Challenges and Supports: Exploring Health Service Accessibility for Key Populations in Mozambique

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Mozambique ranks among the top ten countries with the highest HIV prevalence worldwide, with an estimated 12.5% of People Living with HIV (PLHIV). Despite national strategic efforts and guidelines to address HIV transmission among KP, pervasive stigma and discrimination in healthcare settings remain significant barriers to effective service delivery. This study aims to explore the experiences of KP in accessing healthcare and social services in Mozambique. Methods This qualitative study conducted in 2022 across six urban provinces, key informant interviews (KII) and focus group discussions (FGD) to explore the experiences of KPs in accessing HIV-related health and social services. Participants included Female Sex Workers (FSW), Men who have Sex with Men (MSM), People Who Inject Drugs (PWID), transgender individuals, health providers, and members of community-based organizations (CBOs). Data were collected, transcribed, and analyzed using NVivo software based on Grounded Theory. Results A total of 440 interviews were conducted, including 151 KIIs and 293 FGD participants. Despite the availability of targeted healthcare services and community-based support, findings indicated pervasive stigma and discrimination within healthcare settings, particularly affecting transgender individuals and PWID. Many participants reported experiencing discriminatory attitudes from healthcare providers, leading to refusal of care and inadequate treatment, which deterred KP from seeking necessary medical assistance. Discussion While the country has made progress in providing services tailored to KP, stigma and discrimination within healthcare settings remain critical barriers. This issue disproportionately affects transgender individuals and PWID, who often face refusal of care and poor treatment. Although CBOs have been instrumental in offering support, systemic changes are needed to create a more inclusive healthcare environment. Conclusion These findings underscore the importance of considering systemic changes to address stigma and discrimination in healthcare settings in Mozambique. Comprehensive training for healthcare providers, robust anti-discrimination policies, and strengthened collaboration between healthcare facilities and CBOs are essential to improve healthcare access and outcomes for KP. Promoting inclusive healthcare practices can help reduce health disparities and advance national HIV response efforts in Mozambique. Key population HIV health services Stigma and Discrimination Mozambique Introduction HIV remains a global epidemic and remains a major contributor to mortality from infectious diseases worldwide. According to the Joint United Nations Programme on HIV and AIDS (UNAIDS), an estimated 39.9 million people were living with HIV in 2023 and 630.000 died of AIDS-related illness ( 1 ). Key populations (KP), including sex workers (SW), men who have sex with men (MSM), people who inject drugs (PWID), incarcerated individuals, and transgender individuals are disproportionately affected by HIV. In 2023, these populations and their sexual partners are estimated to have accounted for 55% of all new HIV infections globally, highlighting their need for health services and heightened vulnerability compared to the general population ( 2 ). Mozambique is recognized as being among the countries with the highest HIV prevalence and number of new infections globally ( 3 , 4 ). According to the latest data from the Mozambique Population-based HIV Impact Assessment (INSIDA 2021), the HIV prevalence rate among adults is 12.5%, which corresponds to approximately 1.9 million adults living with HIV in the country ( 3 ). Recognizing the critical nature of this issue, Mozambique's National Strategic Plan for the Response to HIV/AIDS (PEN) emphasizes the need to monitor HIV prevalence and risk behaviors, and to target interventions specifically to these key populations ( 5 ). Second round of Biobehavioral Surveys (BBS) among KP in Mozambique conducted between 2019–2021 estimated high HIV prevalence among MSM (range: 7.1–14.9%) ( 6 ) and FSW (range: 10.2%-46.5%) ( 7 ). The Mozambique Ministry of Health issued Guidelines for Integrated Services for Prevention, Care, and Treatment of HIV and AIDS among KP in 2016. These guidelines aim to enhance the capacity of health professionals to deliver integrated services that effectively meet the unique needs of KPs ( 8 ). Despite these efforts, pervasive stigma, discrimination and structural barriers within community and healthcare settings continue to challenge access to necessary health services for KPs. Discriminatory practices not only increase vulnerability to HIV, but also violate the fundamental human rights of individuals to access health care. Socio-cultural factors contribute significantly to HIV-related stigma and discrimination, exacerbating the challenges faced by KPs due to their sexual behaviors, involvement in sex work, drug use, or gender expression ( 5 , 9 , 10 ). A qualitative study was conducted to explore experiences of KP's access to health care and social services, aiming to identify practical strategies to enhance their health outcomes and integrate these strategies into national HIV response efforts. Methods Study sites and design Since 2022, Mozambique has been conducting a phased national comprehensive KP population size estimation with hotspot mapping, implemented at the provincial level. As part of this exercise, a formative assessment was conducted in each of the six provinces in Mozambique: Maputo City and Province, Gaza, Inhambane, Manica, and Zambézia, to gather in-depth information on key populations. Prioritizing on these provinces first allows us to leverage existing data and tailor our discussions to the challenges and opportunities identified in the initial survey, ultimately leading to a more comprehensive understanding of the characteristics, risk behavior and healthcare access for KPs in this region. Provinces such as Gaza, and Maputo, which are located in the southern region, have some of the highest HIV prevalence rates in the country, while Zambézia has the largest PLHIV. Manica was selected due to its unique cross-border dynamics that affect key populations. This approach ultimately leads to a more comprehensive understanding of the characteristics, risk behaviors, and healthcare access for KPs in these regions. Data collection was based on qualitative research techniques of key informant interviews (KII) and focus group discussions (FGD). Participants were eligible for the FGDs and KIIs if they were aged 18 and have been residing in or actively socializing within the province where the study was conducted for at least six months before the beginning of the assessment. This assessment included a broad range of participants, consisting of FSW, MSM, PWID, transgender members of community-based organizations (CBOs), and healthcare providers. Participants were selected through purposive sampling, which is commonly used in qualitative research to ensure that individuals with relevant experiences and perspectives are included. This approach was coordinated with stakeholders and civil society organizations focused on key populations, ensuring that a diverse and representative sample of participants was recruited. The sampling strategy aimed to capture a wide range of views and experiences, thereby enriching the study's findings. Key informant interviews (KII) KII were utilized to explore the perceptions, experiences, and challenges that KP face in accessing health services in each province. The KII format was specifically chosen for certain topics and participants to allow for a more in-depth exploration of sensitive issues that may not be suitable for group discussions, and to capture detailed insights from key individuals. Questions focused on participants' perceptions of healthcare services, specific barriers to access, experiences with stigma and discrimination, and suggestions for improving service delivery. The insights gathered from the KPs and health professionals, was instrumental in shaping the FGD. Each session was designed to last between 45 to 90 minutes, facilitating a thorough investigation into the nuanced dynamics impacting KP's access to health services. All interviews were conducted in Portuguese, the official language of Mozambique and the most widely spoken, to ensure clear communication with the participants. Focus group discussions (FGD) The FGDs were designed to assess behavioral issues on KP's lifestyle, social organization, interaction networks, and access to and use of health services. Each FGD consisted of 6–10 participants from the same KP groups including FSW, MSM, PWID of both genders, and transgender individuals (both female and male) to ensure participants felt comfortable discussing sensitive issues In addition, mixed FGDs were held, which included participants from different groups, such as healthcare providers, CBO members, and KP individuals, to provide a broader contextual perspective on the interactions between these group. The discussions were held in Portuguese. Sessions were conducted in accessible, safe, and discreet venues arranged by local health partners, fostering an environment conducive to open and honest dialogue. Each FGD lasted approximately 120 minutes. Data collection tools Structured interview guides for both KII and FGD were used to facilitate discussions on main socio-demographic characteristics, access to public health services, structural health barriers, and risk behaviors among KPs. These guides were developed in line with research parameters that had been previously conducted ( 11 ). For each provincial implementation, the research team consisted of 9 members: 4 annotators, 4 interviewers, and 1 data manager. Notes and recordings were taken during the KIIs and FGDs after obtaining the participants' written informed consent. Transcripts were made after the interview sessions and annotations sent within 24 hours to the data manager, who assigned each a unique and confidential identification code. Data analysis Field notes were compiled immediately following each KII and FGD. to capture non-verbal cues, observations, and initial reflections that were not fully conveyed in the transcripts. The collected data, including both transcripts and field notes, were stored in a common word processing format to streamline the analysis process. Analysis was conducted using NVivo qualitative data analysis software (NVivo, Version 12, QSR International, 2018). The approach was based on Grounded Theory ( 12 ), where key thematic codes were identified and grouped into categories, which were then synthesized into broader themes emerging from the interviews. An initial codebook was developed by the survey team, which included predefined codes based on the study objectives and was reviewed as new data were added. This iterative process allowed for the refinement of codes and the emergence of new themes, ensuring that the coding framework remained relevant and comprehensive as the analysis progressed. Ethical Considerations All study participants provided informed consent. No names or any personal identifiers were used at any stage of the data collection or analysis to safeguard the privacy and anonymity of participants. During the FGD and KII, participants were specifically instructed not to use names or any personal identifiers to further ensure confidentiality. The study protocol was reviewed by Institutional Committee on Bioethics in Health (CIB-INS), the National Bioethics Committee for Health of Mozambique (CNBS). This activity was also reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy. Results Participants demography A total of 440 interviews were conducted across the six provinces, with 151 KII participants and 293 FGD participants. Participants represented a wide range of groups including 76 FSW (17.4%), 59 MSM (13.4%), 101 PWID (22.8%), 77 males transgenders (17.4%), 64 females transgenders (14.5%). Additionally, there were 45 participants (10.3%) from CBOs who represent or provide services to KPs and 18 health care providers (4.2%). The distribution of participants across the provinces was as follows: Maputo City (13.5%), Maputo Province (17.8%), Inhambane (14.6%), Manica (18.2%), Zambezia (18.4%), and Gaza (17.5%). The participant’s age distribution was as follows: 6.9% were between 18–19 years old, 30.5% were between 20–24 years old, and the majority, 62.6%, were over 25 years of age. Support and Services for Key Populations in Mozambican Healthcare Facilities In all provinces, participants noted health facilities provided services for KP. Additionally, it was mentioned that CBOs offer health and social services and support to KP prioritizing KP needs. Participants highlighted that these organizations have shown considerable support for KP, primarily by providing sexual protection supplies such as condoms and water-based lubricants. “"...there are counseling and testing services for KP, as well as follow-up." (KII, HCP, Manica) "…They serve anyone who seeks the services. They serve FSW, MSM, and PWID..." (KII, MSM, Manica) “There is an organization…; they have invited us to give lectures and provide us with supplies, and when it comes to discrimination, there is a focal point who assists us." (FGD, MSM, Manica) "...They offer counseling, testing, delivery of protective supplies, and assistance when we seek more information about human rights..." (FGD, MSM, Gaza) Persistent Discrimination and Barriers in Healthcare Settings The majority of participants felt that there was a lack of KP awareness and supportive mindset among many healthcare professionals, and that discrimination is still common in healthcare facilities. Many KP, especially transgender individuals, felt that their health issues were often overlooked or inadequately addressed due to stigma related to their gender identity or lifestyle. These feelings are powerfully echoed in the narratives shared by participants, such as the fear and reluctance to seek healthcare services due to the pervasive gossip and judgment they face from health facility staff, as well as instances where healthcare professionals outright did not provide adequate treatment because of their personal biases. "We are suffering and afraid to call these health services. It´s normal to have symptoms and want to visit health professionals but you can't talk to them because they are the same ones who keep on badmouthing like 'you get this because you get involved with other men” . (KII, Female Trans, Gaza) “…due to the stigma, people on ART do not to adhere to treatment services because of the lack of privacy and confidentiality from healthcare professionals." (KII, CBO, Maputo City) "...There are several issues that we see and have faced in health units, such as testing, where instead of proceeding with the test, the doctor refuses to treat..." (FGD, Male Trans, Zambezia) “…it was embarrassing to go to the health facility as Trans. Health workers sometimes reacted poorly upon seeing someone with a male name but presenting in a feminine. Sometimes they even asked them to leave the facility, claiming that they could not serve the patient under those circumstances. It becomes easier when the health worker is also part of the KP, making it more comfortable..." (FGD mixed, Zambézia) “How will we seek services if we are not treated well? The hospital is not prepared to receive people like us..." (KII, Female Trans, Gaza) PWID respondents reported that they hardly go to the health units on their own initiative, even with serious health conditions. PWID participants reported that if the health professionals know that the patient is PWID, the way they are treatment automatically changes. " We only go to the hospital when we are very sick….” (KII, PWID, Gaza Province) “The doctors just knowing that it's someone who injects drugs makes the service different." (KII, PWID, Maputo Province) “…It has to be someone understanding, not discriminating because they go without bathing for long periods, and they are looked down upon due to their appearance of being dirty and smelling bad.” (KII, CBO, Maputo Province) Discussion The findings of this study reaffirmed the availability of KP-focused services within healthcare facilities in the provinces where the study was conducted. However, the study also highlighted persistent gaps in providing appropriate treatment. Participants across all provinces highlighted that health services tailored for KPs are provided within general population facilities, reflecting a targeted approach to meeting their healthcare needs. Despite this, services available within the general health service setting were often delivered with stigma and discrimination, making them less effective. The healthcare access for KP presents both challenge and opportunities. While progress has been made in service provision ( 13 ), significant barriers still exist. Participants expressed concerns about the lack of supportiveness from healthcare professionals, stemming from discriminatory attitudes and inadequate support for KP individuals ( 14 – 16 ). Transgender and PWID individuals in particular reported feeling marginalized and underserved within healthcare settings due to stigma and judgment from healthcare providers. Instances of refusal of care and poor treatment were reported, highlighting the need for systemic change to create a more inclusive and empathetic healthcare environment within the general health care setting where many KP seek services ( 17 , 18 ). The stigma associated with PWID often results in differential treatment from healthcare professionals, impacting the quality and accessibility of healthcare services ( 11 , 21 , 22 ). Despite these challenges, there are positive developments in service delivery for KP. CBOs were recognized for their positive role in offering health and social services tailored to KP, emphasizing the importance of prioritizing KPs needs within the healthcare landscape. These organizations have been crucial in their provision of essential sexual protection supplies and play a crucial role in promoting sexual health and reducing the transmission of sexually transmitted infections (STI) ( 19 ). The positive experiences shared by participants underscore the value of collaborative efforts between healthcare facilities and CBOs in providing comprehensive support for KP. Quotes from participants highlighted the tangible benefits of these collaborations, which include educational lectures, HIV testing and counseling services, and assistance in accessing information about human rights. These interventions not only address immediate healthcare needs but also contribute to broader efforts aimed at empowering KP communities and reducing health disparities ( 19 , 20 ). Both systemic changes in healthcare settings and targeted initiatives could help address gaps in service delivery. Community-Led Monitoring (CLM) and KP listening sessions, recommended by PEPFAR and UNAIDS, could be crucial in improving the quality and completeness of services for KPs ( 21 ). These initiatives allow KPs and their communities to actively monitor services, identify gaps, and advocate for improvements. By involving KPs directly in the evaluation process, CLM and listening sessions help make services more responsive to their needs and address issues like stigma and discrimination. Studies have shown that community-led efforts can significantly enhance service quality and accessibility, especially when integrated into existing health systems ( 22 , 23 ). In 2023, the Mozambique MoH updated the national comprehensive HIV services guidelines to better serve KPs. These guidelines incorporate best practices, including those recommended by PEPFAR and UNAIDS, and aim to create a more inclusive and supportive healthcare environment. They are comprehensive and grounded in the real experiences of KPs, making them more effective. While the findings provide valuable insights into the experiences of the study population in specific provinces, caution should be exercised in generalizing these results to other provinces, all locations within the same province, or the broader KP community in Mozambique. The context-specific nature of the data may limit its applicability to different regions, where cultural, social, and economic factors could influence the experiences of KP individuals differently. Additionally, the purposive sampling method employed in this study, while appropriate for capturing diverse perspectives within the sampled population, may introduce selection bias. This bias could potentially exclude certain segments of the KP community, for example those KP who are not comfortable identifying themselves as KP and are therefore not visible to the study, leading to an incomplete representation of all KP experiences. Furthermore, the scope of this analysis primarily focused on access to comprehensive health services and did not explore other critical health aspects for the KP community, such as mental health support, substance abuse treatment, or violence, which are being explored through other reports and papers. Additionally, as this article is a sub-analysis of the formative research results, it was not possible to capture more detailed or additional information beyond what was included in the original data set. This limitation may affect the depth of analysis and the ability to provide a more comprehensive understanding of the experiences of the KP community. Conclusion Our study underscores the critical importance of specialized healthcare services and community-based support for KP in Mozambique. Despite significant efforts to enhance the provision of healthcare services for KP, pervasive stigma and discrimination within healthcare settings remain substantial barriers to accessing quality care. The findings revealed that while CBOs play crucial roles in providing necessary health services and support, including sexual protection supplies and education, the persistent discriminatory attitudes and inadequate preparedness among healthcare professionals continue to marginalize KP individuals, particularly transgender people and PWID. Addressing these issues would benefit from continuous investment and reinforcement of comprehensive training for healthcare providers, the implementation of robust anti-discrimination policies, and stronger collaboration between health facilities and CBOs. Promoting inclusive healthcare practices and strengthening support systems are important steps that could help reduce health disparities and advance the national HIV response efforts. Declarations Competing interests The authors declare that they have no competing interests. Author’s contributions SJ conceptualized and wrote the original manuscript. AMV, PM supported the field activities. ARB supervised study implementation. PM, JM and CSB were involved in the study implementation and provided critical revision of the manuscript. All authors read and approved the final version. Acknowledgments The authors thank the key population community for their participation in this study. We are grateful for all their support during the study implementation. Funding This research has been supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of CoAg number GH002021. CDC Disclaimer The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the funding agencies. Data Availability The data used in this manuscript are fully available from the Mozambique National Institute of Health (INS) data repository. Researchers who meet the necessary criteria for accessing confidential information can access the data, which originates from the KP Mapping and Population Size Estimation Study. For more information or to request access, please visit the INS website at www.ins.gov.mz or contact the authors. References UNAIDS, Global HIV. & AIDS statistics — Fact sheet. 2024; https://www.unaids.org/en/resources/fact-sheet UNAIDS. The urgency of now: AIDS at a crossroads. 2024; https://www.unaids.org/en/resources/documents/2024/global-aids-update-2024 INS. Inquérito Nacional sobre o impacto do HIV e SIDA em Moçambique. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5387851","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":374677624,"identity":"ddc22312-ec5f-4986-9fc0-31979edd25f9","order_by":0,"name":"Simeão Hanhane Junior","email":"","orcid":"","institution":"Instituto Nacional de Saúde","correspondingAuthor":false,"prefix":"","firstName":"Simeão","middleName":"Hanhane","lastName":"Junior","suffix":""},{"id":374677625,"identity":"a32e3b60-f11f-4fdf-90bf-643dc3dc57c6","order_by":1,"name":"Ana Matusse Vuvo","email":"","orcid":"","institution":"African Field Epidemiology Network","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"Matusse","lastName":"Vuvo","suffix":""},{"id":374677626,"identity":"15ed7427-1b76-4866-a851-bf67053f1f25","order_by":2,"name":"Pedro Manuel","email":"","orcid":"","institution":"U.S. Centers for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Pedro","middleName":"","lastName":"Manuel","suffix":""},{"id":374677627,"identity":"38ad399f-1ae4-485f-a3b4-860d01ae3b14","order_by":3,"name":"Jordan McOwen","email":"","orcid":"","institution":"U.S. Centers for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Jordan","middleName":"","lastName":"McOwen","suffix":""},{"id":374677628,"identity":"c581526b-afe0-42a4-8eac-19f0a03e0613","order_by":4,"name":"Áuria Ribeiro Banze","email":"","orcid":"","institution":"Instituto Nacional de Saúde","correspondingAuthor":false,"prefix":"","firstName":"Áuria","middleName":"Ribeiro","lastName":"Banze","suffix":""},{"id":374677629,"identity":"f612b8ec-7225-488a-9b00-afcabe3706d1","order_by":5,"name":"Cynthia Semá Baltazar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYJACZgYDMM34gIHhAFE6GJuhWpgNSNACAWwSRGnhn5F7/HFBgZ09v9jhZ9U8NXfk+BmYHz66gUeLxI28xOYZBsmJM2enmd3mOfbMWLKBzdg4B48WA4kcw2YeA+YEg9sJQC1shxM3HOBhkyZCS729/e30b8U8/4jXcphxg3SOGTNvGxFaJM68MZzNY3A8ccbtnGLJuX2HjSWbCfiFvz3H4DPPn2p7/tnpGz+8+XZYjp+9+eFjfFoYBBIQbCYeEMmMTznYmgMINuMPQqpHwSgYBaNgRAIAddFKkTnUl68AAAAASUVORK5CYII=","orcid":"","institution":"Instituto Nacional de Saúde","correspondingAuthor":true,"prefix":"","firstName":"Cynthia","middleName":"Semá","lastName":"Baltazar","suffix":""}],"badges":[],"createdAt":"2024-11-04 11:53:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5387851/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5387851/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69231228,"identity":"fc03e0c5-bba7-4d05-a463-ef16759eb2c5","added_by":"auto","created_at":"2024-11-18 08:54:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":393330,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5387851/v1/196e4554-417c-4007-a89c-fa7120f09f7d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Challenges and Supports: Exploring Health Service Accessibility for Key Populations in Mozambique","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHIV remains a global epidemic and remains a major contributor to mortality from infectious diseases worldwide. According to the Joint United Nations Programme on HIV and AIDS (UNAIDS), an estimated 39.9\u0026nbsp;million people were living with HIV in 2023 and 630.000 died of AIDS-related illness (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Key populations (KP), including sex workers (SW), men who have sex with men (MSM), people who inject drugs (PWID), incarcerated individuals, and transgender individuals are disproportionately affected by HIV. In 2023, these populations and their sexual partners are estimated to have accounted for 55% of all new HIV infections globally, highlighting their need for health services and heightened vulnerability compared to the general population (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMozambique is recognized as being among the countries with the highest HIV prevalence and number of new infections globally (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). According to the latest data from the Mozambique Population-based HIV Impact Assessment (INSIDA 2021), the HIV prevalence rate among adults is 12.5%, which corresponds to approximately 1.9\u0026nbsp;million adults living with HIV in the country (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Recognizing the critical nature of this issue, Mozambique's National Strategic Plan for the Response to HIV/AIDS (PEN) emphasizes the need to monitor HIV prevalence and risk behaviors, and to target interventions specifically to these key populations (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Second round of Biobehavioral Surveys (BBS) among KP in Mozambique conducted between 2019\u0026ndash;2021 estimated high HIV prevalence among MSM (range: 7.1\u0026ndash;14.9%) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and FSW (range: 10.2%-46.5%) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e The Mozambique Ministry of Health issued Guidelines for Integrated Services for Prevention, Care, and Treatment of HIV and AIDS among KP in 2016. These guidelines aim to enhance the capacity of health professionals to deliver integrated services that effectively meet the unique needs of KPs (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Despite these efforts, pervasive stigma, discrimination and structural barriers within community and healthcare settings continue to challenge access to necessary health services for KPs. Discriminatory practices not only increase vulnerability to HIV, but also violate the fundamental human rights of individuals to access health care. Socio-cultural factors contribute significantly to HIV-related stigma and discrimination, exacerbating the challenges faced by KPs due to their sexual behaviors, involvement in sex work, drug use, or gender expression (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA qualitative study was conducted to explore experiences of KP's access to health care and social services, aiming to identify practical strategies to enhance their health outcomes and integrate these strategies into national HIV response efforts.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy sites and design\u003c/h2\u003e \u003cp\u003eSince 2022, Mozambique has been conducting a phased national comprehensive KP population size estimation with hotspot mapping, implemented at the provincial level. As part of this exercise, a formative assessment was conducted in each of the six provinces in Mozambique: Maputo City and Province, Gaza, Inhambane, Manica, and Zamb\u0026eacute;zia, to gather in-depth information on key populations. Prioritizing on these provinces first allows us to leverage existing data and tailor our discussions to the challenges and opportunities identified in the initial survey, ultimately leading to a more comprehensive understanding of the characteristics, risk behavior and healthcare access for KPs in this region. Provinces such as Gaza, and Maputo, which are located in the southern region, have some of the highest HIV prevalence rates in the country, while Zamb\u0026eacute;zia has the largest PLHIV. Manica was selected due to its unique cross-border dynamics that affect key populations. This approach ultimately leads to a more comprehensive understanding of the characteristics, risk behaviors, and healthcare access for KPs in these regions.\u003c/p\u003e \u003cp\u003eData collection was based on qualitative research techniques of key informant interviews (KII) and focus group discussions (FGD). Participants were eligible for the FGDs and KIIs if they were aged 18 and have been residing in or actively socializing within the province where the study was conducted for at least six months before the beginning of the assessment. This assessment included a broad range of participants, consisting of FSW, MSM, PWID, transgender members of community-based organizations (CBOs), and healthcare providers.\u003c/p\u003e \u003cp\u003eParticipants were selected through purposive sampling, which is commonly used in qualitative research to ensure that individuals with relevant experiences and perspectives are included. This approach was coordinated with stakeholders and civil society organizations focused on key populations, ensuring that a diverse and representative sample of participants was recruited. The sampling strategy aimed to capture a wide range of views and experiences, thereby enriching the study's findings.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eKey informant interviews (KII)\u003c/h3\u003e\n\u003cp\u003eKII were utilized to explore the perceptions, experiences, and challenges that KP face in accessing health services in each province. The KII format was specifically chosen for certain topics and participants to allow for a more in-depth exploration of sensitive issues that may not be suitable for group discussions, and to capture detailed insights from key individuals. Questions focused on participants' perceptions of healthcare services, specific barriers to access, experiences with stigma and discrimination, and suggestions for improving service delivery. The insights gathered from the KPs and health professionals, was instrumental in shaping the FGD. Each session was designed to last between 45 to 90 minutes, facilitating a thorough investigation into the nuanced dynamics impacting KP's access to health services. All interviews were conducted in Portuguese, the official language of Mozambique and the most widely spoken, to ensure clear communication with the participants.\u003c/p\u003e\n\u003ch3\u003eFocus group discussions (FGD)\u003c/h3\u003e\n\u003cp\u003eThe FGDs were designed to assess behavioral issues on KP's lifestyle, social organization, interaction networks, and access to and use of health services. Each FGD consisted of 6\u0026ndash;10 participants from the same KP groups including FSW, MSM, PWID of both genders, and transgender individuals (both female and male) to ensure participants felt comfortable discussing sensitive issues In addition, mixed FGDs were held, which included participants from different groups, such as healthcare providers, CBO members, and KP individuals, to provide a broader contextual perspective on the interactions between these group. The discussions were held in Portuguese. Sessions were conducted in accessible, safe, and discreet venues arranged by local health partners, fostering an environment conducive to open and honest dialogue. Each FGD lasted approximately 120 minutes.\u003c/p\u003e\n\u003ch3\u003eData collection tools\u003c/h3\u003e\n\u003cp\u003eStructured interview guides for both KII and FGD were used to facilitate discussions on main socio-demographic characteristics, access to public health services, structural health barriers, and risk behaviors among KPs. These guides were developed in line with research parameters that had been previously conducted (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor each provincial implementation, the research team consisted of 9 members: 4 annotators, 4 interviewers, and 1 data manager. Notes and recordings were taken during the KIIs and FGDs after obtaining the participants' written informed consent. Transcripts were made after the interview sessions and annotations sent within 24 hours to the data manager, who assigned each a unique and confidential identification code.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eField notes were compiled immediately following each KII and FGD. to capture non-verbal cues, observations, and initial reflections that were not fully conveyed in the transcripts. The collected data, including both transcripts and field notes, were stored in a common word processing format to streamline the analysis process. Analysis was conducted using NVivo qualitative data analysis software (NVivo, Version 12, QSR International, 2018). The approach was based on Grounded Theory (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), where key thematic codes were identified and grouped into categories, which were then synthesized into broader themes emerging from the interviews. An initial codebook was developed by the survey team, which included predefined codes based on the study objectives and was reviewed as new data were added. This iterative process allowed for the refinement of codes and the emergence of new themes, ensuring that the coding framework remained relevant and comprehensive as the analysis progressed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e All study participants provided informed consent. No names or any personal identifiers were used at any stage of the data collection or analysis to safeguard the privacy and anonymity of participants. During the FGD and KII, participants were specifically instructed not to use names or any personal identifiers to further ensure confidentiality.\u003c/p\u003e \u003cp\u003e The study protocol was reviewed by Institutional Committee on Bioethics in Health (CIB-INS), the National Bioethics Committee for Health of Mozambique (CNBS). This activity was also reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eParticipants demography\u003c/h2\u003e \u003cp\u003eA total of 440 interviews were conducted across the six provinces, with 151 KII participants and 293 FGD participants. Participants represented a wide range of groups including 76 FSW (17.4%), 59 MSM (13.4%), 101 PWID (22.8%), 77 males transgenders (17.4%), 64 females transgenders (14.5%). Additionally, there were 45 participants (10.3%) from CBOs who represent or provide services to KPs and 18 health care providers (4.2%).\u003c/p\u003e \u003cp\u003eThe distribution of participants across the provinces was as follows: Maputo City (13.5%), Maputo Province (17.8%), Inhambane (14.6%), Manica (18.2%), Zambezia (18.4%), and Gaza (17.5%). The participant\u0026rsquo;s age distribution was as follows: 6.9% were between 18\u0026ndash;19 years old, 30.5% were between 20\u0026ndash;24 years old, and the majority, 62.6%, were over 25 years of age.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSupport and Services for Key Populations in Mozambican Healthcare Facilities\u003c/h2\u003e \u003cp\u003eIn all provinces, participants noted health facilities provided services for KP. Additionally, it was mentioned that CBOs offer health and social services and support to KP prioritizing KP needs. Participants highlighted that these organizations have shown considerable support for KP, primarily by providing sexual protection supplies such as condoms and water-based lubricants.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\"...there are counseling and testing services for KP, as well as follow-up.\" (KII, HCP, Manica)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"\u0026hellip;They serve anyone who seeks the services. They serve FSW, MSM, and PWID...\" (KII, MSM, Manica)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There is an organization\u0026hellip;; they have invited us to give lectures and provide us with supplies, and when it comes to discrimination, there is a focal point who assists us.\" (FGD, MSM, Manica)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"...They offer counseling, testing, delivery of protective supplies, and assistance when we seek more information about human rights...\" (FGD, MSM, Gaza)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePersistent Discrimination and Barriers in Healthcare Settings\u003c/h2\u003e \u003cp\u003eThe majority of participants felt that there was a lack of KP awareness and supportive mindset among many healthcare professionals, and that discrimination is still common in healthcare facilities. Many KP, especially transgender individuals, felt that their health issues were often overlooked or inadequately addressed due to stigma related to their gender identity or lifestyle. These feelings are powerfully echoed in the narratives shared by participants, such as the fear and reluctance to seek healthcare services due to the pervasive gossip and judgment they face from health facility staff, as well as instances where healthcare professionals outright did not provide adequate treatment because of their personal biases.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"We are suffering and afraid to call these health services. It\u0026acute;s normal to have symptoms and want to visit health professionals but you can't talk to them because they are the same ones who keep on badmouthing like 'you get this because you get involved with other men\u0026rdquo;\u003c/em\u003e. \u003cem\u003e(KII, Female Trans, Gaza)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;due to the stigma, people on ART do not to adhere to treatment services because of the lack of privacy and confidentiality from healthcare professionals.\" (KII, CBO, Maputo City)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"...There are several issues that we see and have faced in health units, such as testing, where instead of proceeding with the test, the doctor refuses to treat...\" (FGD, Male Trans, Zambezia)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;it was embarrassing to go to the health facility as Trans. Health workers sometimes reacted poorly upon seeing someone with a male name but presenting in a feminine. Sometimes they even asked them to leave the facility, claiming that they could not serve the patient under those circumstances. It becomes easier when the health worker is also part of the KP, making it more comfortable...\" (FGD mixed, Zamb\u0026eacute;zia)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;How will we seek services if we are not treated well? The hospital is not prepared to receive people like us...\" (KII, Female Trans, Gaza)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePWID respondents reported that they hardly go to the health units on their own initiative, even with serious health conditions. PWID participants reported that if the health professionals know that the patient is PWID, the way they are treatment automatically changes.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\" We only go to the hospital when we are very sick\u0026hellip;.\u0026rdquo; (KII, PWID, Gaza Province)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The doctors just knowing that it's someone who injects drugs makes the service different.\" (KII, PWID, Maputo Province)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;It has to be someone understanding, not discriminating because they go without bathing for long periods, and they are looked down upon due to their appearance of being dirty and smelling bad.\u0026rdquo; (KII, CBO, Maputo Province)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study reaffirmed the availability of KP-focused services within healthcare facilities in the provinces where the study was conducted. However, the study also highlighted persistent gaps in providing appropriate treatment. Participants across all provinces highlighted that health services tailored for KPs are provided within general population facilities, reflecting a targeted approach to meeting their healthcare needs. Despite this, services available within the general health service setting were often delivered with stigma and discrimination, making them less effective.\u003c/p\u003e \u003cp\u003eThe healthcare access for KP presents both challenge and opportunities. While progress has been made in service provision (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), significant barriers still exist. Participants expressed concerns about the lack of supportiveness from healthcare professionals, stemming from discriminatory attitudes and inadequate support for KP individuals (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Transgender and PWID individuals in particular reported feeling marginalized and underserved within healthcare settings due to stigma and judgment from healthcare providers. Instances of refusal of care and poor treatment were reported, highlighting the need for systemic change to create a more inclusive and empathetic healthcare environment within the general health care setting where many KP seek services (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The stigma associated with PWID often results in differential treatment from healthcare professionals, impacting the quality and accessibility of healthcare services (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite these challenges, there are positive developments in service delivery for KP. CBOs were recognized for their positive role in offering health and social services tailored to KP, emphasizing the importance of prioritizing KPs needs within the healthcare landscape. These organizations have been crucial in their provision of essential sexual protection supplies and play a crucial role in promoting sexual health and reducing the transmission of sexually transmitted infections (STI) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The positive experiences shared by participants underscore the value of collaborative efforts between healthcare facilities and CBOs in providing comprehensive support for KP. Quotes from participants highlighted the tangible benefits of these collaborations, which include educational lectures, HIV testing and counseling services, and assistance in accessing information about human rights. These interventions not only address immediate healthcare needs but also contribute to broader efforts aimed at empowering KP communities and reducing health disparities (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Both systemic changes in healthcare settings and targeted initiatives could help address gaps in service delivery. Community-Led Monitoring (CLM) and KP listening sessions, recommended by PEPFAR and UNAIDS, could be crucial in improving the quality and completeness of services for KPs (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). These initiatives allow KPs and their communities to actively monitor services, identify gaps, and advocate for improvements. By involving KPs directly in the evaluation process, CLM and listening sessions help make services more responsive to their needs and address issues like stigma and discrimination. Studies have shown that community-led efforts can significantly enhance service quality and accessibility, especially when integrated into existing health systems (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In 2023, the Mozambique MoH updated the national comprehensive HIV services guidelines to better serve KPs. These guidelines incorporate best practices, including those recommended by PEPFAR and UNAIDS, and aim to create a more inclusive and supportive healthcare environment. They are comprehensive and grounded in the real experiences of KPs, making them more effective.\u003c/p\u003e \u003cp\u003eWhile the findings provide valuable insights into the experiences of the study population in specific provinces, caution should be exercised in generalizing these results to other provinces, all locations within the same province, or the broader KP community in Mozambique. The context-specific nature of the data may limit its applicability to different regions, where cultural, social, and economic factors could influence the experiences of KP individuals differently. Additionally, the purposive sampling method employed in this study, while appropriate for capturing diverse perspectives within the sampled population, may introduce selection bias. This bias could potentially exclude certain segments of the KP community, for example those KP who are not comfortable identifying themselves as KP and are therefore not visible to the study, leading to an incomplete representation of all KP experiences.\u003c/p\u003e \u003cp\u003eFurthermore, the scope of this analysis primarily focused on access to comprehensive health services and did not explore other critical health aspects for the KP community, such as mental health support, substance abuse treatment, or violence, which are being explored through other reports and papers. Additionally, as this article is a sub-analysis of the formative research results, it was not possible to capture more detailed or additional information beyond what was included in the original data set. This limitation may affect the depth of analysis and the ability to provide a more comprehensive understanding of the experiences of the KP community.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study underscores the critical importance of specialized healthcare services and community-based support for KP in Mozambique. Despite significant efforts to enhance the provision of healthcare services for KP, pervasive stigma and discrimination within healthcare settings remain substantial barriers to accessing quality care. The findings revealed that while CBOs play crucial roles in providing necessary health services and support, including sexual protection supplies and education, the persistent discriminatory attitudes and inadequate preparedness among healthcare professionals continue to marginalize KP individuals, particularly transgender people and PWID.\u003c/p\u003e \u003cp\u003eAddressing these issues would benefit from continuous investment and reinforcement of comprehensive training for healthcare providers, the implementation of robust anti-discrimination policies, and stronger collaboration between health facilities and CBOs. Promoting inclusive healthcare practices and strengthening support systems are important steps that could help reduce health disparities and advance the national HIV response efforts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors declare that they have no competing interests.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSJ conceptualized and wrote the original manuscript. AMV, PM supported the field activities. ARB supervised study implementation. PM, JM and CSB were involved in the study implementation and provided critical revision of the manuscript. All authors read and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the key population community for their participation in this study. We are grateful for all their support during the study implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research has been supported by the President\u0026apos;s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of CoAg number GH002021.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCDC Disclaimer\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the funding agencies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used in this manuscript are fully available from the Mozambique National Institute of Health (INS) data repository. Researchers who meet the necessary criteria for accessing confidential information can access the data, which originates from the KP Mapping and Population Size Estimation Study. For more information or to request access, please visit the INS website at www.ins.gov.mz or contact the authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUNAIDS, Global HIV. \u0026amp; AIDS statistics \u0026mdash; Fact sheet. 2024; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unaids.org/en/resources/fact-sheet\u003c/span\u003e\u003cspan address=\"https://www.unaids.org/en/resources/fact-sheet\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNAIDS. 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J Account Organ Change. 2007;3(3):209\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Key population, HIV, health services, Stigma and Discrimination, Mozambique","lastPublishedDoi":"10.21203/rs.3.rs-5387851/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5387851/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eKey populations (KP) can have poor access to public health services. Mozambique ranks among the top ten countries with the highest HIV prevalence worldwide, with an estimated 12.5% of People Living with HIV (PLHIV). Despite national strategic efforts and guidelines to address HIV transmission among KP, pervasive stigma and discrimination in healthcare settings remain significant barriers to effective service delivery. This study aims to explore the experiences of KP in accessing healthcare and social services in Mozambique.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis qualitative study conducted in 2022 across six urban provinces, key informant interviews (KII) and focus group discussions (FGD) to explore the experiences of KPs in accessing HIV-related health and social services. Participants included Female Sex Workers (FSW), Men who have Sex with Men (MSM), People Who Inject Drugs (PWID), transgender individuals, health providers, and members of community-based organizations (CBOs). Data were collected, transcribed, and analyzed using NVivo software based on Grounded Theory.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 440 interviews were conducted, including 151 KIIs and 293 FGD participants. Despite the availability of targeted healthcare services and community-based support, findings indicated pervasive stigma and discrimination within healthcare settings, particularly affecting transgender individuals and PWID. Many participants reported experiencing discriminatory attitudes from healthcare providers, leading to refusal of care and inadequate treatment, which deterred KP from seeking necessary medical assistance.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eWhile the country has made progress in providing services tailored to KP, stigma and discrimination within healthcare settings remain critical barriers. This issue disproportionately affects transgender individuals and PWID, who often face refusal of care and poor treatment. Although CBOs have been instrumental in offering support, systemic changes are needed to create a more inclusive healthcare environment.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThese findings underscore the importance of considering systemic changes to address stigma and discrimination in healthcare settings in Mozambique. Comprehensive training for healthcare providers, robust anti-discrimination policies, and strengthened collaboration between healthcare facilities and CBOs are essential to improve healthcare access and outcomes for KP. Promoting inclusive healthcare practices can help reduce health disparities and advance national HIV response efforts in Mozambique.\u003c/p\u003e","manuscriptTitle":"Challenges and Supports: Exploring Health Service Accessibility for Key Populations in Mozambique","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-18 08:53:45","doi":"10.21203/rs.3.rs-5387851/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-06T06:29:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-05T09:51:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-05T09:50:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-11-04T11:43:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"20c92a46-1f95-4714-a827-b22979d1b584","owner":[],"postedDate":"November 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-11-18T08:53:45+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-18 08:53:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5387851","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5387851","identity":"rs-5387851","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}