Articles on Mozambique Point to the Challenges and Potential in Scaling Up HIV/AIDS Care
Our Mozambique team has published several papers recently that all speak to the issue of public-sector health systems and how to scale up services.
In November 2009, the Journal of Acquired Immune Deficiency Syndromes published a paper by Mark Micek (our Technical Advisor for HIV/AIDS Treatment and Operations Research) and colleagues called "Loss to follow-up of adults in public HIV care systems in central Mozambique: identifying obstacles to treatment." This article discusses the five steps of HIV/AIDS testing and treatment, and where patients are being lost to follow-up in this "treatment cascade."
The authors found that drop-offs occurred at each step of the cascade, particularly getting an HIV test in the first place, then from testing to enrolling at a clinic offering antiretriviral therapy (ART) within 30 days, and from getting a CD4 result and starting on ART when eligible. These drop-offs are likely due to a number of factors, including the then-centralized nature of HIV/AIDS services, meaning separate facilities from primary care, which has been changing in Mozambique to a more decentralized model. Also, the article suggests that several health worker-related factors could also be at play -- the number of workers trained to provide HIV services, whether or not patients have positive interactions with these workers, and available counseling services.
Kenny Sherr, our Director of Implementation Science, and colleagues published two papers in the past few months on task shifting and its impact on numbers of people treated and quality of care. One paper highlights how Mozambique's decision to add a new mid-level cadre of health workers called "técnicos de medicina" has increased the number of facilities that provide HIV/AIDS services, and the number of people who get those services.
The other paper, "Quality of HIV care provided by non-physician clinicians and physicians in Mozambique: a retrospective cohort study," discusses study findings that indicate that the técnicos provide care that is as good, if not better, than physicians along certain measures of quality. These two articles together suggest that developing new cadres of health workers to deliver HIV/AIDS services can help to expand services and reach more people, addressing some of the bottlenecks that Micek et al identified in their study above.
Table comparing quality of care by physicians and técnicos de medicina (also called nonphysician clinicians or NPC)
Finally and most recently, James Pfieffer (our Director of Mozambique Projects) and colleagues published a case study in the Journal of the International AIDS Society on the expansion of ART in Mozambique. The paper, "Integration of HIV/AIDS services into African primary health care: Lessons learned for health system strengthening in Mozambique," looks at lessons learned from our experience working with the Mozambican Ministry of Health to expand ART and HIV care from 2001-2008.
The rapid scale up of ART and HIV care across Africa over the past five yeas has provoked an important and lively debate about the impact of "vertical" disease specific programming on primary health care. This case study shares our experience in Mozambique with the integration of HIV care services into the public sector primary health care system and provides an alternate "diagonal" approach. We provide a model for how to simultaneously strengthen both HIV/AIDS services and the broader health system in which those services are embedded.
The number of patients tested for HIV per month before/after integration
With the Ministry of Health, we initiated an effort in two provinces to integrate ART into the existing primary health care system. The integration included:
- placing ART services in existing units;
- retraining existing workers;
- strengthening laboratories, testing, and referral linkages;
- expanding testing in TB wards;
- integrating HIV and antenatal services;
- improving district-level management.
The integration approach enabled the primary health care system in these two provinces to test more patients for HIV, place more patients on ART more quickly and efficiently, reduce loss to follow-up, and achieve greater geographic HIV care and coverage compared to the vertical model of free-standing HIV facilities.
Together, these papers highlight the challenges of scaling up HIV/AIDS services, the benefits of integrating HIV/AIDS services into public-sector primary health care as a means of improving reaching more people and reducing loss to follow-up, and the role that task shifting can play in helping to expand services and provide quality care, both for HIV and with the potential of improving all health services.
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