Results: One third of the survey participants (37%) would definitely take the vaccine. Meanwhile, 31% believed the vaccine would prevent the COVID-19 infection, and 27% believed the vaccine would be safe. There was a significant decrease in COVID-19 vaccine acceptance between waves 1 and 3 of the survey. Institutional trust was consistently and strongly correlated with different measures of vaccine acceptance. There was a greater decline in vaccine acceptance in people with lower institutional trust. The positive correlation between institutional trust and vaccine acceptance was stronger in younger than older adults. Vaccine acceptance also varied by gender and marital status., Conclusions: Vaccine acceptance can be volatile even over short periods of time. Institutional trust is a central driver of vaccine acceptance and contributes to the resilience of the health system. Our study highlights the importance of health communication and building a trustful relationship between the general public and the institutions in the context of a global pandemic., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Reduction of unmet need for contraception is associated with enhanced health outcomes. We conducted a randomised controlled trial in Mozambique analysing the effects of text messages encouraging use of family planning services., Methods: This trial was conducted within a sample of women served by the Integrated Family Planning Program implemented by Population Services International, in which community health workers provide clinic referrals for family planning services. The evaluation enrolled 5370 women between 20 January and 18 December 2020 who received a referral, reported access to a mobile phone and provided consent. Women were randomly assigned to a treatment group that received a series of text message reminders encouraging them to visit a clinic or to a control arm. An intention-to-treat analysis was conducted to analyse the effect of reminders on the probability of a clinic visit and contraceptive uptake. The final analysis includes 3623 women; 1747 women were lost to follow-up., Results: Women assigned to receive the text reminders are weakly more likely to visit a clinic (risk difference 2.3 percentage points, p=0.081) and to receive a contraceptive method at a clinic (2.2 percentage points, p=0.091), relative to a base rate of 48.0% and 46.9%, respectively. The effect on clinic visits is larger and statistically significant in the prespecified subsample of women enrolled prior to the COVID-19-related state of emergency (3.2 percentage points, p=0.042)., Conclusion: Evidence from this trial suggests that text message reminders are a promising nudge that increases the probability that women receive contraception., Trial Registration Number: AEARCTR-0005383., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To pilot an intervention on the prevention of mother-to-child transmission (PMTCT) of hepatitis B virus (HBV) in an antenatal care and maternity unit in Maputo, Mozambique, during 2017-2019., Methods: We included HBV in the existing screening programme (for human immunodeficiency virus (HIV) and syphilis) for pregnant women at their first consultation, and followed mother-child dyads until 9 months after delivery. We referred women who tested positive for hepatitis B surface antigen (HBsAg) for further tests, including hepatitis B e antigen (HBeAg) and HBV viral load. According to the results, we proposed tenofovir for their own health or for PMTCT. We administered birth-dose HBV vaccine and assessed infant HBV status at 9 months., Findings: Of 6775 screened women, 270 (4.0%) were HBsAg positive; in those for whom data were available, 24/265 (9.1%) were HBeAg positive and 14/267 (5.2%) had a viral load of > 200 000 IU/mL. Ninety-eight (36.3%) HBsAg-positive women were HIV coinfected, 97 of whom were receiving antiretroviral treatment with tenofovir. Among HIV-negative women, four had an indication for tenofovir treatment and four for tenofovir PMTCT. Of 217 exposed liveborn babies, 181 (83.4%) received birth-dose HBV vaccine, 160 (88.4%) of these < 24 hours after birth. At the 9-month follow-up, only one out of the 134 tested infants was HBV positive., Conclusion: Our nurse-led intervention highlights the feasibility of integrating PMTCT of HBV into existing antenatal care departments, essential for the implementation of the triple elimination initiative. Universal birth-dose vaccination is key to achieving HBV elimination., ((c) 2022 The authors; licensee World Health Organization.)

The COVID-19 pandemic has increasingly disrupted the global delivery of preventive health care services, as a large number of governments have issued state of emergency orders halting service delivery. However, there is limited evidence on the realized effects of the pandemic and associated emergency orders on access to services in low-income country contexts to date. To address this gap, this paper analyzes administrative data on utilization of contraceptive health services by women referred via community health promoters in two large urban and peri-urban areas of Mozambique. We focus on the period immediately surrounding the national state of emergency declaration linked to the COVID-19 pandemic on March 31, 2020. Data reported for 109,129 women served by 132 unique promoters and 192 unique public health facilities is analyzed using logistic regression, interrupted time series analysis and hazard analysis. The results demonstrate that the imposition of the state of emergency is associated with a modest short-term drop in both service provision and utilization, followed by a relatively rapid rebound. We conclude that in this context, the accessibility of reproductive health services was not dramatically reduced during the first phase of the pandemic-related emergency., Competing Interests: The authors have declared that no competing interests exist.

Objective: To describe long-term treatment outcomes of a pediatric HIV cohort in Mozambique., Design: Retrospective analysis of routine monitoring data., Setting: Secondary health care facilities in the Chamanculo Health District of Maputo., Subjects: A total of 1,335 antiretroviral treatment (ART) naïve children <15 years of age enrolled in HIV care between 2002 and 2010., Intervention: HIV care, ART (since 2003), task shifting to lower cadre nurses, counseling by lay counselors, active patient tracing, nutritional support, support by a psychologist, targeted viral load testing, and switch to second-line treatment., Main Outcome Measures: Kaplan-Meier estimates for retention in care (RIC), CD4 cell percentage, body mass index for age z-score, and adjusted incidence rate ratios for attrition (death or loss to follow-up) as calculated by Poisson regression., Results: The RIC at 6 years in the pre-ART cohort was 44% (95% confidence interval: 38-49), and the one at 8 years in the ART cohort was 70% (64-75). Risk factors for attrition included young age, low CD4 percentage, underweight, active tuberculosis, and enrollment/treatment initiation after 2006. The mean CD4 percentage increased strongly at 1 year on treatment and remained high thereafter. The body mass index for age z-score sharply increased at 1 year after treatment initiation before stabilizing at pre-ART levels thereafter., Conclusions: Good clinical and immunological treatment outcomes up to 8 years of follow-up on ART can be achieved in a context of shortage of health workers and a high level of task-shifting approach.

The population of men who have sex with men (MSM) has been largely ignored in HIV-related policies and programming in Mozambique and there is little information about the contribution of MSM to the HIV epidemic. An integrated biological and behavioral study among MSM using respondent-driven sampling was conducted in 2011 in Maputo, Beira and Nampula/Nacala. Men who reported engaging in oral or anal sex with other men in the last 12 months answered a questionnaire and provided a blood sample for HIV testing. The prevalence of HIV was 8.2 % (Maputo, n = 496), 9.1 % (Beira, n = 584) and 3.1 % (Nampula/Nacala, n = 353). Prevalence was higher among MSM ≥ 25 vs. 18-24 years: 33.8 % vs. 2.4 % (p < 0.001), 32.1 vs. 2.8 % (p < 0.001), and 10.3 vs. 2.7 % (p < 0.06), in each city respectively. The difference in prevalence demonstrates the need to increase prevention for younger MSM at risk for HIV and ensure care and treatment for older HIV-infected MSM.