Heightened vulnerability to HIV among key populations during the COVID-19 crisis: a formative assessment in Mozambique (2022)

Abstract

Background

In recent years, the intersecting challenges of AIDS, COVID-19, economic instability, and humanitarianism have significantly hindered the advancement of HIV/AIDS mitigation strategies, especially in key populations (KPs) within low-to middle-income nations. This formative study aims to evaluate the direct and indirect impacts of the COVID-19 pandemic emergency measures on HIV/AIDS prevention and treatment services for key populations in Mozambique.

Methods

In the first quarter of 2022, we conducted a qualitative study across six provinces in Mozambique: Maputo Province, Maputo City, Gaza, Inhambane, Manica, and Zambezia. Our study involved a diverse group of key informants (KI), including men who have sex with men (MSM), people who inject drugs (PWID), female sex workers (FSW), members of community-based organizations (CBO), police, and healthcare professionals specializing in KP. The assessment employed standardized scripts for key informant interview (KII) and focus group discussion (FGD), primarily assessing risk behaviors and access to health services since the start of the COVID-19 state of emergency in March 2020. Data collection continued until reaching saturation, and the analysis followed grounded theory principles in qualitative research.

Results

A total of 126 interviews were conducted, comprising 100 key informant interviews (KIIs) and 26 focus group discussions (FGDs). FSW expressed concerns about discontinuing antiretroviral treatment (ART) due to fears of COVID-19 transmission at healthcare facilities, and there was a decrease in the availability of HIV testing and prevention services at hotspots due to restrictions on HIV testing brigades. MSM observed reduced HIV education and training within CBOs. PWIDs highlighted the suspension of collective therapy sessions, while healthcare providers pointed out the halting of KP-focused health promotion coordination meetings during the emergency period.

Conclusion

The COVID-19 pandemic underscores the urgent need for health systems to implement flexible, adaptive service delivery models for KPs. The study’s findings call for immediate action to ensure the continuity and accessibility of HIV/AIDS services amidst ongoing global health emergencies, highlighting the importance of resilience in health service planning and execution.

Background

In the last few years, the convergence of the HIV epidemic with the COVID-19 pandemic along with economic and humanitarian crises, has posed an escalating threat to the global HIV response. The disruptions caused by COVID-19 and other instabilities have severely impacted healthcare services worldwide, rendering millions of individuals even more susceptible to HIV infection [1,2,3]. This complex interplay of health crises has not only disrupted healthcare systems globally but has also amplified the vulnerabilities of millions, particularly affecting key populations (KPs) such as men who have sex with men (MSM), people who inject drugs (PWID) and female sex workers (FSW). These groups already face disproportionate risks of HIV infection due to systemic barriers, including stigma, discrimination, and legal challenges, which are further exacerbated in the pandemic context [3].

While some regions and communities have demonstrated remarkable resilience in their response to the HIV pandemic during these challenging times, global progress in the fight against HIV is stagnating rather than advancing. Recent data from UNAIDS indicates that although new HIV infections decreased globally in the past year, the reduction was only 3.6% from 2020, marking the smallest annual decline since 2016. East and Southern Africa remain the regions most heavily affected by HIV, with a combined total of 20.6 million individuals (18.9 million − 23.0 million) constituting 54% of the global HIV-positive population [3].

In Mozambique, HIV prevalence among the adult population is one of the highest in the world estimated at 12.5% according to the most recent Mozambique Population-Based HIV Impact Assessment 2021 (INSIDA 2021) [4]. The National HIV Strategic Plan (PEN) advocates for special attention to be given to monitoring HIV prevalence and risk behaviors of key and vulnerable populations due to their high risk of HIV infection [5]. Biological and behavioral surveys (BBS) in Mozambique, conducted from 2011 to 2014, revealed an estimated HIV prevalence of 8.2% among MSM in Maputo City, 9.1% in Beira, and 3.1% in Nampula/Nacala. Among FSW the HIV prevalence was 31.2% in Maputo, 23.6% in Beira, and 17.8% in Nampula/Nacala. HIV prevalence estimates among PWID were 50.1% in Maputo and 19.9% in Nacala [5].

The COVID-19 pandemic significantly limited access to essential HIV services for KP. Mobility restrictions for antiretroviral (ARVs) and viral load testing, while the suspension of community-based programs hindered early detection and referrals. Prevention efforts, such as syringe exchange and condom distribution, were also disrupted. Containment measures, though necessary, inadvertently reduced service availability. Fear of COVID-19 exposure led many to avoid in-person consultations risking ARV treatment interruptions and increased HIV and COVID-19 further marginalized MSM and FSW. Additionally, health resources and staff were redirected to COVID-19 care, causing shortages in HIV services. These issues are compounded by pre-existing challenges faced by KPs, including discrimination and a lack of tailored healthcare services, creating a multifaceted barrier to effective HIV prevention and treatment [1, 2].

Approximately one week after Mozambique identified its first COVID-19 case, the government issued a Presidential Decree (No.11/2020) declaring a state of emergency. Preventive measures included social isolation, the prohibition of public and private events, and the suspension of school activities. The enforcement of these measures was actively carried out by the police and Defense and Security Forces, with non-compliance considered a crime of disobedience punishable by imprisonment and fines [6, 7].

While the BBS provided valuable insights into the characteristics, size, and behaviors of KP in Mozambique, these data did not cover the entire country. Recognizing this, the Ministry of Health and its partners initiated a comprehensive mapping and estimation project to better understand the size, characteristics, and health service needs of KPs in Mozambique. This effort aimd to inform the development of more inclusive, resilient, and adaptable healthcare models that can navigate the challenges presented by global health crises and ensure that KPs receive the support and services they need.

This manuscript seeks to highlight the impacts of the COVID-19 pandemic on HIV service provision for KPs in Mozambique, with a focus on identifying barriers to access and utilization of healthcare services. By doing so, it contributes to the broader dialogue on how health systems can adapt to better meet the needs of KPs, ensuring no one is left behind in the global fight against HIV/AIDS.

Methodology

Study sites and design

The present study is a secondary analysis of qualitative data collected as part of the Hotspot Mapping and Population Size Estimation among Key Populations for HIV in Mozambique study. The parent study employed a mixed-methods approach, integrating both quantitative and qualitative data collection techniques to assess the size, distribution, and service needs of KPs in Mozambique.

For this specific analysis, we focused exclusively on the qualitative component of the parent study, utilizing in-depth, semi-structured KIIs and FGDs. These qualitative methods provided rich, contextual insights into the lived experiences, challenges, and service access barriers faced by KPs, particularly in the context of the COVID-19 pandemic.

The research was conducted in six provinces known for their high urban population density and presence of KPs: Maputo Province, Maputo City, Gaza, Inhambane, Manica, and Zambézia. Participants were recruited using purposive sampling to ensure representation across different KP groups, including MSM, PWID, FSW, members of community-based organizations (CBOs), police officers, and healthcare professionals specializing in KP services.

Study inclusion criteria were designed to ensure representative participation across each of the major population groups. To be eligible, individuals had to be 18 years or older. For MSM, participants had to be biological men who had engaged in oral or anal sex with another man in the 12 months prior to the survey. For FSWs, criteria included being a biological woman who had received money or goods in exchange for sex from someone other than a primary partner in the 6 months prior to the survey. For PWIDs, eligibility required having reported non-prescription injection drug use in the 12 months prior to the survey. Additionally, participants included members of organizations that provide services to key populations and health care providers.

Furthermore, to guarantee that participants have a significant connection to the study’s locale, they must have been living in or actively engaging with the community within the province where the research is conducted for at least six months before the survey. This requirement ensures the inclusion of individuals who are well-acquainted with the local context, thereby enabling the collection of data that accurately reflects the nuanced experiences of the key population community. Such criteria are pivotal in capturing the specific challenges and needs of KPs in a distinct geographical setting, thereby enriching the study’s outcomes with valuable insights into their unique circumstances.

Key informant interviews (KII)

The Key informants served as “community experts,” offering invaluable insights into various facets of KP. They provided essential information regarding KP demographics, risk behaviors, access to health and support services during the state of emergency, social interactions, and experiences of social and health disparities. The key sources of information included MSM, PWID, FSW, TG, members of community-based organizations (CBO), and healthcare professionals specializing in KP.

Structured interviews were conducted utilizing standardized interview scripts, continuing until data saturation was achieved. The interviews were carried out by a team comprising two trained research assistants and two note-takers, with all sessions being recorded for analysis.

Focus group discussions (FGD)

The FGDs were facilitated by a trained moderator and annotated by a trained research assistant. These discussions were designed to explore a range of engaging topics, including lifestyle, social structures, network connections, and the utilization of health services. To ensure a comprehensive representation of each province, a purposive sampling approach was employed to select FGD participants. Each FGD session lasted approximately 120 min and was conducted in locations that prioritized accessibility, security, and privacy.

Data collection tools

Standardized interview guides for both KII and FGD were used. These guides were designed to facilitate discussions on a wide range of topics, including socio-demographic characteristics, sexual risk behaviors, access to and utilization of health services, as well as barriers encountered in healthcare provision for KP. In light of the COVID-19 pandemic, the original data collection tools were adapted to include specific questions related to the impact of COVID-19 on service access, behavioral risk, stigma, and community engagement. These adaptations were made prior to fieldwork and were included in the revised protocol submitted for ethical approval. All interviews were documented in written form, audio-recorded, and subsequently transcribed into Portuguese. Stringent measures were implemented to safeguard participants’ confidentiality; notably, no names or other identifying details were recorded.

Data analysis

Immediately following each KII and FGD, field notes were compiled. The data generated from these interviews were stored in a standardized word-processing format to streamline the analysis process. Analysis was conducted using NVivo qualitative data analysis software (Version 12, QSR International, 2018). The analysis approach was based on the principles of Grounded Theory [8], wherein key thematic codes were organized into categories, and these categories were further grouped to form the emerging themes identified during the interviews.

To maintain participant anonymity and data security, all identifying information was removed from transcripts, and access to the data was restricted to the research team. Data storage and management adhered to ethical guidelines for research involving human subjects.

Ethical considerations

The study protocol Hotspot Mapping and Population Size Estimation Among Key Populations in Mozambique been approved by the Institutional Committee on Bioethics in Health (CIBS) of the National Institute of Health (INS) under reference 47/CIBS-INS/2021, by the National Committee on Bioethics for Health (CNBS) of Mozambique, under reference 609/CNBS/21 and was reviewed by the CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.¹ Authorization was requested from the National Health Institute to use the database and the protocol. All participants provided written informed prior to participating in the interview.

Results

A total of 294 individuals participated in this study, comprising 100 KII and 194 participants involved in 26 FGD, with each group typically consisting of 6 to 10 individuals. The study participants exhibited a diverse range of characteristics, educational backgrounds, marital statuses, and religious affiliations. The majority of participants were PWIDs (33.3%), followed by FSWs (25.5%) (Table 1).

The religious affiliation showed a majority identifying as Christian (69.0%), and the educational background of the group was mostly secondary level (44.8%), with a significant portion having higher or technical education (21.2%) (see Table 1).

Table 1 Characteristics of key informants in the formative assessment of hotspot mapping and population size Estimation among key populations for HIV in Mozambique (2022)

Impact of COVID-19 on access to health and support services

Participants reported significant disruptions in essential services, including HIV testing, counseling, health promotion activities, and care support. The shortage of condoms and lubricants was notably concerning highlighting potential risks for unsafe sexual practices and an increased likelihood of HIV transmission. Additionally, there was a noticeable decline in the number of brigades conducting health education and promotion activities, indicating a reduction in HIV efforts within these communities.

Participants also reported a decrease in healthcare clinic visits during the pandemic, which may have been influenced by concerns about COVID-19 transmission in healthcare settings. The suspension of therapy sessions including those providing psychological support, was also reported particularly affecting PWID.

“…There are no testing services anymore. Counseling is no longer available. Activists no longer came to support us in the field. There was a lack of distribution of condoms and lubricants…"²

“…One of the major constraints in terms of health services was the reduction of brigades to carry out health education and promotion activities. The disadvantage is that before there were brigades in the communities and now, they no longer happen they give out condoms and lubricants…"³

“…When COVID-19 was strong, there were no condoms, we had to buy them at the pharmacy,…. I didn’t bring condoms…"⁴

“… Yes, during the pandemic, people start to appear less at health centers…"⁵

“…It didn’t help drug users because many of them no longer went to the consultations… the occupational therapy sessions were suspended. The community therapy circles carried out by the psychologist, in the association were also canceled… “⁶

The impact of Covid-19 on the KP community

The COVID-19 pandemic has significantly impacted key populations (KP), with female sex workers (FSW) experiencing a notable decline in service demand. This downturn has led to a gradual decrease in income, hindering their ability to secure housing or invest in entrepreneurial ventures. Additionally, increased police violence has further compounded the challenges these communities face, underscoring the critical need for enhanced protective measures and support services.

The pandemic has also influenced the dynamics of hotspots. Reports of hotspots being inundated with additional KPs, potentially indicating a rise in drug use, have raised public health concerns and fears of worsening addiction issues. Moreover, the closure of specific hotspots has necessitated adaptations, with FSWs seeking alternative employment venues. Conversely, PWID have shown resilience and innovation in navigating the pandemic’s challenges, maintaining their activities despite increased surveillance and control by law enforcement. Notably, reports have emerged of these hotspots being overwhelmed with minors PWID, pointing to an alarming trend of younger individuals being drawn into environments associated with drug use. Such observations underscore the urgent need for targeted public health interventions to address the increasing vulnerability of minors within these contexts.

… It affected because there are others who don’t have a job, we depended on the program and the money they earned through the program, and they couldn’t stay until 11 pm or midnight and it was at those times that the clients would show up…”⁷

“… It affected a lot because some of the hotspots closed…"⁸

…Due to the curfew, FSW end up having limited hours of work, as a result, many of their plans were interrupted (building houses and opening businesses). Due to the pandemic, the number of customers also reduced a lot and the amount of violence from the police against KP increased…”⁹

… It affected them very badly, but they didn’t stop because they depended on that, each one wanted to have their own thing to defend themselves. Their routine changed, the police control a lot, many made their prescriptions at dawn in those places, and without dawn, there is no income that they had before Covid…”¹⁰

“…I arrived in the drug spot and I found many minors… and there wasn’t even space…with COVID-19 it got worse, and it tripled. Now with COVID-19 in Mozambique, there are a lot of drugs, more drugs circulate…"¹¹

Impact of COVID-19 on hotspot visits

The participants indicated that COVID-19 led to a decrease in the frequency of visits to hotspots. This decline was attributed to reduced demand for services and shortened durations of stay due to curfews. Some hotspots were compelled to cease their operations, while others continued covertly. Additionally, new hotspots surfaced in specific areas in response to these changes. Several participants underscored the adverse socio-economic consequences stemming from these shifts, prompting many FSWs to opt for providing their services from their own homes.

“…Clients were afraid to come to meet us, there was a lack of clients…"¹²

… At the beginning of the COVID-19, the police kicked us on the road and the customers were afraid to approach, so the meetings were more in bars…”¹³

“… We suffered aggression and theft of money…., I client who did not want to use a condom and I said no, I cannot have sex without a condom. Fortunately, my manager was in the next room and came to my aid. Even the police have been attacking us many times. They find us in the room with the client and they demand money from the client and, sometimes they force us to have sex with them and sometimes they don’t use condoms…Sometimes they want money and when you don’t give them money, they beat you and sometimes they use a gun.”¹⁴

Discussion

The findings of this study shed light on the profound and multifaceted impact of the COVID-19 pandemic on KP in Mozambique. These vulnerable communities, already facing numerous challenges in accessing healthcare and support services, experienced further disruptions to their routines and essential services due to the pandemic.

The pandemic has notably altered the landscape of hotspot visits, crucial for the acquisition of healthcare, prevention, and support services by KP. The observed decrease in service demand, compounded by the imposition of curfews and other restrictions, has dramatically shifted the operational dynamics of these critical zones. The closure of some hotspots and the secretive operations of others have raised significant concerns regarding the continuity and safety of essential services. Moreover, the advent of new hotspots underscores the KP community’s resilience and their adaptive strategies in the face of adversity [1,2,3].

Economically, the pandemic has wrought considerable hardship, particularly among FSW, whose reduced earnings have pushed them towards offering services from their homes a testament to the dire need for economic support and comprehensive aid services during such crises. Furthermore, the escalated risk of violence and harassment, especially from law enforcement, alongside difficulties in accessing protective measures like condoms and lubricants, highlighted the critical importance of protecting KP’s rights and well-being during health emergencies [9,10,11].

It was noted the alarming increase of minors engaging in drug use at hotspots, highlighting the urgent need for interventions targeting youth during health emergencies. The suspension of some health services, including therapy sessions for psychological support, posed additional risks to their well-being. Young PWID usually faces critical barriers to accessing HIV and sexual and reproductive health services, marked by inequalities, discrimination, and exclusion [8, 12]. This reality emphasizes the urgency of intensifying efforts to ensure that young individuals, particularly those at high risk, receive the support and care they need during health emergencies, preventing them from being left behind.

Findings from our assessment resonate with broader global trends, as evidenced by studies conducted in India and across multiple countries [1, 13, 14]. The disruptions caused by COVID-19 have not been limited to Mozambique alone; they have reverberated across regions, affecting access to healthcare, and increasing instances of harassment by law enforcement agencies. A study carried out in India also showed that the restrictions imposed by COVID-19 affected access to health care and harassment by the police [13].

Our study offers important insights into the KP population in certain provinces but has limitations. Because the study focused on specific provinces and used purposive sampling, the findings may not reflect the full diversity of KPs across the country. This sampling approach, while appropriate for qualitative research, may have limited the range of perspectives and introduced selection bias. The study focused mainly on access to health services, and did not explore other important areas such as mental health and social support, which are key to understanding the broader needs of KPs. Although stigma and discrimination were mentioned by participants, these issues were not explored in depth, even though they are known to affect service access. In addition, the study relied on self-reported information, which may be influenced by recall bias or the tendency to give socially acceptable answers. This could affect the accuracy of reports on sensitive topics like stigma, health behaviors, and service use. To help reduce this, we used triangulation across different types of respondents (KP members, CBO staff, and healthcare workers), trained interviewers familiar with KP contexts, and flexible interview guides that allowed participants to speak freely and in their own words.

Despite these limitations, the study contributes valuable knowledge to support more inclusive and community-based HIV services for KPs, especially during public health crises.

The lessons learned from this study, along with international insights, emphasize the critical need for robust healthcare infrastructure and adaptive systems to ensure the uninterrupted provision of essential services, including HIV prevention and care, for KP during health emergencies. As the world continues to grapple with the challenges posed by the pandemic, these findings serve as a clarion call to prioritize the well-being, rights, and resilience of KP, who remain among the most vulnerable and underserved communities in the fight against HIV/AIDS.

Conclusions

In summary, this study highlights the profound impact of the COVID-19 pandemic on key populations in Mozambique. The disruptions to their routines and access to essential services have been substantial, particularly in the context of hotspots. Disruptions to their routines and access to essential services have been substantial, particularly in the context of hotspots. The reduction in visits to these locations by health, prevention and support service providers has raised concerns about access to services and security in times of crisis and emergency. There is therefore a continuing need to adapt health services for KP to the changing dynamics and challenges presented by the modern world.

The socio-economic consequences have been severe, with FSW experiencing financial hardships due to reduced incomes. Some have had to adapt by providing services from home, emphasizing the need for economic alternatives and comprehensive support services. Additionally, heightened risks of violence, harassment by law enforcement, and challenges in accessing condoms underscore the importance of protecting the well-being and rights of KP during health emergencies.

These findings resonate with global trends, emphasizing the necessity of robust healthcare infrastructure and adaptive systems to ensure uninterrupted essential services, including HIV prevention and care, for KP worldwide. As we continue to confront the challenges posed by the pandemic, prioritizing the resilience, well-being, and rights of these vulnerable communities remains paramount in our efforts to combat HIV.