Objectives HIV prevalence and incidence are higher among key populations including Men who have Sex with Men (MSM) and transgender women in low and middle income countries, when compared to the general population. Despite World Health Organisation guidelines on the provision of services to key populations recommending an evidence-based, culturally relevant and rights-based approach, uptake of HIV services in many resource-limited and rights-constrained settings remains low. Mé decins Sans Frontières (MSF) has been offering health services for MSM and transgender women in Beira, Mozambique since 2014 using a peer-educator driven model, but uptake of services has not been as high as expected. This qualitative study aimed to learn more about these key populations in Beira, their experiences of accessing MSM-and transgender-friendly services and their use of face-to-face and virtual networks, including social media, for engagement with health care. Methods In-depth interviews were carried out with MSM and transgender women who were 1) enrolled in, 2) disengaged from or 3) never engaged in MSF's programme. Purposive and snowball sampling were used to recruit the different groups of interviewees. Interviews were conducted in Portuguese, transcribed and translated into English before being coded and manually analysed using a thematic network framework. Results Nine transgender women and 18 cisgender MSM participated in the study. Interviewees ranged in age from 19 to 47 years, with a median age of 29. Three main themes emerged from the data: perceptions of stigma and discrimination, experiences of the peer-educator driven model and the use of face-to-face and virtual platforms for communication and engagement,

Background: Cascades have been used to characterize sequential steps within a complex health system and are used in diverse disease areas and across prevention, testing, and treatment. Routine data have great potential to inform prioritization within a system, but are often inaccessible to frontline health care workers (HCWs) who may have the greatest opportunity to innovate health system improvement. Methods: The cascade analysis tool (CAT) is an Excel-based, simple simulation model with an optimization function. It identifies the step within a cascade that could most improve the system. The original CAT was developed for HIV treatment and the prevention of mother-to-child transmission of HIV. Results: CAT has been adapted 7 times: to a mobile application for prevention of mother-to-child transmission; for hypertension screening and management and for mental health outpatient services in Mozambique; for pediatric and adolescent HIV testing and treatment, HIV testing in family planning, and cervical cancer screening and treatment in Kenya; and for naloxone distribution and opioid overdose reversal in the United States. The main domains of adaptation have been technical—estimating denominators and structuring steps to be binary sequential steps—as well as logistical—identifying acceptable approaches for data abstraction and aggregation, and not overburdening HCW. Discussion: CAT allows for prompt feedback to HCWs, increases HCW autonomy, and allows managers to allocate resources and time in an equitable manner. CAT is an effective, feasible, and acceptable implementation strategy to prioritize areas most requiring improvement within complex health systems, although adaptations are being currently evaluated.

To describe current outpatient mental health service use and treatments in Mozambique, the authors reviewed registry entries for 2,071 outpatient psychiatric visits at the Beira Central Hospital in Sofala Province from January 2012 to September 2014. Service use was most common for schizophrenia, followed by epilepsy, delirium, and organic behavioral disorders. Only 3% of consultations for schizophrenia were first-visit patients. Treatment seeking among women was more likely for mood and neurotic disorders and less likely for substance use disorders and epilepsy. First-generation antipsychotics, most often paired with promethazine, dominated treatment regimens. Evidence-based reforms are needed to improve identification of mood disorders and broaden care beyond severe mental disorders.

Background Epilepsy remains the most frequent diagnosis in Psychiatric and Mental Health Services in Mozambique. Because it is a major concern, in 2013 a Program for “ Reducing the Epilepsy Treatment gap ” was launched in 16 districts of five provinces covering a population of over 1.9 million. Using the WHO Mental Health Gap Program (mhGAP), a pilot Program was developed to provide effective quality care and treatment for people with epilepsy at primary health care level. Implementation was against a background of a shortage of human resources trained to address epilepsy and difficulties in the availability of antiepileptic medicines. Methods The first step for implementation was advocacy from the Government level to relevant stakeholders in the community. mhGAP training materials were translated and adapted to the local context. Non-specialists health providers and community health workers were trained and supervised regularly. Population awareness raising and community involvement were key for acceptance of the Program. Results After 4 years of implementation, 177 health professionals and 1161 community health workers were trained and ensured services delivery for people living with epilepsy (PwE). The implementation led to 89,869 consultations, representing an increase of 67% since the Program’s inception. From 2015 to 2017 a total of 13,563 new cases were attended and the treatment gap was reduced from 99 to 96%. More than 60% of the new cases are children and adolescents. Awareness actions reached more than 14,000 people per year using all available broadcast means. Preliminary positive results were used as evidence for the Ministry of Health (MoH) to increase the purchase of antiepileptic drugs and improve delivery at district level. Discussion mhGAP is an important tool for reducing the treatment gap in low-income countries. Adapting guidelines to the country context and involving community stakeholders are key for Program sustainability. As in other settings, the strategy was cost-effective resulting in an increase in new cases and follow-up consultations. Conclusions Implementation of an adapted mhGAP strategy and the involvement of community stakeholders and commitment of the MoH resulted in significant increase in the number of PwE attending outpatient services in primary health care facilities.