BACKGROUND
Mozambique is a country of approximately 29 million people[1] challenged by a generalized HIV epidemic. National HIV prevalence is estimated at 13%, with substantial variation in provincial prevalence ranging from 5% in Tete Province to 24% in Gaza Province.[2] At the end of 2016, there were an estimated 1.9 million people living with HIV (PLHIV), with a higher prevalence among women, 15% vs. 10% among men.[3] Prevalence among adolescent girls 15-19 is estimated at 6% and among young women 20-24 is estimated at 13%, compared to 2% and 5% among adolescent boys and young men.[4] Of the estimated number of PLHIV, 45% are currently on antiretroviral treatment (ART). The HIV epidemic has contributed to a reduced life expectancy of 55 years, and there are approximately 2 million orphaned children, of whom 800,000 were orphaned by HIV. The overarching goal of the United States Government (USG) for the President's Emergency Plan for AIDS Relief (PEPFAR) in Mozambique is to support country efforts to achieve epidemic control by 2020 through evidence-based policies and interventions to drive progress and save lives.
KEY CHALLENGES
ART Retention: Mozambique has low national retention rates. Twelve month retention among PLHIV newly initiating ART was 70% at APR16. Rates are even lower in pregnant women, children under 15, and adolescents 15-19 (61%, 69% and 69% respectively at APR16). PEPFAR Mozambique is currently planning and implementing innovations at the facility and community level to retain and track PLHIV on treatment such as monthly monitoring and quality improvement cycles for retention and adherence. Fragile Health Systems: The health system contends with major challenges, including limited funding, insufficient infrastructure, and a critical shortage of human resources. Over 90% of Mozambicans live in an underserved primary health care area defined as over a one hour walk from a primary health care center.[5] Overall, the ratio of population per hospital bed is one bed per 1,038 persons, with substantial variation across the country.[6] Human resources for health (HRH) are severely constrained with 7.8 doctors, 26.8 nurses, and a total of 100.2 health care workers (HCW) per 100,000 people.[7] Together with uneven geographic distribution and limited supervision, there are an inadequate number of trained and competent HCW in all cadres.
POLICY IMPACTS
In February 2016, the Ministry of Health announced its decision to adopt the UNAIDS 09-90-90 goals and the revised WHO guidelines released September 30, 2015. Mozambique initiated ART for all patients at CD4<500 in March 2016, and began phased rollout of Test and Start (T&S) in August 2016. Over half of all PLHIV live within current T&S districts, and the remainder will be covered during FY17 and FY18. To support the new T&S treatment thresholds, Mozambique is transitioning to three-month scripting for stable ART patients, increased availability of viral load (VL) monitoring, and reduced frequency for clinical check-ups to decongest health facilities. The National HIV Strategic Plan (Plano Estratégico Nacional de Resposta ao HIV e SIDA-PEN IV) is now being implemented and will be updated based on the revised HIV treatment policies for the period 2017-2020.
PREVENTION
PEPFAR Mozambique implements a multi-phased prevention strategy including prevention among Priority Populations such as adolescent girls, commercial sex workers, and men who have sex with men, voluntary medical male circumcision (VMMC), prevention of mother to child transmission (PMTCT), and HIV testing and counseling linking HIV positive individuals with treatment. In 2015, PEPFAR/Mozambique launched the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) Initiative targeted at achieving a significant reduction in new HIV infections among adolescent girls and young women by the end of 2017. In addition, to the activities listed above, USAID also implements an orphans and vulnerable children (OVC) program that spans both prevention and care and treatment. The OVC activities focus on improving the health, nutritional status, and well-being of OVC living in PEPFAR priority districts.
CARE AND TREATMENT
The goal of the adult treatment portfolio is to increase early initiation of ART, provide high quality services, ensure robust retention strategies and achieve epidemic control. Additionally, a number of modifications to the service delivery model were proposed in COP16 to decrease clinic congestion, provider workload, and improve delivery of patient-friendly services. Mozambique’s pediatric ART eligibility criteria include universal coverage for all children <5, coverage for children 5-14 with CD4<500 or meeting WHO stage III/IV criteria, and presumptive diagnosis and treatment of exposed infants. Significant challenges to pediatric care and treatment include very slow growth in pediatric coverage poor retention (69% for children <15 and 69% for adolescents 15-19),[8] and slow roll-out of routine viral load monitoring with high rates of pediatric virologic failure (65% among children <5 and 53% among children 5-14 who received routine VL testing).[9] USAID’s main treatment partner is FHI360 who implements the Clinical HIV/AIDS Systems Strengthening (CHASS) program, which operates in four provinces and will operate in a fifth province in FY2018.
KEY USAID PROJECTS
Priority Populations: Consolidated Community for the Southern Region, Strengthening Communities through Integrated Programming (SCIP) Zambezia, CHASS, Communication for Improved Health Outcomes (CIHO), Consolidated Community for Nampula, Integrated HIV Prevention and Health Services for Key and Priority Populations (PASSOS)
DREAMS: Consolidated Community for the Southern Region, Child and Community Strengthening, SCIP Zambezia, CHASS
VMMC: AIDS-Free Generation
PREVENTION OF MOTHER TO CHILD TRANSMISSION: CHASS
HIV TESTING AND COUNSELING: CHASS, Consolidated Community for the Southern Region, SCIP Zambezia, CIHO, Consolidated Community for Nampula, PASSOS
OVC: Service Delivery and Support for Orphans and Vulnerable Children (CoVIDA), Child and Community Strengthening
CARE AND TREATMENT: CHASS
KEY ACCOMPLISHMENTS
- Despite myriad challenges and the heavy burden of the HIV/AIDS epidemic, there has been remarkable progress. As of March 2017, PEPFAR supported the following achievements in Mozambique:
- Life-saving antiretroviral treatment for over 900,000 people;
- VMMC for HIV prevention for almost 380,000 men;
- Testing and counseling for over 3.3 million people;
- Care and support for over 170,000 orphans and vulnerable children affected by HIV/AIDS