PEPFAR: Responding to HIV/AIDS Challanges in Mozambique
In 2003, United States President George Bush and a bipartisan Congress announced the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR). The overarching goal of PEPFAR is to reduce the burden of HIV/AIDS in select countries with high HIV prevalence. Initial PEPFAR efforts quickly identified central Mozambique as a priority target due to its high HIV burden. The estimated prevalence for the region was 20% and reached as high as 36% in the city of Beira. By early 2003, HIV services had expanded in the region but remained focused on prevention rather than treatment. The first anti-retroviral treatment clinics supported by PEPFAR were opened in 2004 in the region.
HAI has been supporting health initiatives in central Mozambique since 1987. USAID recognized this commitment and expertise by selecting HAI as the primary non-governmental organization for the implementation of PEPFAR-funded projects in two central provinces (Sofala and Manica). HAI’s model of support emphasized close coordination with the public sector, including both the national level Ministry of Health and its provincial health departments. This fostered the integration of services into the region’s primary health care system.
In 2004, USAID and HAI entered a six-year agreement for an HIV/AIDS Care Rapid Expansion program. The broad goals were to scale-up anti-retroviral treatment, reduce HIV transmission, and mitigate the impact of HIV/AIDS through the expansion and improvement of HIV care services in Sofala and Manica provinces. There were five objectives:
- Increase motivation and skills for women and adolescent girls to protect themselves and their infants from HIV infection;
- Increase awareness of HIV status and decrease stigma via expansion of counseling and testing services;
- Improve the capacity of communities to prevent further HIV/STI infection and care for those already infected;
- Improve the capacity of health systems to care for those living with HIV; and
- Integrate HIV/AIDS care and treatment services into a cohesive network providing support along the continuum of care.
In 2008, USAID asked HAI to expand activities to a third province (Tete). HAI’s PEFPAR-funded program was completed in December 2010.
Overview of Program Successes
The program achieved all of its objectives and transformed the landscape of HIV/AIDS services in Sofala, Manica, and Tete.
The availability of services dramatically increased:
| 2004 | 2010 | |
|---|---|---|
| Number of sites offering services for the prevention of mother-to-child transmission of HIV (PMTCT) | 11 | 204 |
| Number of sites offering counseling and testing services | 18 | 131 |
| Number of sites offering antiretroviral therapy (ART) | 2 | 94 |
| Percent of districts offering community-based palliative care services (Sofala and Manica) | 26% | 100% |
The program also enhanced the quality of these services by providing technical assistance at the national level. Four advisors supported the Medical Assistance Department at the Ministry of Health, which coordinates the scale-up of ART, the pediatric AIDS program, and the national TB program.
Prevention of Mother-to-Child Transmission of HIV (PMTCT)
Summary of Activities
HAI supported the implementation of a broad range of PMTCT services among pregnant and breastfeeding women. The package of services included:
- Antiretroviral prophylaxis at birth for mother and child
- HIV testing and counseling services
- “Positive Mothers” groups to provide psychosocial and peer-to-peer support
- Information about HIV/AIDS, nutrition and safe infant feeding practices
- Scale-up of an innovative integrated antenatal care package since 2005 that integrates PMTCT services with to syphilis testing and treatment, malaria treatment, and other routine ANC services.
Key Accomplishments
- Scaled-up PMTCT counseling and testing from 6,200 individuals in 2005 to nearly 122,000 in 2010 (a 20-fold increase).
- Increased the provision of a complete course of ARV prophylaxis from 320 individuals in 2005 to more than 10,000 in 2010.
- Trained over 1,800 health care workers in the effective provision of PMTCT.
Clinical Care and Treatment
Summary of Activities
HAI contributed to the rapid creation of a cohesive health system capable of caring for HIV-infected populations across the continuum of care. This required a robust clinical care infrastructure to treat opportunistic infections as well as HIV. To accomplish this goal, HAI opened ART clinics and trained health care workers in ART delivery as well as treatment of individuals infected with both tuberculosis and HIV.
Key Accomplishments
- Expanded the number of ART facilities from 2 in 2004 to 94 in 2010, including both rural and urban sites across all 36 districts included in the program.
- Enrolled 63,444 patients in ART by 2010.
- Trained over 1,100 health care workers in ART delivery and TB/HIV co-infection.
Counseling and Testing (CT)
Summary of Activities
HAI worked with partners to launch new CT centers, expand capacity within the workforce to provide expanded CT services, and integrate testing into routine health services. CT centers were staffed by accredited counselors who provided both pre- and post-test counseling according to national protocols. Individuals who tested positive for HIV were referred to support groups, home-based palliative care, and facility-based clinical care. HAI trainings and job aids enabled providers to provide CT services at general care sites rather than requiring patients be seen at HIV-specific sites.
Key Accomplishments
- Increased the number of testing centers directly supported by PEPFAR in Sofala and Manica provinces from 7 to 131.
- Increased the number of people receiving CT services from 19,000 in 2005 to more than 175,000 in 2010.
Home-based Palliative Care (HBC)
Summary of Activities
HAI partnered with community-based groups to increase access to quality home-based care for people living with HIV/AIDS. This required strengthening the links between patients, the health system, and the community to provide support for patients and their families and increase treatment adherence. The program activities included capacity building for local community-based organizations, such as training and support for volunteers.
Key Accomplishments
- Expanded access to HBC services from one catchment area to all 23 districts in Sofala and Manica as well as Tete City.
- Increased the number of individuals served by HAI-supported HBC from 720 in 2003 to 12,000 in 2010, nearly 10% of whom were under the age of 15.
Complementary Services
Summary of Activities
HAI recognized that numerous health system and societal constraints would threaten the effectiveness of the program if not addressed. These potential barriers included inadequate infrastructure, ineffective communication strategies, and inadequate access to food among individuals living with HIV/AIDS. To strengthen the infrastructure, HAI renovated or expanded several existing facilities in addition to constructing new ones. HAI also invested heavily in the regional laboratory network. To address concerns about communication, HAI launched media campaigns and encouraged collaboration between different stakeholder groups, including community-based organizations, non-governmental organizations, and health care providers. HAI also worked with World Food Program to distribute nutritional supplements to HIV-vulnerable populations in Sofala and Manica.
Key Accomplishments
- Remodeled 42 health centers and 7 laboratories to accommodate added personnel and equipment.
- Aired 93,121 radio spots that promoted the utilization of PMTCT and CT services, provided information about HIV prevention, and described the benefits of adherence to ART.
- Provided critical assistance to support food distribution to an annual beneficiary population of approximately 7,000 children and 22,000 adults.