I' Pereira, A' Assan, K' Sturbeck, A' Vergara, R' Fernandes, M' Fonseca, A' Almirall, M'G' Lain, D'

1
The International Center for AIDS Care and
Treatment Programs
REPÚBLICA DE MOÇAMBIQUE MINISTÉRIO DA SAÚDE
PEPFAR
Scaling-up ART in Mozambique
I. Pereira¹, A. Assan², K. Sturbeck³, A.
Vergara³, R. Fernandes¹, M. Fonseca¹, A.
Almirall¹, M.G. Lain¹, D. Arakaki¹, M. Mello¹,
L. Polejack¹, J. Lima1, A. Thompson¹, D. Hoos1,
W. El-Sadr1 ¹ International Center for Aids Care
and Treatment Programs, Columbia University,
Mailman School of Public Health, ² Ministry of
Health, Mozambique, ³ CDC/Mozambique
INTRODUCTION

• Mozambique has one of the highest HIV prevalence
  rates in Southern Africa. In 2004, the national
  prevalence among individuals aged 15 to 49 years
  was estimated to be 16.2 (Fig. 1, based on 2004
  Sentinel Survey). Nearly 1.5 million Mozambicans
  are living with HIV/AIDS, with 200,000-240,000 in
  need of antiretroviral therapy (ART).
• Currently, approximately 22,000 people are
  receiving ART in Mozambique. The national plan
  for HIV/AIDS set an ambitious target of expanding
  ART to 132,280 patients by the end of 2008. This
  scale-up is a huge challenge for the health
  system in Mozambique, which faces many challenges
  in terms of weak infrastructure, paucity of
  health care workers and limited management
  systems. To achieve this target, the Ministry of
  Health (MoH) relies in part on assistance from
  international partners, including support
  provided by the International Center for AIDS
  Care and Treatment Programs (ICAP) at Columbia
  University.
• In collaboration with the Ministry of Health
  (MOH), ICAP-Mozambique is supporting the
  implementation of HIV care and ART services in
  five provinces designated by the MOH. This effort
  requires addressing challenges in the following
  areas the health infrastructure, beneficiaries
  of services, and human resources.

9.3
20.4
National Prevalence16.2
18.1
Fig.1 National and Regional Prevalence of HIV
2004 ? Northern ? Central ? Southern
region.
PROGRAM DESCRIPTION
Health infrastructure Existing hospitals,
clinics and laboratories have been in a state of
disrepair with limited space, and require
substantial rehabilitation to make them
functional. To speed up the provision of services
and in response to the shortage of physical
space, existing structures are adapted to be used
as temporary Day Hospitals (DH), while awaiting
approval for the rehabilitation of larger
permanent structures (Fig.2,3). Most
laboratories are structures from the colonial
period in great disrepair, with most equipment
non-functional. Basic lab tests as well as CD4
testing are often not available. Expansion of
HIV care at DH has lead to increased demand for
laboratory services. CDC and ICAP are renovating
existing laboratories, purchasing equipment, and
providing supplies. Health infrastructure for
children is the most crowded and deteriorated.
Child health services are overburdened and
initiation of pediatric HV ART has been
challenging. ICAP has been able to accomplish
essential renovation and most ICAP supported
sites have initiated pediatric ART. ICAP
follows MoH guidelines regarding essential
services provided without cost to patients. ICAP
provides logistical support, furnishing and
supplies, clinical precepting, adherence support,
access to laboratory services, pharmacy services
and support for outreach activities at DH.

Human resources Mozambique has approximately
600 physicians (1/31,000 inhabitants) , few with
experience in ART. There are significant staff
shortages in other areas such as laboratories and
pharmacies. Until recently, only physicians were
permitted to treat PLWHA. ICAP has facilitated
the first two MOH ART training for tecnicos in
February and May 2006 in order to augment the
number of health care workers who can treat
PLWHA. In May trained tecnicos were authorized
to prescribe ART. ICAP has also developed several
in-service trainings on medical and psychological
support to address aspects of AIDS care. To
retain trained staff to remain in public sector
HIV/AIDS services, ICAP in collaboration with the
MoH is providing staff support. Additional
methods of supportive supervision are being
piloted such as the South to South Collaboration
program that brings experienced medical doctors
and nurse from Brazil to work with Mozambican
staff.

Fig. 2, 3 (before and after) ICAP Supported
Temporary Day Hospital at General Hospital of
Mavalane, Maputo.
Fig. 5 Cumulative Enrollment in HIV Care (ART),
ICAP, March 2006
Fig. 4 Scale up of ICAP support to HIV Care and
ART program
Beneficiaries of services All identified PLWHA
who are clinically and/or immunologically
eligible are entitled to receive ART. Patients
begin care from multiple entry points such as
VCT, PMTCT programs, hospital wards, health
centers, or referrals from home-based care
associations. Information and data sharing
through referral forms, registers, reports etc
are the touch points in the collaboration between
the DH and entry points. Patients are tested on a
voluntary basis at VCT and then referred to DH.
Patients at other health services displaying
AIDS-like symptoms are encouraged by medical
staff to be tested at the VCT. Seropositive
patients are counseled and referred to the DH,
but continue to be treated at their original
point of entry, where they provider feedback from
the DH.
Where are we now? ICAP initiated support to the
MOH in Mozambique in September 2004, began direct
support to the Day Hospitals in February 2005 and
currently supports services at 14 Day Hospitals
(Fig. 4). By March 2006, 34,000 patients were
enrolled in care, and 7,589 adults and children
were receiving ART (Fig.5). This represents 33
of the total patients on ART in Mozambique.
Innovative strategies such as provider initiated
diagnostic and testing in hospital wards, TB
model centers and pMTCT model centers are
increasing referral to Day Hospitals and the
numbers on ART.
LESSONS LEARNED

• Other conclusions from 2 years of PEPFAR
  implementation in Mozambique are
• Despite considerable challenges to the
  implementation of HIV care and ART such as poor
  infrastructure, paucity of human resources, and
  lack of equipment and supplies, it has been
  possible to initiate services at multiple sites
  in Mozambique.
• Willingness to adjust approaches and revise
  strategies is necessary when confronted with
  constraining factors (e.g. temporary clinic space
  use while permanent space is rehabilitated).
• Technical support provided to counterparts at the
  MoH insures that DH services are fully
  consistent with the National Program.

RECOMMENDATIONS
The ICAP approach represents a best practices
example of the implementation of an HIV care and
ART program that is responsive to local needs and
circumstances and that is fully integrated within
the national AIDS control plan.
Acknowledgements ICAP in Mozambique is supported
by the Presidents Emergency Plan for AIDS Relief
(PEPFAR) We acknowledge the support of the
Mozambican Ministry of Health, CDC, program
participants, and Day Hospital staff