Mozambique has one of the world’s highest HIV/AIDS burdens.¹ The national HIV prevalence is estimated at 11.5% among adults aged 15–49 years, with prevalence as high as 25% in some provinces.^1,2 Although from 2001 to 2012, Mozambique saw the incidence of HIV among adults fall by more than 25%, continued high prevalence rates demonstrate the need for additional prevention strategies to effectively reduce HIV transmission.¹

The rapid scale-up of HIV care and treatment in Mozambique has provided an opportunity to engage people living with HIV (PLHIV) in strategies targeting the prevention of onward HIV transmission. Focusing prevention efforts on people who know their HIV status is crucial as this can reduce transmission of HIV to partners and children who are not already infected. Meta-analyses have suggested that interventions delivered in routine medical care settings significantly reduced sexual risk behaviors and may be ideal locations for behavior change counseling to reduce the onward transmission of HIV.³ Such Positive Health, Dignity, and Prevention (PHDP) interventions have already been developed and tested in sub-Saharan African settings and have been found to reduce risky sexual behaviors and increase condom use.^4–8 Other studies have found that PHDP interventions are feasible to implement during routine clinical care and are acceptable to PLHIV in sub-Saharan African contexts.^5,9,10 In some cases, however, difficulties have been noted with intervention fidelity and high quality implementation.^11,12

The PHDP framework guides clinical practice evaluation and improvement for treatment and prevention among PLHIV in Mozambique and is included in Mozambique’s 2015–2019 National Strategic Plan for HIV/AIDS.^13,14 PHDP, which is known locally as Positive Prevention (PP), encompasses nine evidence-based approaches to reducing transmission, including addressing sexual risk and promoting condom use, supporting disclosure and partner testing, antiretroviral therapy (ART) adherence, screening for sexually transmitted infections (STIs), prevention of mother-to-child transmission (PMTCT) or offering family planning (FP), addressing the use of alcohol and drugs, referral to community support services and, addressing gender-based violence (GBV) (see Table 1).¹⁵ PP training has been offered in Mozambique since 2006 and targets healthcare providers who see PLHIV during routine HIV care.

Reports of PHDP message delivery in clinical care settings in Mozambique suggested that after receiving PP training, some providers struggled with offering PP messages during their daily interactions with PLHIV. Dewing and colleagues in South Africa found a similar situation and reported that following a PP training, providers failed to reach full proficiency but benefited from refresher training and supervision.^11,16 Work by various researchers has suggested that in order to achieve and maintain proficiency with HIV prevention counseling and behavior change communication, more intensive training as well as follow-up technical assistance (TA) may be needed.^12,17 Effective strategies that improve the implementation of PP are desperately needed to improve clinical care and reduce HIV transmission.

Therefore, in order to support the implementation of PP in Mozambique, we provided on-site, observation-based TA to providers following a three-day PP training workshop. We evaluated the impact of TA implemented over six months on the delivery of accurate PP messages. We hypothesized that on-going TA would increase the delivery of PP messages over-time. By assessing the impact of on-site TA, we hoped to learn lessons and develop best practices that would help refine TA approaches to ultimately improve HIV provider prevention counseling for PLHIV.

In total, 153 healthcare providers were followed at 39 health centers in 5 provinces. The sample consisted of 103 clinicians and 50 non-clinicians. The majority of providers were female (68%), 67% were clinicians, and 35% were providing care during integrated consultations (where most PLHIV access HIV care and treatment services). Just over half (55.6 %) of the clients being seen by the healthcare providers were women and almost half (47.7%) were on ART (see Table 2). Across all data collection time points, PP messages were delivered an average of 3.05 (SD=1.48) times per client.

In this study, we examined the impact of an implementation improvement strategy that could be used in various settings. Overall, longitudinal TA was shown to increase the frequency of accurate and complete PP message delivery implemented during routine practice within low resource, public sector clinics in Mozambique. In addition to TA visits, the strongest predictor of PP message delivery following training was the sector where the provider offered services. Providers in the integrated consultations and TB sectors delivered fewer messages than providers in the maternal and child health and maternity sectors. Additionally, provider professional category (whether the provider was a clinician versus a non-clinician) was significant and suggested that clinicians may be slightly worse than non-clinicians at delivering PP messages at baseline but that over time, clinicians improve their PP message delivery more quickly than non-clinicians. These results support the value of on-site observation based repeated TA for improving provider competency and the importance of providing ongoing technical support during implementation in order to improve PP message delivery by various types of HIV care providers.

In this analysis, the mean number of PP messages delivered was three messages. Full implementation of the PP intervention is the provision of eight prevention messages. Therefore, on average, providers were not reaching full intervention implementation. Other HIV prevention counseling studies have also found that providers may have difficulty achieving full proficiency with prevention interventions and techniques.^18–20 Transferring evidence-based practices into real-world settings can present implementation challenges and barriers.^{9,16,18,21–23} Furthermore, it may be unrealistic outside of study settings to expect near-perfect implementation.¹⁷ For example, structural barriers such as limited time and space for counseling, high client load, and frequent staff turnover, have been noted in South Africa and Mozambique.^9,16,18

The models presented also suggest that individual provider characteristics do not make a substantial impact on PP message delivery. As it relates to HIV service provision, this lack of a provider effect may mean that providers are delivering PP messages based on their clinical judgment. This is reasonable and suggests that providers may be delivering only those messages they felt were pertinent to a given client, versus implementation of all messages regardless of current client needs. Such an adaptation would arguably be more consistent with tailored approaches, such as patient-centered counseling. Tailoring the intervention to the specific needs of the target population may improve the fit of the intervention and may also promote maintenance and implementation over time.^23–26 This finding suggests there is an opportunity to impact provider clinical practices over time.

With each additional TA visit, providers delivered about one additional PP message, showing steady improvement over time. TA has generally been found to be associated with more effective implementation following the initiation of new programs¹⁷. One strength of the TA support provided was that it was offered shortly after the initial training and it was delivered repeatedly over time in the providers’ practice environment. Similar interventions have shown that training alone is not enough to ensure fidelity and implementation of PP interventions¹¹ and have also suggested that TA can improve message provision over time, therefore allowing providers to address more PLHIV prevention needs.¹² Since the transfer of learned skills into practice is an ongoing process that is influenced by the work environment²⁷, regular supervision incorporated in the context of the daily work environment may help to reinforce competencies as providers learn how to implement PP during regular care.

Our results also suggest that although clinicians and non-clinicians may start at slightly different levels of PP message delivery at baseline, clinicians improve their PP message delivery at a more rapid pace than non-clinicians. It is possible that clinicians may feel more comfortable delivering biomedical messages (such as about STI treatment or FP method provision)²⁸ and this may aid in their faster improvement. However, not all PP messages are clinically based and many focus on psychosocial support (such as messages about referrals to community support services or addressing GBV). Although messages offered by clinicians can be especially effective at impacting the transmission risk behaviors of PLHIV²⁹, it is necessary to find approaches for discussing risk behavior and prevention that are acceptable to providers regardless of clinical cadre. All providers should be encouraged to discuss all PP messages with their clients and develop comfort providing both biomedical and behavioral prevention messages, as this is an important opportunity to prevent HIV transmission.

These findings should be interpreted in light of some limitations. As this was a longitudinal study, evaluating provider practice and not clients, we did not track client data. It is possible that the same client could have been seen multiple times adding an additional level of clustering to the data. Given the varied observation schedules, we do not suspect that this occurred often. Additionally, the data for this study comes from consultations with PLHIV clients observed by trained Mozambican PP staff members. Since counseling sessions were observed, it could be argued that the results may be overly favorable as the presence of an observer would likely cue providers to implement messages. While this is possible, all observation data was collected in the same manner over time, and we did have variability in the data collected. Thus, for most providers the presence of the PP team member did not produce “perfect” performance. Finally, there was no control group or comparison condition. It is possible that provider PP message delivery would have improved over time in the absence of TA. However, other studies have found that following trainings, providers benefit from refresher training and supervision,^11,16 suggesting that TA provides an added enhancement in HIV prevention counseling.

In this analysis, we report the results of an effective implementation improvement strategy. Overall, longitudinal TA steadily increased the frequency of PP message delivery in Mozambique. While these results are encouraging, there is still much to be explored in order to know whether the PP intervention can reduce transmission risk behavior since the delivery of PP messages does not necessarily translate into patient behavior modification. Moreover, whether all PP messages are indeed needed or if changes to the PP approach represent valuable adaptations to client needs should be carefully evaluated. In order to maintain the gains noted here, ongoing support is needed to achieve full integration and to ensure the delivery of PP with good quality. Given ongoing supervision that is tailored to the needs of providers, additional follow-up should continue to build competence and enable providers to deliver PP counseling that can address the prevention needs of PLHIV and ultimately reduce HIV transmissions.