Inquisitor

Thank you for agreeing to speak to me today, the purpose of this interview is to find out more
about the challenges to HIV care experienced by women in Nampula and your opinion on this
topic, we want to understand why women in Nampula transmit HIV to their babies at such a high
rate compared to the rest of the country, and how to prevent this transmission, we are both
interested in HIV-positive women who are pregnant or who have had a baby in the last two years.
To answer these questions, throughout the year and last year, we conducted interviews with health
professionals and HIV-positive mothers living in Nampula, as well as international experts based
in Maputo and Nampula. During this interview I would like to share some of our preliminary
findings with you and hear your thoughts on how you think some of the issues could be addressed.
Do you have any questions for me before we start?

Respondent

No.

Inquisitor

I would like to start by asking you a few brief questions, can you tell me about your organization,
your role as a healthcare professional?

Respondent

Good afternoon, my name is Saíde Felex, I am currently the provincial responsible for the ITS
HIV-AIDS program. Well in terms of organization, our program belongs to the medical authority,
it is a particularity that we only have in the province of Nampula, because in other parts of the
country they are in public action. But in principle in Nampula it was decided differently and this
is in the medical instance, and that we are part of the provincial services, and my position at the
moment is provincial supervisor of the program. What is the role of the supervisor basically? The
role of the supervisor is basically to monitor all standards that are issued by the ministry and
disseminate them, monitor the supervisions that are carried out at the level of health units, monitor
the training that is carried out for the ITS and HIV program , basically this is what our role is, at
this moment as the provincial supervisor.
Inquisitor

Thank you very much. How do you see your role in the organization in the healthcare sector?

Respondent

Well, as a provider and particularly as a doctor, the role of the provincial supervisor is quite
important, because whoever deciphers what happens in the health units, both in terms of qualities
and as health supervisor, is the one who carries out this analysis to transmit this to the higher bodies,
we are Talking here, for example, about indicators that we have within the program, the person
who carries out the studies and who oversees improvement and who gives proposals for
improvement and monitors these proposals at program level is the provincial supervisor.

Inquisitor

Thanks. In introductory terms, I will ask some general questions and I would start by asking you,
what do you think can explain the high rates of mother-to-child transmission, both vertical
transmission, and low ART retention rates, among pregnant women in Nampula, in compared to
the rest of the country?

Respondent

Well, it's a very interesting question from an analytical point of view, well in principle when we
have our national discussions I would like to ask this question, and it is difficult to make a
comparison between the south and the north, particularly because we can make an assessment from
the point of view of, for example, social as well as educational development, poverty levels and
also the provision of medical assistance to our population, which in general terms is the northern
zone in terms of conditions that the MS foresees , we are still far from having the desired number
of health units in order to respond to the demand of our population, particularly the province of
Nampula, which has the largest number of population in the country, and has a lot of challenges.

Inquisitor

Thank you very much. Let's talk a little about supply-side issues within the barriers of the health
system. Questions some expertise health providers and some HIV positive women about factors
related to the health system that facilitate or hinder the care of pregnant women and worse for HIV
positive women in Mozambique-Nampula, to understand care for HIV infection, they discussed
mainly many Barriers to care, including health system barriers that are, resource supply challenges,
disruptions in medical equipment, medicines and supplies, are common barriers to providing
quality, timely and quality PMTCT or MTCT services, for example, lack of health supplies such
as gloves, viral load collection tube, in health units, interruption in medicine stocks, for example,
suspension of AZT, co-trimoxazole, delay in obtaining medicines, particularly viral load, delay in
repair or repair of necessary equipment, healthcare infrastructure, lack of basic facilities with
bathrooms, overcrowded consultants, lack of privacy and opportunity for meaningful interaction
with healthcare providers, in this case nurses, leads to disengagement with ART, difficulties in
access due to distances that some women live, health services, transport difficulties, costs. They
also mentioned data redirection issues and a lack of comprehensive patient tracking, so service
linkage, experts consistently cited a lack of unified understanding.

So, in your experience, what are the major challenges that were mentioned here, consistent and
high-quality provision of resources to prevent vertical transmission in Nampula, compared to other
regions, relative to everything that was mentioned here?

Respondent

Well, it's a question, first I want to agree with all the statements made, regarding this whole subject,
but in principle I wanted to take an approach first looking at what we have as an information
system, firstly I think we have to work more , in the SMI program if we understand, just looking
at the instruments I think it is the program that contains more instruments than any other, at this
moment we are talking about an SMI nurse who has approximately 14 books to follow of your
patients, both maternal and child health, this is the first point. A good next step would be to be able
to capture all the information and create evidence so that we can support any statement we make,
this I think should be the first point that we face as a challenge, to ensure that the information is
realistic for the province. Next, I would say that in terms of assistance care, well, looking at
assistance care, I would look at two aspects, we talked about community assistance care at some
point, but we have it in the health unit, I will focus on the health unit. In the health unit, the first
aspect is that probably with population growth, we have the great challenge of improving our
infrastructures in our health units, since in a certain way they must accompany the population
growth of our province, this is the first. Next, we would have to touch on the issue of the human
aspect in the involvement of health providers as such, in terms of improving the technical
component, this we have to start prioritizing and ensuring that every new provider has an effective
integration to enter our national system. of healthcare so that it can provide better quality care to
every child who needs assistance, this is the second point, looking at the third point would be the
issue of privacy which I want to agree that yes, this has been a major barrier, the lack of privacy
really attracts our patients, and at some point stigma and discrimination are still felt in our
community, at some point this may even extend to our care, and naturally today we still cannot
reach the goal, of HIV, unless it is a problem in terms of social acceptance, we still have this
difficulty and that our infrastructure in the health unit at some point does not allow us to respond
with due privacy, which means that patients are retained in our care. .

Inquisitor

Thank you very much. Continuing, I would like, considering your knowledge of the challenges,
what policy would you recommend to resolve the issues related to the supply chain and limited
resources for the vertical transmission program in Nampula?

Respondent

Good. There is one aspect that is very important to highlight here, which is the issue of availability
in terms of medicines in our health units, at this moment I think that the province is unlikely to
experience the opening of a medicine that is essential for the HIV STI program, Looking at
antiretroviral treatment, this is an important aspect to remember, it is important to mention here
that this management aspect is basically linked to what our information system is, which is what
we produce in our health unit, which at some point I already explained that we have to open our
minds, in order to know what we consume, what our expenditure is as a health unit, and transmit
this information at the source to whom we must transmit it more realistically and who must comply
with all the records that we need in all tools that are important for managing these inputs, this is a
very important aspect to take into account. Next, I would say that one aspect that we have some
difficulty with is in relation to the management of some inputs, I would say in relation to
prophylaxis, which is closely linked to this issue of the information system, which at some point
is defective and at some point interferes with the availability of what they are inputs for prophylaxis
at some point, this is a reality, now there is another aspect that is also part of management for
laboratory issues in terms of climates and point, which we think is quite important to be discussed
because these at some point are made by the central level, for example one of the issues that was
raised is the issue of several constants that we have in our devices, which at some point in our
health units, due to some difficulty, for example the electrical system, wire system, end up
interfering with the functioning of both the climate , because it also influences in a certain way the
management of our assistance component, so at some point we may have some difficulty, for
example in testing this issue. So looking not only at the PCR but also looking at the issue of testing,
I would say that we also have a great challenge because Nampula, in terms of justification as well
as the determination of syphilis, we have difficulties in terms of justification, this can naturally be
linked to the first aspect that was here to explain that it was a matter of obeying all the rules of
registration and ministry emanates, and in a way we, as well as the health District Province itself,
have to monitor this situation, which at some point we even have difficulty doing full monitoring
by some situations that we have in terms of limitations in reaching all health units, which are
currently 233 in the province of Nampula.

Inquisitor

What improvements can be made to the current care infrastructure to better support effective and
accessible mother-to-child transmission and prevention services?

Respondent

Good. I think it's time for us to start having more thorough discussions on issues of care and quality
assistance, I think we have already reached a stage where in the units we do have difficulties in
having the number of health units that the WHO predicts but it's probably time to start thinking
about quality care, what opportunities do I have to improve the quality of care that already exist,
this is the first point, we are saying here that we have to stick to the infrastructures that provide us
with we currently have and in the current technical component that we have, I think we need to
improve mainly in the technical component so that we can respond to the demand that has been
created in our health units for people living with HIV, and respond to these and the various
challenges that present.

Inquisitor
Thank you very much. Regarding data management and patient tracking, experts consistently
mentioned the lack of a unified and comprehensive database used across facilities to track testing
and treatment of patients across different health facilities creates challenges. To ensure continuity
of treatment for women arriving at health facilities, multiple registries for different services make
it challenging to track and follow women across health facilities, traditional healers or traditional
medicine practitioners when patients do not trust the health system and feel uncomfortable seeking
HIV care, antiretroviral treatment, they rely heavily on traditional medicine practitioners or
traditional doctor, who they consider safer, accessible and reliable, in relation to barriers in service
provision, I would like to understand with you, would it be reliable and reliable way to implement
a national patient tracking system between health units?

Respondent

Well, I want to agree with the difference and advantage of us having the creation of data processing,
centralization, for example at the district, provincial and national level, would ease some
difficulties that we have faced as barriers in the health unit itself, little by little we address here the
aspect that at some point some health units are unable to offer 100% privacy, for example, and at
some point the patient does not feel comfortable admitting that they are HIV positive, or are a
patient living with HIV, and that we should go through the whole process again and the patient
agrees that it is a new case, while in fact it is not a new case, it is a couple that is already being
followed up, but for some reason the patient does not feel comfortable revealing their zero status,
so the direction of a database I think is one of the solutions for the province of Nampula and not
only at the country level, because if we look in general and carry out an in-depth data analysis, for
example for the SMI, let's realize that women on ART, more and more women on ART are seeing
new cases, which leads us to some reflection, could it be that the new cases we currently have are
not cases that they cannot reveal to their providers? So we return to this question, because naturally
new infections tend to increase in a timid way, which also requires study to truly understand
whether the influence of this barrier has not created false data that we are having more new
infections, regarding the issue the first barrier, for example related to privacy, so it is a challenge,
I think it is one of the advantages that would be created is exactly that, the creation of a flow of
information in all health units, so that when a patient enters a unit We basically already had a
minimum amount of information about this patient in order to avoid other types of situations that
we could then interpret incorrectly, and then we could have an action plan that will not be effective
for the problem we are going to face, so I want to agree, yes. , that the creation of a database will
facilitate, I want to give an example of the situation we experienced in the province of Nampula
regarding the military conflict in Cabo Delgado, that we received many patients who came from
Cabo Delgado and that naturally we had to create a connection with the province of cabo delgado
in terms of information system, in which if the patient, for example, said that he was in a health
unit that had access in the province of cabo delgado, it was easy to capture this patient in order to
follow up here in the province of Nampula, and with this database, which is the sixth that we are
currently using here in the province of Nampula, it was easy to use and identify and follow up and
offer the services that the patient actually needed, this is one of the advantages that we who We
ended up realizing that there was a database. Regarding the community scope in terms of barriers,
I will say that it is cultural, traditional, which is the follow-up of our patients through alternative
medicine at some point, I will say so.

Inquisitor

Regarding data management and databases, would it be reliable or flexible to standardize patient
registration between health units to facilitate data collection and improve patient tracking, is it
possible to operationalize this?

Respondent

Yes, I believe it is possible, we just need to note that our databases, currently the databases that
are in health units, for example, are supported, for example, by implementation partners, that they
use the sixth system, which is the system monitoring of these patients but in a limited way because
they do not support all health units, they basically support let's say 61, 62 health units at the
province level and that is possible with the interconnection in these databases between these health
units, they already facilitate the screening and follow-up of patients living with HIV, for example
if I leave a health unit that has access, for example, rural hospital in Angoche, and go to the health
center, for example, rural hospital in Ribaué or Moma, I identify myself and can have information
from the sixth of this patient because the bases are already interconnected, but we do not have a
provincial base so that we as a province have access to be able to explore, but it is an advantage
that we would have to improve the quality of information tracking.
Inquisitor

Regarding traditional medicine practitioners, when patients do not trust the healthcare system and
feel uncomfortable seeking care from antiretroviral treatment services they rely heavily on
traditional medicine which they consider safer and more reliable, you can share your thoughts on
potential models collaboration with traditional medicine?

Respondent

Well, it's a very interesting question, because looking at the assistance point of view, it is important
that the community is engaged, and the healer and the practitioner of traditional medicine are part
of the community, and naturally we have important cultural and traditional issues that in some way
At the moment we cannot compare it because, as conventional medicine, at some point we can
lose our patients, I think it is important to make a connection with alternative medicine so that both
the screening and follow-up of patients living with HIV are improved, and naturally the patient is
not obliged to follow conventional medicine, but we have to be able to convince the patient to
follow conventional medicine because it is scientifically proven and at some point it is easy for us
to create evidence on various aspects that we can see, for example about the antiretroviral therapy,
while with alternative medicine we will not be able to achieve it, in fact we will have many barriers
if we want to create successful follow-up for these patients, so I personally, like Félix as supervisor,
I would say that we do respect medicine and alternative medicine, but We will choose to clearly
disseminate information so that patients come to conventional medicine due to the aspects I have
already discussed here. Now we have to have the ability to pull alternative medicine so that there
is a direct connection because with this the patient or user will benefit, now there are several
strategies that agents can use, we have, for example, health committees health, management
committees, we can clearly integrate these alternative medicine practitioners so that follow-up is
carried out in a combined way, because this allows us to easily win over this patient, otherwise we
think that looking from a public health point of view we would have a lot to lose.

Inquisitor

What are the major challenges and opportunities for collaboration between traditional medicine
and conventional medicine in promoting the prevention of vertical transmission?
Respondent

Well, we have, I will say that we have some experience, for example with the follow-up of pregnant
women, in which we had a community component that carried out the follow-up and that at some
point we had to provide some knowledge to these community authors who followed up the
pregnant woman in places where we did not have access to a health unit, and at least to be able to
provide what is a basic package of what HIV is, the forms of transmission in a way that does not
harm what is culture and tradition, but also shows what are the risks of some practices that an agent
may have within the scope of alternative medicine.

Inquisitor

Regarding service delivery barriers, health workforce and its challenges, changes in implementing
partners interrupt continuity of services and support for prevention of vertical transmission,
inadequate screening during prenatal consultations leads to loss of opportunity for early detection,
waiting time, the number of people attending the health center leading to long waiting times and
interruptions in health providers' services, affecting patients' adherence to treatment regimens, for
example when only one provider provides assistance to various services such as family planning,
prenatal consultation, CRC consultation, child at risk consultation, for example inadequate
appointment scheduling leads to an inefficient flow of patients, including scheduling appointments
for mother and children separately, making it necessary to make several visits to health centers,
the one-stop model in some health units where women receive all their health care needs in one
place, reduces the need for multiple visits to services and improves care coordination, particularly
postpartum for mother and baby. These one-stop care models and workload, what would be
considerable health strategies to facilitate the management of long waiting lists and also improve
the flow of patient care in health units?

Respondent

Well, for this point, I would say that we, as a national health system, offer several offer packages
that we call a differentiated model of health services, in which within the models we have less
intensive models and more intensive models. What is the advantage of a less intensive model? the
advantage of this, I'm going to talk about less intensive because it ends up matching the question
you ask me and contextualization, the less intensive is the model by which we reduce the frequency
of visits to the user's health unit, which will allow there to be a decrease in the number of users in
health units, but it also increases the quality of care at some point, looking at PTV, SMI, there are
different models of services in these that are already being implemented and at some point we
think that they are models that favor both for both the provider and the user, one of these models
associated with the question you asked me is the biannual dispensation, in which follow-up is
carried out on the mother and the child, at the same time it is the one-stop model, which allows the
mother has assistance and the child has assistance, which will mean that they do not have separate
consultations.

Inquisitor

Thank you, these models implementation strategies will be more efficient in patient management
such as expanding the one-stop model or promoting the planning of appointment booking practices
of pre-booking appointments, in the one-stop model it would be an effective solution for PTV in
Nampula?

Respondent

Clearly I want to agree with this information, I would say that it would not be the only one but
with this we would have a great gain, in terms of implementation because the one-stop model also
has its requirements, let's say, it requires the health unit to have some component as Human
Resources, in order to follow up on the one-stop, not only in terms of inputs as they are made,
because the one-stop model recommends that the patient will receive all assistance up to the
collection of medications, for example in this consultation.

Inquisitor

What policy changes could be implemented to ensure the shortest possible transition between
implementation between partners and to minimize the discontinuity of health services in Nampula?

Respondent
Well, related to partnerships, I think on two sides, there is a side that we can achieve a certain
result in a certain time, but there is also a negative side that we are not, in which the provider of
the national system ends up distancing itself a little with what is the follow-up within the HIV STI
program, which I think ends up having a negative impact in a certain way, but it is an aspect that
needs to be worked on, and at some point when we create differentiated service models, we have
to creating sustainable, sustainable models means that only in the future and even in the absence
of implementing partners, we have the capacity to be able to maintain this activity, I would say
that we could start thinking about creating both a robust system in terms of infrastructure , but also
to offer model material, for example the one-stop shop, as I said, it has its requirements, for
example in terms of storing medicines, it has to be quality storage, there is no point in just storing
the medicines, but we also have to respect the criteria to store medications.

Inquisitor

Thank you, regarding the behavior and performance of the healthcare provider or healthcare
professional, the lack of motivation of the healthcare provider and the poor communication style
of the healthcare provider, can lead to patient engagement and non-engagement, equally gaps in
provider training and knowledge about the complete package of vertical transmission prevention
services, for example bad advice, or weak advice, some mothers think that ART is only necessary
for the baby's health and not their own, and discontinue after weaning , some women feel
overwhelmed by the amount of information received during diagnosis at the start of ART,
inefficiencies and unawareness in monitoring and treatment approaches can lead to patient
discomfort and interruption of ART. In your experience, what are the challenges that can be
ensured and effectively trained and motivated for vertical transmission services in Nampula?

Respondent

Well, on this issue of motivation, I think there is a need for more in-depth study to understand why
professionals are not motivated, and I don't know if this is just for the HIV STI program, but if it
interferes with other programs, but I would say that an issue that should start thinking about is the
issue on the part of the provider, I think it is an aspect that should be discussed, because we have
bodies that can give reasons for this aspect, one thing is a matter of responsibility, what the
provider has to do, what services he must provide, and we are obliged to provide quality services,
this is the first aspect, the other aspect is perhaps that we start to leave the national system in itself
only work directly, but for this we would have challenges, we have the issue, for example, of
human resources that it is not possible for us to include them in our system, we are talking about
activists, mentor mothers and different types of activists who we have in our health units, which
play an important role but which our human resources framework is unable to adapt to, this is
another aspect, and which in a certain way also ends up interfering with what is the engagement
of the national system, because Those who do this are providers who come from the implementing
clinical partner, and in a way gives a false image that the issue of HIV issues is specifically for the
partner while it is something like we in the national system have an obligation to do the follow-up

Inquisitor

Thank you, what policy changes could be implemented to strengthen pre-service and in-service
training or pre-training program both training in education, in-service training, of health
professionals in vertical transmission prevention services communication skills and patient
motivation?

Respondent

Well, I'm going to touch on two aspects, the first aspect is related to the integration of our providers,
which in a way I think should be more worked on and improved in order to offer the technical
capacity to the new provider in order to be When it comes to responding to what is required,
another situation I would say regarding training are basic aspects that we have to look at seriously,
which is the issue of cifo, where the agent records all the training that an individual has, and this
will facilitate the management of what we are going to provide in our health units, I feel that this
is an opportunity for improvement that we can provide in the health units, just because we are
training the same people for the same things, so we could cover in some moment new groups that
were to improve assistance care, we could prioritize the issue of cifo.

Inquisitor

What policies could be adopted and introduced to ensure consistent, high-quality counseling to
promote an optimized mother-to-child transmission prevention process?
Respondent

Well, here we need to understand a very important aspect, I think that one of the solutions that we
have, first I will touch on one aspect in order to justify my question, is the question of what is the
number of users that the health units that at some point are under load, and at some point we are
unable to respond to the demand that is created in our health units due to the limitation of human
resources, for example, this is one aspect, which means that there is not a quality reception, there
is a reception if Maybe we have to improve or improve quality, which is the first basic aspect that
we have to follow, so this reception aspect, looking at the relationship between provider and
number of users, we will realize that in principle we will have some type of problem, well in In
my humble opinion, we might start to think, for example, we have good experience with SMI, in
particular groups that are created for collective monitoring, we have, for example, the mother-to-
mother group, which is a group that has the same characteristics, for example, they are HIV
positive and each one begins to give their experience to the oldest and the new, the new ones end
up absorbing what is the experience of the old ones and at some point they even have a full opening
and at some point these women do not abandon HIV treatment , so this could be an alternative for
us to start collecting experiences of what we offer with quality and that we have evidence of
positive situations and start to minimize this, this is an example of creating a mother-to-mother
group.

Inquisitor

In relation to the issue of demand and individual and contextual issues, barriers and facilitators,
whether at the individual level, therefore knowledge about HIV, ART fear of breach of
confidentiality age side effects of medications, the interpersonal level for example domestic
violence, domestic dependence, and at the community level stigma, structural level counseling
treatment and group supports. We asked the expertise of HIV-positive women health providers
about some of the personal, interpersonal, and contextual factors that make it easier or harder for
pregnant women in Mozambique-Nampula to seek care for HIV infection, and they discussed the
following factors: at an individual level, fears and concerns, breaches of confidentiality in health
establishments, for example, the presence of several people including students, colleagues,
consultation areas, makes it difficult to communicate openly about their health status, fear of being
rejected by those stigmatized by family, communities, difficulties in accepting the diagnosis and
inadequate psychosocial support, are there strategies that can be implemented to ensure
confidentiality and privacy for patients seeking HIV testing and treatment services in Nampula?
For example integrated services.

Respondent

Well, there is the issue of integrated consultations that we have been defending as one of the
solutions that we must solve and that at some point we are able to respond to these consultations,
we do not serve specifically, for example, patients living with HIV, which allows greater openness
for some patients living with HIV to make these appointments, this is an example of a strategy that
is used, there are also issues linked to privacy and confidentiality linked to monitoring students,
which is a huge barrier to our province, we feel that we have really had some challenges because
of the presence of multi-providers in the consultation room, which often has students, the solution
we have is to work on a roster basis for the students, supervising them in order to reduce the
number of people at the consultation, and naturally this could help reduce the number of people
present at the consultation.
Inquisitor

Are there opportunities to improve physical space in rooms or offices to improve or reduce privacy issues
and concerns? Are there opportunities to improve the room layout to prevent cabinet issues?

Respondent

Okay. At some point we are challenged by population growth in the infrastructure barrier. And we were
forced to create alternatives and at some point we had to create flows that were comfortable for patients or
users of health units.

One of the strategies that was used, for example, is the question of the child's what's , which is a care office
that offers a certain amount of privacy and is an isolated office where the patient is followed up properly.
Now, in health units where we have some space difficulties within them, we have created alternatives, but
they do not guarantee total privacy and will always prevail as a barrier. Perhaps it is time for us to start
carrying out a more in-depth study of what the next health units will be like in order to ensure that this issue
of privacy and confidentiality is resolved.

Inquisitor

Could Nampula integrate additional psychological, social and mental support from health services to
improve the emotional issues and needs of women in the vertical transmission program?

Respondent

Well, in terms of follow-up.

Inquisitor

I will repeat.

To address the emotional issues and needs of women within HIV services, specifically PMTCT. Would
Nampula additionally require integration of mental health and psychosocial support services within the
program?
Respondent

Clearly yes, I want to agree with that. Of course, I will answer this, taking as evidence some experiences
that we have as a province, which is the follow-up of patients at some point with a certain difficulty, where
follow-up is carried out in a specific way by a psychiatric technician or a psychologist. The other way would
be for us to be able to increase the technical component of maternal and child health nurses in the APSS
component and I think this needs to be improved, because a lot of the time there had to be a special APSS
package for maternal and child health nurses so that that we improve their technical capacity and
understanding.

The ideal would be for everyone to have additional psychological support, this would mean having another
psychiatric provider or technician or a psychologist. Or on the other hand, we have to train our maternal
and child health nurses in order to answer all the questions they are asked to answer.

Inquisitor

Thanks. In relation to interpersonal factors (challenges of domestic violence, so many domestic challenges),
many women, in relation to dependence and all these aspects. I would like to hear what programs or
initiatives exist to resolve these decision-making dynamics, the power of decision-making between the
inhabitants of the same house. Are there any initiatives on women's decision-making power? And can you
mention in what context?

Respondent
There are some initiatives that work precisely on female engagement or empowerment. There are some
organizations that we have in our province that work with this requirement, for example savings groups in
which women lead to create businesses, etc. This in itself gives women an opening and a certain
empowerment to be able to overcome certain issues within the home. Now, looking at violence and building
a bridge, well, here we have to work with evidence and one of the pieces of evidence that we have the
ability to create is the creation of the CETA tool, which is a very interesting tool because it makes a brief
assessment , in five, ten minutes for me to understand if the individual has some type of psychological
disorder and that at some point we can kidnap this, track it and be able to provide the necessary follow-up.
We often only manage to capture women who have suffered physical violence, but we do not have the
capacity to capture aspects related to property violence, moral violence and psychological violence, but we
properly follow up on women who have suffered physical violence. Perhaps it would be an opportunity for
this study that is being carried out in Nampula, therefore, Nampula is piloting a basic instrument that can
capture and track this, then we can do a more in-depth study of how we can do this calculation.

Inquisitor

Thanks!

Community-level factors , stigma. Is there a widespread stigma towards HIV, is there a denial or disbelief
about HIV and does this lead women to avoid health services?

Respondent

Women with HIV are treated differently to men. Women can suffer more serious consequences such as loss
of home, abandonment and removal from residence. Cultural and religious challenges, some religious
discourage adherence to ART alone, believing in a shared cure. Community support, some experts say it is
necessary to involve the community in interventions and support for women. This Approach involves the
involvement of community leaders and the dissemination of information about the importance of continued
ART and the risks associated with interrupting treatment.

Inquisitor

What specific community outreach programs or awareness campaigns are being implemented in Nampula
to address HIV stigma and promote positive attitudes towards mother-to-child transmission services?
Respondent

In terms of stigma and discrimination, in terms of a package to offer I would say that we, in specific terms,
are not offering any as such. Yes, we take this approach, but the creation of a specific index is still under
study. A stigma and discrimination package is currently being studied, based on a study carried out in
2022/2023, which will then be disseminated and clear criticisms of stigma and discrimination will be
established. Now, looking specifically, we don't have any programs that I remember that are related in a
specific way. We have, for example, the gender office that has some approaches related to this, but I don't
reinforce one specifically.

Inquisitor

What structures or organizations could be used to provide support to pregnant and worse positive women
in Nampula?

Respondent

Well, my personal experience is that we have UCBs that are responsible for monitoring, for example,
children living with HIV, and at some point also pregnant women. For example, we have the issue of an
organization whose name I can't think of right now, but which works for the district of Moma, in which
they identify these people and follow up by giving them a basic food basket. Having special attention to the
clinical follow-up of these participants, I think it is a situation that must be taken into account, not only in
Moma, I believe it is in other corners of the province, but I think it was a good opportunity to improve this
issue related to those who specifically monitor pregnant and lactating women and their children.

Inquisitor

Thank you very much. What strategies could be developed to involve pregnant and positive women in
Nampula in support? Are there successful examples for PTV that could be replicated in Nampula?
Respondent

Such examples, we have some developed experiences, example of lectures that we give in our Mosques, at
some point we advise that these women should go to health units and at some point we have contact with
them through their husbands and we do good related follow-up to them, we have this example for the
District of Angoche , although the prevalence rate still remains high, but these are experiences that we can
carry out.

Inquisitor

Thanks! Let's move on to the effectiveness of interventions.

Respondent

For example, questions of effectiveness of interventions, e.g. integrated models, antiretroviral care service
and fully integrated adult antenatal services, proximal models, ART services and separate but closely
adjacent adult antenatal consultation models, models seating, ART services for adults and pregnant women
at ANC located in different facilities, travel and referrals required. We asked the specialist for this case,
about the current antiretroviral treatment programs and vertical transmission PTV withdrawal, they
discussed, raised some questions and some current programs , some strategies and assistance models that
could be considered, including strategies to promote diagnosis and initiation of ART. Male partner
engagement, current strategies include couples queues, couple testing initiatives to encourage partner
disclosure, education and potentially the initiation of joint treatment. Enhanced testing for pregnant women,
some experts recommend testing pregnant and lactating women, initially test negative for HIV, PREP with
update due to their high-risk status, some experts recommend that PREPO should be offered as an Opt-Out
Service for pregnant women . Test and start protocol, Nampula test and start protocol guarantees the
immediate start of ART after diagnosis, eliminating delays caused by laboratory tests.

Inquisitor

What are the biggest challenges in promoting male partner involvement in the PMTCT program in
Nampula? Are there strategies to expand or improve male engagement?
Respondent

I would say that Nampula, perhaps, is one of the provinces that, in terms of partners present in the
consultation, is one of the cultures. And one of the questions that comes up randomly to answer this is
exactly the male engagement strategy and some others that are naturally carried out, the prioritization of
consultation by the couple and much more, are important aspects to take into account so that the partner is
present at the consultation. Now, the challenges still somehow prevail, the issue of the few who don't come
either because they have little information or because they are afraid to follow up the consultation to identify
some pathologies or because they are afraid because of their day-to-day activities that He was unable to
make the Consultation and at some point it was related, for example, to fishing activities in the coastal
districts, which we have a tendency for women to present themselves alone because of this issue.

Inquisitor

How viable and acceptable would it be to implement PREP as an update service for pregnant women in
Nampula?

Respondent

I think the issue of PREP is quite sensitive, and pregnant women, with their particularities, should study all
possibilities. Well, I could say yes, I could say no, but the truth is that pregnant women are more vulnerable,
and it is clear that, with the new testing algorithm for pregnant women, we are testing every three months,
but in a way we always have to try to test pregnant women in the last trimester so that we can identify
positive cases. Now, this combined with the free information that we sometimes have from our communities
and naturally the illiteracy rate that we have and the poor information, this can be a risk for pregnant women
themselves. This would force us to pay more attention to couples that are zero discordant so that they
understand exactly what information we are passing on in relation to PREP, so I see this as a great challenge,
because due to the ability to obtain information , we know that the North region has certain particularities
in which we may have this challenge at some point, so, in my humble opinion we would have to work very
well with the information aspect of this woman and her partner, so much so that we have to remember that
for Because of the weak empowerment of women, we at some point have difficulties in following up a
couple in which the man has some difficulties and some lack of information and does not accept, for
example, being tested at some point, so we can present a certain risk to the transmission of HIV.

Inquisitor
How can PREP be effectively integrated into existing PMTCT services in Nampula, to ensure that women
are aware of the option and receive appropriate advice and support for its use?

Respondent

Well, I would say that, when I look at PREP, I look at it as a method that must be supported by others, the
issue of condom use, etc., because then the agent largely eliminates the opportunity for virus transmission,
so I look at maternal and child health services in the same way that yes, it is good that we have PREP, but
it is also good that there is a combination of forms of prevention for PMTCT and not just for PREP.

Inquisitor

Are there social challenges to implementing the testing protocol starting in Nampula?

Respondent

Initial testing protocol that I remember, at some point we did have some difficulties because of accepting
the diagnosis, in this we have had some difficulty, accepting the diagnosis is still a challenge for the
province of Nampula.

Inquisitor

Thank you very much.

Strategies to promote ART adherence and retention, peer support or sponsorship programs, more mentors,
more flashlights and adolescent mentors reinforce adherence and reduce vertical transmission. Community-
based care, there are efforts to decentralize health services, extend communities for example, modern
mobile active , tracking prenatal appointment appointments and facilitating follow-up including community
surveys, mobile brigades dispense medications for stable individuals , not pregnant, but there is a challenge
in providing this care to pregnant women who need qualified professionals. There are home care models in
other countries that have shown success, however this model may incur costs compared to professional
facility-based care.

Technology, technological innovations for improvement in Mozambique include SMS, videos, electronic
systems that provide personalized health information about viral load and health during pregnancy.

Inquisitor
As follow-up questions. How can the ministry of health leverage the successful strategies identified in
Nampula to improve adherence and retention rates in Mozambique?

Respondent

Well, in principle we have to base ourselves on evidence that we have, Nampula is perhaps one of the
provinces in which we did have a high positivity rate in children, in pregnant women but, with different
strategies that were carried out, such as that you just mentioned, we think they did have a positive impact,
but perhaps, due to financial reasons, we could have some difficulty implementing many of these strategies,
because it ends up involving the community component in which at some point we, as a national system,
only have one per For example, APS, which will not be able to respond to all the needs that we have as a
national health system, therefore, I would say that we do and can pass this experience on to other provinces.

Inquisitor

What are the biggest obstacles the ministry foresees in expanding successful programs to a wider range of
communities in Nampula?

Respondent

The major limitation will be the sustainability of these strategies.

Inquisitor

Thank you, we are almost done, we wanted to hear some additional points. Is there anything you would like
to share about mother-to-child transmission and low ART retention in Nampula?

Respondent
Basically, we, as the province of Nampula, have shown some positive results in general but we still have
basic aspects to be worked on at the moment and we, as a province, feel that the strategies that are being
implemented, many of them in terms of costs, are quite high, Now we have the great challenge of creating
strategies that are sustainable, I would say that, we have to produce strategies that are sustainable and one
of them is the integration of these elements that are part of these strategies, within our framework of human
resources, if any, that are can create a framework for this so that we can maintain this sustainable activity .

Inquisitor

Thank you very much. Well, I want to thank you for your participation, but before finishing, I would like
you to take a look at this cascade, adapted from the option B+ cascade which is ART in pregnant women
and observe it, see if it is well structured, if it is ok asked your questions and comment and what comments
you could make regarding, for example in the cascade the author, for example in the HIV diagnosis cascade,
the necessary steps would be access to the health system, testing, knowing the result of the test and if
possible a retesting taking into account the scenario in which you are therefore diagnosed with HIV. In
connection with services, the inclusion of patients in care, at the beginning of ART, receiving brief
counseling and starting antiretroviral treatment. Adherence, receiving and understanding adherence
counseling and adhering to antiretroviral treatment. If there is a need for a consultation for the postnatal
service, adapt the new papers in the postpartum consultation, same services but different dynamics and
regulate the follow-up consultations, scheduled postpartum, after which to transfer it to the postnatal
consultation consultation. chronic diseases the adaptation of new services, receiving consultations in
different offices, therefore clinical, psychosocial, different services and receiving medication at the
pharmacy and attending in a consistent and unloaded manner to collect medication from healthy patients in
accordance with the program that is there . How do you look at that waterfall?

Respondent

Well, maybe I could go back to the question of starting treatment. Here I think counseling should be pre
and post, where we prepare the patient for a positive life.

Inquisitor
Good, doctor! Thank you very much for participating in this interview, it takes time to participate in these
discussions and we greatly appreciate your valuable time. Are there any other questions you would like to
ask the research team or the HIV program?

Respondent

Well, maybe we have to start thinking about decentralizing the issue of input management, especially
looking at the laboratory we have had some difficulties, in cases of breakdown, we have a lot of difficulty
in having the device resolved on time, that in a way, it ends up affecting both the population and us as a
care system, I'll say care and assistance, and it naturally interferes with our performance as a program, so I
think this should be a priority at this moment, so we have to try to expand of the PIMO device that allows
us to have information on the viral load and CV4, which means that we pay attention to important cases of
patients who are HIV positive with a very high viral load and these in themselves can cause a greater number
of new infections , so that will be my comment, the expansion of these devices from both PIMA and POP
to identify positive cases but also the decentralization of the assistance component of these devices, so it
could be from a certain provincial level, because at the national level we are not having much experience
pleasant.

Inquisitor

Thank you, doctor! Once again we thank you for participating in this interview, we appreciate the time you
dedicated and your contribution will be valuable to the vertical transmission program in Nampula and
Mozambique in general. Thanks .