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.
- Key Issues
- Pilot Sites & Interventions
- Positive Prevention Pilot Intervention
- Qualitative Research, Monitoring & Evaluation
- Next Steps
In October 2005, the American International Health Alliance (AIHA) and the University of California (UCSF), in partnership with staff members from the Mozambique Ministry of Health (MOH) Voluntary Counseling and Testing (VCT) and Home-Based Care (HBC) programs, the U.S. Centers for Disease Control and Prevention (CDC) Global AIDS Project (GAP), and the CDC Prevention 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, UCSF (funded by AIHA) and CDC staff members visited the proposed sites and met with MOH and NGO personnel, local volunteers, and people living with HIV/AIDS (PLHIV) 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.
In Mozambique in 2006, most prevention interventions targeted persons who were 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 increased U.S. domestic and international awareness 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 (Janssen et al., 2001). Given that HIV is transmitted from someone who is positive to someone who is uninfected, a change in the risk behavior of a person living with HIV/AIDS (PLHIV) will have a greater impact on the spread of HIV than an equivalent change in behavior of an uninfected person (King-Spooner, 1999). Therefore, prevention interventions aimed specifically at people who are aware of their HIV-positive sero-status have been developed. Programmatic guidance from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the World Health Organization (WHO) now include such interventions, known as Positive Prevention (PP), Prevention with Positives (PwP) or more recently as Positive Health, Dignity and Prevention (PHDP), as cornerstones of HIV prevention efforts (Bunnell, Mermin, & De Cock, 2006; Global Network of People Living with HIV, April 2009; Kennedy, Medley, Sweat, & O'Reilly, 2010; World Health Organization, 2008; PEPFAR, August 2011).
In the CDC's Advancing HIV Prevention Initiative, four core strategies have been identified:
- Make HIV testing a routine part of medical care whenever and wherever patients go for care.
- Use new models for diagnosing HIV infections, outside traditional medical settings.
- Prevent new infections by working with people diagnosed with HIV and their partners (when serodiscordant couples are involved).
- Continue to decrease mother-to-child-transmission.
Clinical 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 within health care settings to reduce transmission risks. As part of the standard of care for HIV, PP services should optimally be integrated into existing HIV care, treatment, and support services, whether in a health clinic or in the community. Studies have illustrated that communicating prevention messages within the HIV care system is most effective when done by a health care worker (Cornman, et al., 2008; Myers, et al., 2010).
Although the results of clinic-based interventions are encouraging, with key constraints in developing country settings with few clinicians, 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, home-based care, or PLHIV peer groups. Such community-based interventions are an important component of a comprehensive approach and allow for a focus that extends beyond the individual patient to incorporate one’s family and community.
The focus of PP clinic or health facility based interventions is on building the skills of clinical providers to meet the needs of those who are HIV-infected, including initiating HIV care and treatment, supporting disclosing to partners and family members, preventing transmission to partners or unborn children, addressing the stigma of HIV infection and addressing risk behavior (such as decreasing the number of sexual partners, increasing the use of condoms, and negotiating sexual relationships as a PLHIV. In developing country contexts, within the counseling and testing sphere and after ART initiation, PP interventions have been shown to have a positive impact on condom use and reduction in risky sexual acts (Bunnell, Ekwaru, et al., 2006; Mola, et al., 2006).
The Government of Mozambique (GoM) MOH has done much to stem the epidemic including a Prevention-of-Mother-to-Child Transmission (PMTCT) program and by providing free antiretroviral therapy (ART). Still, continued high prevalence rates demonstrated the need for additional prevention strategies to effectively reduce HIV transmission. To this end, PP was endorsed by the MOH as an HIV prevention strategy and is included as a priority in Mozambique’s 2010-2014 National Strategic Plan for HIV/AIDS (PEN III) (CNCS, 2009; Government of Mozambique, 2008).
Pilot PP Sites and Interventions
Following the discussions described above, in November 2005, the MOH/UCSF/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 Centeris 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 PLHIV 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:
- To prevent morbidity among PLHIV
- To prevent HIV transmission to sexual partners and children of PLHIV
- To reduce stigma for PLHIV 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, et al., 2010) 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 sexual risk behaviors, encourage partners to test for HIV, adhere to HIV treatment including medications if prescribed, disclosure, decrease number of partners, decrease alcohol and drug intake especially during sex, plan for additional pregnancies (family planning) and prevention of HIV to unborn children (PMTCT)); and (c) integration 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 PLHIV 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 being rolled out at trainings nationally throughout Mozambique – with specific focus in the provinces of Maputo, Gaza, Inhambane 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. To achieve this goal, UCSF transitioned from working with AIHA and developed a partnership with the International Training and Education Centers for Health (I-TECH) in Mozambique. The first TOT was piloted in January 2009 in Maputo, and was implemented again in Beira in July 2009. TOTs continued in 2010 and 2011. With key leadership from I-TECH, the PP training focus has now moved to offering in-service trainings directly at health centers so that providers do not need to be removed from their health centers in order to learn about and implement PP.
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 the acceptability and feasibility of the PP intervention, a qualitative research study was undertaken from January to June 2010. Individual in-depth interviews were conducted at five rural MOH clinics within three selected provinces (the Namaacha Health Center and Esperanca-Beluluane Counseling and Testing Center in Maputo Province, Mafambisse Health Center in Sofala Province, and the Namacurra Health Center and Inhassunge Hospital in Zambézia Province) with 31 providers who had been trained in the PP curriculum and 70 PLHIV who received care from trained providers. Interviews were designed to provide a descriptive evaluation of the PP training program and to ascertain how effective the training materials and approach were for providers, including which lessons providers learned and were able to implement in interactions with PLHIV, which PP messages were difficult for them and the applicability of training topics. For patients, questions focused on their experience and understanding of PP as it was addressed with them as part of the health services they received.
The evaluation was useful in assessing the effectiveness of our PP training materials and approach, and helped elucidate which lessons providers learned and were able to implement. It also helped identify areas where future PP trainings and specific messages could be strengthened and refined for the Mozambican context. Overall, providers described the importance of the topics covered in the PP training and found them useful. Providers gained knowledge about many of the lessons in the training, including: how to conduct a risk assessment and client-centered counseling, negotiating disclosure, partner testing, reducing the number of sexual partners, condom use, treatment adherence, PMTCT, and approaches for positive living.
Providers also reported learning skills that were not specific goals of the training, but were inherent in the teaching style, such as learning not to discriminate against patients and providing patients with information that would allow them to make their own choices. Topics that were part of the PP training but that were not mentioned as commonly included discordance counseling, STIs, FP, alcohol and drug use, and frank discussions about sexual risk behaviors.
The study results also suggest that healthcare providers found PP acceptable, feasible to implement in their HIV work in clinic settings, and valued it as a strategy to improve HIV prevention. The PP training also led providers to feel more comfortable counseling their patients about prevention. While overall acceptance of the PP training was positive, several barriers to feasibility surfaced in the data. Patient-level barriers included resistance to disclosing HIV status due to fear of stigma and discrimination, difficulty negotiating for condom use, difficulty engaging men in testing and treatment, and the effects of poverty on accessing care. Providers also identified work environment barriers including high patient load, time constraints, and frequent staff turnover.
Through the Mozambique PP technical working group (TWG), UCSF and I-TECH have also supported the development of M&E systems for PP. The M&E sub-group of the TWG has presented monitoring tools for PP in order to: Pilot instruments to respond to the PP indicator set by PEPFAR; account for the activities of PP in health centers and the community; and provide the information necessary for tracking users by healthcare providers.
In 2012 the TWG agreed to test models of implementation and monitoring for PP in 3 provinces, respectively in the South Zone, Central and North (Gaza, Zambézia, and Cabo Delgado). Each province was to select 3 health centers where a PP form containing the seven components of the PP intervention was to be tested. At each visit, health professionals were to mark the components of PP discussed with patients. These pilot activities took place in 2012. As a result of the piloting, the TWG met to revise the PP data collection form and has subsequently submitted the new form to the MOH for approval.
In addition, I-TECH PP program staff members continue to monitor and evaluate PP training events on a quarterly basis. Also, all training participants are evaluated using a pre- and post-test to measure knowledge gain. We use this monitoring data to improve the training materials and the training approach. Data from trainings on areas where participants excel and where they have difficulty help us to tweak our curriculum appropriately and focus in on trouble areas.
While the UCSF/I-TECH PP Program is now being rolled out nationally in Mozambique (with the support of the GoM and MOH) and forms to collect PP data are now available in health centers, many areas for integration and improved implementation still exist. Current focus areas for the Mozambique PP Program now include:
Positive Prevention in-service Trainings
Led by I-TECH, the project will continue to roll out in-service trainings and provide technical assistance and capacity building to providers from community-based organizations, MOH health care facilities, and United States Government (USG) clinical partner organizations. These in-service trainings will be based directly at health centers in Maputo, Gaza, Inhambane and Zambezia provinces so as to keep healthcare providers in their clinics and provide on-the-job skills.
Ongoing measures that demonstrate impact are needed to show that providers have gained PP skills over time and that they are capable of providing the PP minimum package of interventions (the standard of care). The PP Program has recently begun to use a new approach of targeted technical assistance (TA) in the form of longitudinal TA visits. During these visits, I-TECH team members provide personalized support to health care providers who have been trained in PP. Providers are followed over time and supported to improve their PP skills so that they are capable of offering the full PP package of interventions. Health sectors that have been deemed a priority include Maternal and Child Health (MCH), Chronic Diseases, Psychosocial Support (APSS), and the National Program to Combat Tuberculosis (PNCT). The objectives of these visits include: (1) Monitoring the activities of providers as it relates to integrated PP interventions; (2) Identifying weaknesses in addressing the PP components; (3) Providing technical assistance to improve the performance of health care providers for the PP interventions; and (4) Ensuring that at the end of the 6 month follow-up period, health care providers correctly and completely address the 7 components of PP.
In order to develop further support for PP at the policy level, a national policy on PP and Psycho-social support (APSS) is being developed. When approved, this policy will help to further solidify the role of PP as a basic component of clinical care in Mozambique.
Evaluation underway in Zambezia Province
The plan to scale-up the use of PP interventions on a national level leaves questions about the optimal strategies for delivering PP interventions and how best to document PP interventions provided. There is a lack of information on which PP interventions HCWs are giving to patients during clinical visits, whether offering these interventions leads to greater uptake of PP services, and whether these interventions make sense or are useful to patients.
An evaluation is now underway in Zambezia Province in collaboration with Vanderbilt University’s Friends in Global Health that will assess the performance of providers following only basic PP training as compared to an enhanced PP training model that includes the use of refresher trainings, TA visits, and job aides. We will use routinely collected patient data to: (1) assess the number and type of PP messages that are being delivered to patients at each clinical visit pre- and post-enhancements to the PP training package, (2) assess patient uptake of clinical services pre- and post-enhancements to the PP training package; and (3) assess patient perspectives about PP intervention delivery through patient interviews. In this way, we will be able to evaluate the PP program as it is currently operating (baseline data) and also assess whether the enhancements proposed improve the program and are worthwhile to continue and scale-up. This activity is meant to inform program design/implementation and best practices for future years of implementation.
- 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.htm
- Advancing HIV Prevention: New Strategies for a Changing Epidemic - United States, 2003. Centers for Disease Control and Prevention. MMWR 2003;52(15):329-332.
- Aspden, CE; Boland, MS; Golin, C; Patel, SN; Price, M; Quinlivan, EB; Preferences and Beliefs about Safer Sex Counseling in the Clinical Setting: An Inquiry of HIV-Infected Patients and Their Medical providers. National Prevention Conference, June 2005.
- Bunnell, R., Ekwaru, J.P., Solberg, P., Wamai, N., Bikaako-Kajura, W., Were, W., Coutinho, A., Liechty, C., Madraa, E., Rutherford, G., & Mermin, J. 2006. Changes in sexual behavior and risk of HIV transmission after antiretroviral therapy and prevention interventions in rural Uganda. AIDS, 20, 85-92.
- Bunnell, R., Mermin, J., & De Cock, K.M. 2006. HIV prevention for a threatened continent: implementing positive prevention in Africa. JAMA, 296, 855-858.
- CNCS, 2009. National Strategic Plan for HIV and AIDS 2010-2014, Publishing, Maputo, Mozambique.
- Cornman, D. K. (2008). Clinic-Based Intervention Reduces Unprotected Sexual Behavior Among HIV-Infected Patients in KwaZulu-Natal, South Africa: Results of a Pilot Study. J Acquir Immune Defic Syndr , 48 (5), 553-560.
- Dawson Rose, C; Colfax, G; Metsch, L; McKirnan, D; Courtenay-Quirk, C; Clinician Practices in assessing Risk Behaviors in US HIV Specialty Clinics. National Prevention Conference, June 2005.
- Fisher JD, Cornman DH, Osborn CY, Amico KR, Fisher WA, Friedland GA. (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 Suppl 2:S78-87
- Global Network of People Living with HIV, April 2009. Information note: Positive health, dignity and prevention. , Publishing.
- Gooden, LK; Pereyra, MR; Metsch, LR. 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. National Prevention Conference, June 2005.
- Government of Mozambique. 2008. Estratégia de Aceleraçção de Prevenção de Infecção pelo HIV. Boletim da República, Series 1, Supplement 7.
- Janssen RS, Holtgrave DR, Valdiserri RO, Shepherd M, Gayle HD, De Cock KM. (2001). The Serostatus Approach to Fighting the HIV Epidemic: prevention strategies for infected individuals. Am J Public Health. 91(7):1019-24.
- Kennedy CE, Medley AM, Sweat MD, O'Reilly KR. (2010). Behavioural interventions for HIV positive prevention in developing countries: a systematic review and meta-analysis. Bull World Health Organ. 88(8):615-23.
- King-Spooner, S. 1999. HIV prevention and the positive population. Int J STD AIDS, 10, 141-150.
- Malamba SS, Mermin JH, Bunnell R, Mubangizi J, Kalule J, Marum E, Hu DJ, Wangalwa S, Smith D, Downing R. Couples at risk: HIV-1 concordance and discordance among sexual partners receiving voluntary counseling and testing in Uganda. J Acquired Immune Defic Syndr, 2005 Aug 15; 39(5):576-80.
- Mola, O.D., Mercer, M.A., Asghar, R.J., Gimbel-Sherr, K.H., Gimbel-Sherr, S., Micek, M.A., & Gloyd, S.S. 2006. Condom use after voluntary counselling and testing in Central Mozambique. Trop Med Int Health, 11, 176-181.
- Myers, J., Shade, S., Dawson Rose, C., Koester, K., Maiorana, A. Morin, S. (2010). Interventions Delivered in Clinical Settings are Effective in Reducing Risk of HIV Transmission among People Living with HIV: Results from the Health Resources and Services Administration (HRSA)’s Special Projects of National Significance Initiative. AIDS and Behavior. 14(3):483-92.
- O'Daniels, CM; Yale, AR; Ramsey, K; Sinclair, E; Wright, J; Wilson, TE; Raffanti, S; Gardner, LI; Marks, G. Introducing an HIV Prevention Program into Routine Medical Practice in Seven HIV Clinics. National Prevention Conference, June 2005.
- PEPFAR, August 2011. Guidance for the Prevention of Sexually Transmitted HIV Infections.
- 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.
- Rose CD, Courtenay-Quirk C, Knight K, Shade SB, Vittinghoff E, Gomez C, Lum PJ, Bacon O, Colfax G. (2010). HIV Intervention for Providers Study: A Randomized Controlled Trial of a Clinician-Delivered HIV Risk-Reduction Intervention for HIV-Positive People. JAIDS. Sep 8, 2010.
- Vogel, MR; Lubinski, CB. Prevention with Positives: Primary HIV Care Provider Attitudes and Practices. National Prevention Conference, June 2005.
- World Health Organization, 2008. Essential Prevention and Care Interventions for Adults and Adolescents Living with HIV in Resource-Limited Setting.
- Yordi, CA; Carrel, J; Office of Public Health HIV/AIDS Program. Risk Management: Enhancing Prevention Skills for People Living with HIV. New Orleans, LA; National Prevention Conference, June 2005.