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Concept Paper: Positive Prevention Project in Mozambique

This concept paper outlines the background, rationale, implementation steps, and future plans for the project that inspired this toolkit.

Background

In October 2005, the Twinning Center (TC) team, in partnership with staff members from the Mozambique Ministry of Health (MOH) Voluntary Counseling and Testing (VCT) and Home-Based Care (HBC) programs, the director of the U.S. Centers for Disease Control and Prevention Control (CDC) Global AIDS Project GAP, the CDC Prevention adviser, and CDC Human Capacity Development and Training (HCD) adviser, initiated discussions to evaluate the desirability of a demonstration project for prevention interventions with HIV-infected individuals in Mozambique. As a result of these discussions, conducted jointly with the Provincial Health Directorate (DPS) for Maputo Province, a group of potential pilot sites was identified. The sites under consideration had the following characteristics:

  • Presence of strong supporting partners in HIV/AIDS service provision that were willing to assist with implementation and monitoring of the interventions
  • Expressions of potential interest from staff members and volunteers
  • Proximity to Maputo City to facilitate close supervision and monitoring
  • Existence of health facility- or community-based HIV/AIDS services within which the proposed "Positive Prevention" (PP) could take place
  • Location within semi-rural or rural areas for potential replicability

A team composed of MOH, TC, and CDC staff members visited the proposed sites and met with MOH and NGO personnel, local volunteers, and people living with HIV/AIDS (PLHA) at each site. The team, site staff members, and local volunteers agreed that prevention interventions targeting HIV-infected individuals were very much needed, and they requested assistance from the TC to initiate those efforts.

This initiative is based on the strategies developed under the CDC's Advancing HIV Prevention initiative and informed by recent epidemiological trends in HIV and research studies about behavioral and medical aspects of HIV transmission.

Key Issues

In Mozambique, most prevention interventions currently target persons who are either HIV negative or unaware of their HIV status. The goal of such interventions is to prevent individuals from becoming infected and to encourage HIV testing. The content of primary prevention interventions is generally informational (e.g., how HIV is transmitted, and how transmission risks can be reduced), motivational (e.g., why it is important to reduce HIV risk), and skills-based (e.g., how to negotiate risk reduction with a sex partner). Although MOH program staff and NGO partners in Mozambique have gained experience over the years in HIV/AIDS service implementation and expansion, and in the development of informational and motivational interventions, experience with skills-based interventions as well as monitoring and evaluation of behavior change interventions is still limited.

However, there has been an increased domestic and international awareness in recent years that HIV prevention efforts need to address not only risk reduction among HIV-uninfected individuals but also the adoption of preventive measures by HIV-positive individuals.

One positive person is involved in each case of HIV transmission. A change in the risk behavior of a PLWHA will have a much bigger effect on the spread of HIV than an equivalent change in the behavior of a HIV-negative person. (King-Spooner, 1999)

In addition to developing more efficient approaches to prevention, as antiretroviral therapy becomes more widely available in Mozambique, it is increasingly important to direct intervention efforts toward PLHA. More individuals with HIV are living longer, feeling better, and enjoying a renewed interest in life. These very important improvements in the health and well-being of PLHA bring new challenges, including the challenge of negotiating safer sex behavior as an HIV-infected individual.

Convincing arguments based on research from the United States, Kenya, and Uganda have recently been made for consideration of prevention activities with HIV-infected individuals (commonly referred to as "Positive Prevention" or more recently as "Positive Health, Dignity and Prevention"). Moreover, directing prevention efforts toward individuals who are aware of their HIV-infected status is a cornerstone of the CDC's Advancing HIV Prevention Initiative, for which four core strategies have been identified:

  1. Make HIV testing a routine part of medical care whenever and wherever patients go for care.
  2. Use new models for diagnosing HIV infections, outside traditional medical settings.
  3. Prevent new infections by working with people diagnosed with HIV and their partners (when serodiscordant couples are involved).
  4. Continue to decrease mother-to-child-transmission.

Medical care providers play a crucial role in each of these strategies. In particular, clinicians who provide care for HIV-infected individuals can work effectively with these individuals to reduce the transmission risk.

Most PP interventions in the United States have focused on training health care providers to conduct short risk-reduction interventions with HIV-infected patients during routine clinic visits. From one of the first evidence-based trials of such interventions in the United States, Richardson et al. (2004) reported on the efficacy of a provider-delivered intervention in reducing unprotected intercourse among clinic patients. Six HIV clinics were randomly assigned to receive either the intervention (treatment) or control program. A total of 585 sexually active HIV clinic patients were enrolled in the study and followed over a period of nine months. In the intervention clinics, the entire clinic staff was trained to integrate prevention messages into the clinic setting. Also, medical providers delivered brief risk-reduction counseling to their patients. All clinic counseling was supplemented with written information for all patients who received HIV care and treatment services. Two matched clinics were used as comparison sites, where patients received information only on medication adherence. Rates of self-reported unprotected intercourse were compared between groups and the results indicated that, among patients who had two or more sexual partners, unprotected intercourse was reduced by 38% among those who received brief counseling from their medical provider. Based on these findings, training utilizing this method to introduce prevention into the HIV clinic has been adopted by several U.S.-based HIV clinics.

Although the results of clinic-based interventions are encouraging, with key constraints in settings with few clinicians and overwhelming numbers of patients being similar in the United States and Mozambique, short risk-reduction interventions in clinic settings can be complemented and behavior change can be reinforced by community-based approaches such as incorporating risk-reduction interventions into support groups or into home-based care. Such community-based interventions might more easily incorporate a family-focused approach, which is particularly important in areas with high numbers of serodiscordant couples.

Pilot PP Sites and Interventions

Following the discussions described above, in November 2005, the MOH/TC/CDC team chose two PP pilot intervention sites: the Namaacha Health Center and the Esperanca VCT Center in Matola, both located in Maputo Province. A brief overview of the prevention needs and context of each site is outlined below, followed by a description of the PP pilot intervention.

Namaacha Health Center is an MOH facility supported by an international NGO (Medicos de Mondo Portugal) and provides the following HIV/AIDS and related services: voluntary counseling and testing (one fixed VCT center and four satellites services; i.e., staff from the VCT center providing VCT services at four peripheral sites on a regular basis); prevention of mother-to-child transmission (PMTCT) services; diagnosis and treatment of tuberculosis (TB), sexually transmitted infections (STIs) and opportunistic infections (OIs); and a home-based care program covering villages near the facility. The health center was in the process of rolling out ARV treatment services at the time this PP pilot intervention was initiated.

Health care personnel at this site identified the need for more consistent and systematic prevention counseling across all types of services (VCT, PMTCT, outpatient consultations, etc.) and through different health cadres working at different service points (e.g., VCT counselors, nurses in the antenatal clinic; physicians at the wards). They reported the need to increase skills to assess risk for transmission, to build HIV prevention counseling skills to deliver prevention messages that support behavioral change, and to work with HIV-infected clients to develop individualized plans to reduce risk. Clinicians also reported that they were not comfortable discussing sex and HIV-related stigma with their patients, and thus wanted to develop the skills to discuss strategies for prevention within sexual relationships and the impact of being HIV-infected on sexual lives and behavior.

Esperanca VCT Center is a community-based center located in Matola, Maputo Province, in close proximity to Maputo City. The center is supported by a local NGO, ADPP, and receives assistance from Mozal, a privately owned aluminum factory. The center is assisted by staff and volunteers, and employs more than 80 local volunteers and at least two international volunteers at all times. This site utilizes a peer-education approach through linkages the staff has developed with local community PLHA groups.

Interviews with counselors indicated that the VCT center served a large number of serodiscordant couples. The counselors reported that they needed help addressing the myriad issues that discordant couples face, such as disclosure and negotiation of safer sex. The HIV clients who were interviewed reported a need for psychosocial support. The women wanted a safe space where they could learn about prevention issues and seek help for themselves and their children. The need for support was great, as many of the women had been abandoned by their husband or partner after disclosing their positive serostatus. HIV-infected clients also expressed the need for assistance with transportation to the clinic (which is located several kilometers from the village) and access to information about safe infant feeding options.

PP Pilot Intervention

In response to the needs assessments conducted at each pilot side, an intervention was developed and piloted with the following three goals:

  1. To prevent morbidity among PLHA
  2. To prevent HIV transmission to sexual partners and children of PLHA
  3. To reduce stigma for PLHA in service settings

The Mozambique PP intervention aims to instill in providers the competencies, comfort, and desire to discuss risk behavior and prevention needs with their HIV-infected patients. The intervention includes a three-day PP training, which is modeled on the U.S.-based HIV Intervention for Providers (HIP) curriculum (Dawson Rose, Colfax, IAC 2008) and adapted for use in rural Mozambique. The curriculum components include: (a) sensitization, skills building and training on how to assess risk and motivate behavior change; (b) brief prevention messages to be used by trained staff (e.g., reduce risk behaviors, encourage partners to test for HIV, adhere to HIV treatment including medications if prescribed, disclosure, decrease number of partners, decrease alcohol intake especially during sex, plan for additional pregnancies and prevention of HIV to unborn children); and (c) continuation of prevention during subsequent visits/interactions.

The intervention at both pilot sites involved training health care workers and community-based service providers in the above-mentioned three-day PP curriculum. This curriculum was pilot tested in Maputo in September 2008 and then revised for training in January 2009. The curriculum content is consistent with MOH clinical guidelines and Gabinete de Aconselhamento e Testagem Voluntaria (VCT guidelines) and standards of care.

In addition to the training curriculum, a second intervention component was included at the Esperanca VCT pilot site, in response to the identified need for community support by HIV-positive clients. The University of California San Francisco (UCSF), in conjunction with CDC Mozambique personnel, provided technical assistance to help create a support group for PLHA in the vicinity of the VCT center. This technical assistance entailed the provision of training in support group facilitation, group disclosure, monitoring and evaluation of group activities, and income-generating activities. The support group has been self-sustaining since initiation, with more than 30 active members, and currently is in the process of transitioning to a self-sustaining, official NGO.

Based on the evaluation of the PP training intervention at both pilot sites, the intervention is currently in the stage of rolling out trainings throughout three provinces - Maputo, Sofala, and Zambezia. In order to accomplish this, a Training of Trainers (TOT) curriculum was developed, with the goal of creating a cadre of Mozambican trainers who can replicate the intervention. The first TOT was piloted in January 2009 in Maputo, and was implemented again in Beira in July 2009. In addition, the project will continue to sponsor the development of support groups for PLHA. Two other support groups have been identified in Maputo and Sofala provinces and are currently being assisted by the project.

Qualitative Research, Monitoring and Evaluation

Acknowledging the importance of cultural differences between countries such as the United States and Mozambique, and even between regions and provinces within Mozambique, particular attention needs to be paid to beliefs and traditions that can be facilitators or barriers to HIV prevention and behavior change within the Mozambican context.

To assess acceptability and effectiveness of the PP intervention, qualitative research will need to be conducted. A qualitative feasibility and acceptability study has been designed and approved by the MOH and CDC Atlanta for implementation. Data collection is expected to begin in early 2010.

In addition, monitoring data are being collected at each of the project sites. Monitoring at the Esperanca VCT center consists of descriptive statistics of weekly participants as well as analysis of qualitative summaries. This analysis includes description and categorization of the topics covered during the weekly support groups in order to identify potential gaps in topics covered. This information will be used to design and target future trainings.

Monitoring at Namaacha Health Center consists of weekly counts of the following indicators: number of patients seen, number of HIV-infected patients seen, and number of patients given prevention counseling. It also includes a list of topics included in prevention counseling conversations. Evaluation of PP activities at Namaacha Health Center consists of descriptive statistics of patients seen and counseled as well as a description of the categories of topics included in prevention conversations. Information on discussion categories will be used to identify potential gaps in areas of prevention counseling. These potential gaps will be targeted in future trainings.

The PP trainings and TOTs will be evaluated with pre- and post-test survey instruments, in addition to a three-month follow-up survey with all of the training participants.

Next Steps

Preliminary evaluation of the two pilot intervention sites indicated that the PP intervention is effective in helping clinicians and service providers to address complex prevention issues with HIV-positive patients. Therefore, CDC Mozambique has requested that the intervention be replicated and scaled up throughout the country. The expansion of the intervention will include the following components:

  1. Positive Prevention Trainings

    The project will roll out trainings and provide technical assistance to providers from community-based organizations, health care facilities, home-based care organizations and United States Government (USG) clinical partner organizations. These trainings will be conducted within Maputo, Sofala, Gaza, and Zambezia provinces.

  2. TOTs

    The project will build in-country capacity by creating a cadre of trainers who are able to deliver the PP training. Ongoing mentoring will be provided to Mozambican PLHA and community-based organizations to assist and support the "Master Trainers" in conducting trainings within other organizations. In addition, a PP toolkit will be distributed to participating organizations (including training materials, job aids, flip charts, IEC materials).

  3. Support Groups

    Support groups for PLHA have been created at three of the project sites, in conjunction with local health care and VCT centers. These are Beleluane support group (Machava, Maputo Province) in conjunction with Esperanca, Gabinete de Aconselhamento e Tetagem Voluntaria (VCT), Goba support group (Maputo Province), in conjunction with Namaacha Health Center, and Matua support group (Sofala Province) in conjunction with Mafambezi health center. The program will continue to provide training and technical assistance to these support groups around topics of group facilitation skills, health education, budgeting and reporting guidelines, and development of income generation projects. The creation of a new support group in Zambezia Province will be facilitated with the assistance of Vanderbilt University.

  4. Partnership Program between WORLD and Mozambican PLHA Organizations

    Through a combination of efforts from the WORLD/UCSF team and CDC Mozambique staff, project implementers will develop partner opportunities with the Oakland, California-based organization Women Organized to Respond to Life-Threatening Diseases (WORLD) and a network of Mozambican community-based or PLHA organizations to create prevention messages targeting HIV-positive women and women's empowerment opportunities. WORLD will deliver trainings on peer empowerment and treatment literacy to HIV-positive women from community-based organizations.

References

  • Advancing HIV Prevention Initiative, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, (2003). http://www.cdc.gov/hiv/topics/prev_prog/AHP/default.htmexternal link
  • Advancing HIV Prevention: New Strategies for a Changing Epidemic - United States, 2003. Centers for Disease Control and Prevention. MMWR 2003;52(15):329-332.
  • Jeffrey D. Fisher, PhD, Deborah H. Cornman, PhD, Chandra Y. Osborn, MA, K. Rivet Amico, PhD,William A. Fisher, PhD, and Gerald A. Friedland, MD. (2004). Clinician-Initiated HIV Risk Reduction Intervention for HIV-Positive Persons
    Formative Research, Acceptability, and Fidelity of the Options Project. J Acquir Immune Defic Syndr, 37, Supplement 2.
  • Richardson, Jean L.; Milam, Joel; McCutchan, Allen; Stoyanoff, Susan; Bolan, Robert; Weiss, Jony; Kemper, Carol; Larsen, Robert A.; Hollander, Harry; Weismuller, Penny; Chou, Chih-Ping; Marks, Gary G. (2004). Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: a multi-clinic assessment. AIDS. 18(8):1179-1186.
  • Provision of HIV Transmission Prevention Counseling to HIV-Positive Patients within the Primary Care Setting (the Patients' Perspective): A Snapshot from the Project Team Study. Gooden, LK; Pereyra, MR; Metsch, LR; University of Miami School of Medicine, Miami, FL; National Prevention Conference, June 2005.
  • Risk Management: Enhancing Prevention Skills for People Living with HIV. Yordi, CA; Carrel, J; Office of Public Health HIV/AIDS Program, New Orleans, LA; National Prevention Conference, June 2005.
  • Prevention with Positives: Primary HIV Care Provider Attitudes and Practices. Vogel, MR; Lubinski, CB; HIV Medicine Association, Alexandria, VA; National Prevention Conference, June 2005.
  • Preferences and Beliefs about Safer Sex Counseling in the Clinical Setting: An Inquiry of HIV-Infected Patients and Their Medical providers. Aspden, CE; Boland, MS; Golin, C; Patel, SN; Price, M; Quinlivan, EB; UNC School of Medicine, Chapel Hill, NC; National Prevention Conference, June 2005.
  • Clinician Practices in assessing Risk Behaviors in US HIV Specialty Clinics. Dawson Rose, C; Colfax, G; Metsch, L; McKirnan, D; Courtenay-Quirk, C; UCSF, San Francisco, CA; S.F. Department of Public Health AIDS Office, San Francisco, CA; University of Miami, Miami, FL; University of Chicago, Chicago, IL; CDC Atlanta, GA; National Prevention Conference, June 2005.
  • Introducing an HIV Prevention Program into Routine Medical Practice in Seven HIV Clinics. O'Daniels, CM; Yale, AR; Ramsey, K; Sinclair, E; Wright, J; Wilson, TE; Raffanti, S; Gardner, LI; Marks, G; CDC Atlanta, GA; Emory University School of Medicine, Atlanta, GA; Denver Public Health, Denver, CO; University of North Carolina-Chapel Hill, Chapel Hill, NC; AIDS Research Consortium of Atlanta, Atlanta, GA; University of Missouri-Kansas City, Kansas City, MO; State University of New York-Downstate Medical Center, Brooklyn, NY; Comprehensive Care Center, Nashville, TN; National Prevention Conference, June 2005.
  • Couples at risk: HIV-1 concordance and discordance among sexual partners receiving VCT in Uganda. J Acquired Immune Defic Syndr, 2005 Aug 15; 39(5):576-80.