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The Treatment Era: ART in Africa
Overview - Focus on Mozambique
Maputo Central Hospital: two lab technicians from Malawi learn to do HIV tests, viral load and CD4 counts. Credit: IRIN
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Mozambique is a catalogue of the problems that poor countries face when they expand antiretroviral therapy (ART).
National HIV prevalence in 2004 is projected to be 14.9 percent among people aged 15 to 49, based on sentinel surveillance by the ministry of health and the National Institute for Statistics. The average hides sharp disparities between provinces, ranging from 26.5 percent in Sofala to 8 percent in Nampula. Provinces bordering South Africa, Zimbabwe and Malawi are the worst affected.
Among the estimated 1.4 million people infected, 218,000 need treatment in 2004, according a National Institute of Statistics study.
As of November 2004, 5,900 people were on ART: 4,200 through NGOs, 1,200 at Maputo Central Hospital, a few hundred at provincial sites, and about 50 through private health care.
The goal was to have just under 8,000 people on ART by the end of 2004, with an annual increase to 20,800, 58,000, and 96,000 - reaching 132,000 in 2008.
HEALTHCARE PROVIDERS
The first problem is lack of human resources. There are 800 doctors, 300 of them expatriates, in a population of 18.9 million. This means one doctor for every 24,000 people, against one per 5,000 to 10,000 recommended by the World Health Organisation. The 11,000 nurses represent one per 1,700 people, while WHO recommends one every 300.
Healthcare is also unevenly spread: 80 percent of doctors are in Maputo, the capital; among all health staff, those in the provinces have the lowest qualifications.
Due to AIDS-related deaths, Mozambique needs to train 25 percent more doctors and nurses every year just to maintain the existing low levels of staffing, says a study by the ministry of health.
The University Eduardo Mondlane, the new National Health Institute in Maputo, and the new Nursing School in Beira are increasing student uptake, but to retain them in the country after graduation will require better salaries and working conditions.
Meanwhile, with donor money to offer monthly salaries of US $3,000, the government is recruiting 120 doctors in Cuba and India.
INFRASTRUCTURE
Another problem is poor health infrastructure. In the provinces, sub-standard facilities and lack of basic equipment is common. Many of the 27 rural general hospitals operate below minimum acceptable standards, says the Health Sector Strategic Plan 2002-2005.
To enable ART, the Italian Catholic NGO, Communita de Santo Egidio, rehabilitated three molecular laboratories with state-of-the art equipment. The biggest, at Maputo's Central Hospital, cost US $450,000; those in Maputo and Beira are operational, and Nampula will open soon to serve the northern region.
In the meantime, blood samples are sent weekly from the north to Maputo by courier airplane - run-down inter-provincial roads make some airfreight unavoidable.
The lab in Maputo offers training for health personnel from Mozambique and other African countries where Santo Egidio plans to start ART.
At Maputo Central Hospital, Brazilian cooperation funds ARV training for doctors and nurses, and to date 200 doctors have been trained, so that every province now has ARV-competent doctors.
Dr Rui Bastos is the Mozambican training coordinator. "We are overworked," he says. "We lack diagnosis capacity, drugs for opportunistic infections, nurses, psychologists and resources in general."
Other problems are the lack of legislation on post-exposure prophylaxis and deliberate infection, and the ethical conflict between professional confidentiality versus medical notification to partners, says the HIV/AIDS National Strategic Plan 2004-2008.
TREATMENT PROVIDERS
Two NGOs, Medecins Sans Frontieres (MSF) and Santo Egidio, run model community-based care and treatment projects: MSF treats 1,700 patients in Maputo and Lichinga; Santo Egidio runs 13 sites in Maputo and Beira, treating 2,500 patients.
By 2007 Santo Egidio plans to treat 8,400 persons at 20 sites in five provinces.
In Maputo, MSF is working at full capacity. Its clinic there has 1,500 patients on ART and a waiting list of 1,000. "It is frustrating, but our human and financial resources are limited," says MSF general coordinator Patrick Wieland.
MSF employs 20 medical staff in Maputo, including two Mozambican and three foreign doctors, and 10 non-medical staff. The total annual cost of the programme is $2.5 million, but, being donor-dependent, MSF can only guarantee five years of treatment, and continuation hinges on additional funding. Patients must understand this, sign consent forms, and hope.
"It is not our role to treat everyone," says Wieland. "We showed ART is feasible; we can train others, but we cannot substitute for the government."
Santo Egidio operates on a different model, at a lower annual cost of $2.2 million. The Catholic charity relies on volunteers from Italy and other countries, who pay their travel to Mozambique during holidays and work one month for free at its sites.
The annual treatment cost per patient at Santo Egidio is $700, broken down to $300 for generic antiretrovirals (ARVs) and $400 for tests and other support.
The success of such ART programmes in Mozambique and elsewhere in Africa lies in strong community involvement regarding patient identification, selection, care, support and monitoring. It is labour and capital intensive.
Besides drugs and tests, patients need good food, clean water and a healthy environment; mothers need formula for babies. Santo Egidio distributes food, insecticide-treated mosquito nets, water filters and home-based care kits, while MSF has partners who provide this support.
Can these schemes be replicated by the public health sector?
"As it is, no," says Wieland. "Local solutions are needed - there is no other choice."
Gabriella Bortolot, coordinator at Santo Egidio, says: "We can't export a western model to Africa, but the challenge is to develop an African model of quality care."
Local solutions include using non-medical personnel at all levels. Lay community workers, trained and supported by referral systems, can run pharmacies, do routine follow-up, counselling, and home or palliative care; nurses and clinical officers can offer prescription and consultation, while community health workers can monitor patients for toxicity and clinical failure, freeing scarce doctors to attend mainly to complications.
Eliminating the requirement for viral load and CD4 counts before starting treatment bypasses expensive tests.
EXPANSION
Mozambique began planning nationwide ART in 2002 with a degree of reluctance: health authorities knew first-hand the problems involved.
"AIDS should not detract from other health services, it should reinforce them," says Dr Mouzinho Saidi of the National Programme to Fight HIV/AIDS.
The examples of successful ART schemes run by NGOs helped dissolve the initial reluctance, but today the government is under pressure from activists and donors alike to expand treatment access.
"We are resisting donor pressure to increase the numbers because we want to grow in a sustainable way," says Saidi. "If we lose control, drugs will end up [being] sold on the streets and patients will not be properly monitored."
The fear of creating resistant strains of the virus is palpable, as is the fear of donor funds shrinking in the future.
"The government is very conscious that, once we start, we can't stop, so these are reasonable figures reflecting local capacity," says WHO representative Dr Bokar Toure.
The ethical imperative and the practical feasibility of ART in Africa are now widely accepted. The challenge is at what pace and how.
"Scaling-up was decided by donors in foreign capitals, who don't know the on-the-ground reality of treating patients," says Wieland. "Westerners like to do a lot quickly, and have quick impact, but we need long-term strategies to sustain results, not relying on donors and their whims."
COORDINATION
Throughout the interview with PlusNews, Saidi stressed one point: coordination. "We can't have disorganised growth or parallel systems for treatment, drug procurement and drug supply," he explained.
Mozambique, like other developing countries, has a variety of health care providers, including the state, NGOs, churches and the private sector.
ART began in Mozambique with NGOs; the public health sector came later. The challenge is to coordinate the whole spectrum of ART providers.
One point of friction is patient selection. The medical criteria - a CD4 count under 200 or stage III/IV of AIDS - are established by WHO. Additional social criteria, which become crucial when need exceeds supply, vary.
The government has not developed national social criteria to select patients. Hence, it clashes with Santo Egidio because the charity provides ART to 100 inmates at a prison in its clinic's catchment area. The government argues that prisoners cannot support treatment with healthy living; the Catholic charity argues that every patient has the right to treatment.
Planning and coordination could have avoided this problem.
DONOR DEPENDENCY
In UNDP's Human Development Index, Mozambique ranks at 171 out of 177 countries. In 2003 its GNI per capita was US $210, compared to an average of $450 in sub-Saharan Africa.
In 2000 foreign aid accounted for 70 percent of all spending on health, 46 percent of education expenditure and 75 percent of the funds spent on infrastructure, such as roads and water.
In 1999 foreign aid provided 52 percent of the $100 million health budget, notes the Health Sector Strategic Plan. With increased foreign funding for AIDS, the ratio is higher today.
Mozambique is one of the most donor-dependent countries in the world, and its treatment plan echoes this. The government worries about the long-term sustainability of treatment, and the recent wrangle among donors about next year's financial support for the Global Fund to Fight AIDS, TB and Malaria feeds these concerns.
Then you meet Ana Maria Muhai, 43, a dynamic activist in Machava on the outskirts of Maputo. Her miner husband returned from South Africa in 1998 with a retrenchment bonus and promptly left her and their three young children when she became sick.
In February 2002, Muhai, weighing 29 kg, ravaged by opportunistic infections, bald, with horrible skin rashes and a bad cough, arrived at the clinic. In three weeks ARVs brought her back from the brink of death.
Today, a healthy Muhai helps patients with treatment adherence. When some ask if she is paid by the Italians to say she is HIV positive, she pulls out an old photo. "Then they see it is for real - I know it is not a cure, but I feel cured," she says.
There are 1.4 million people like Ana Maria Muhai in Mozambique, whose contribution to family, community and nation is unique, irreplaceable, and threatened by the virus.
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