PEPFAR strategy shift aims to get ahead of Mozambique's epidemic

Mozambique is at the outset of recalibrating its HIV response, following a global shift in approach by one of the primary donors to the country’s AIDS response — the U.S. President’s Emergency Plan for AIDS Relief.

Across the 40 countries and regions it supports, PEPFAR’s new strategy calls for a massive scale up in services in areas where the most new HIV infections are happening. Along with the Global Fund to Fight AIDS, Tuberculosis and Malaria, PEPFAR underwrites the bulk of Mozambique’s HIV activities, which means the new strategy will have a significant influence on the country’s efforts to fight the virus.

Based on an extensive analysis of public health data, the PEPFAR team in Mozambique prioritized 77 of the country’s 148 districts they expect to generate the most new HIV patients. The goal, officials said, is to dramatically curb transmissions in those districts in a bid to bring the country’s larger epidemic — one of the worst in the world — under control. The strategy offers the best opportunity, within current international funding constraints, to finally get ahead of Mozambique’s epidemic, according to officials.

PEPFAR partners and civil society organizers express concern that the new approach will leave some of the country’s communities behind. Given the ongoing retreat of international donors from the country’s HIV response, though, government officials said PEPFAR’s strategy is the only viable option.

Increasing access to antiretroviral therapy

An estimated 1.5 million people are currently living with HIV in Mozambique, according to UNAIDS, and 120,000 new patients are infected each year. While it has been nearly 30 years since the country’s first patient was diagnosed with the disease, stigma is rife and people are still afraid to get tested or disclose their status.

Nevertheless, there have been significant improvements over the past three years, following the government’s unveiling of a plan to dramatically increase access to antiretroviral therapy and reduce transmission.

In many ways, the government proposal predicted the current PEPFAR strategy.

“We realized that probably we need to do something in terms of increasing the number of people taking [antiretroviral drugs] and also doing more counseling and testing,” said Diogo Milagre, the deputy executive director of the National AIDS Council.

The plan the government ultimately rolled out targeted 70 districts with increased services in a bid to increase national ART coverage to 80 percent of all eligible patients and halve the number of new HIV infections by this year.

“It’s very ambitious, but you can only fight epidemics like HIV and AIDS with bold decisions, with emphasis on knowing that eradication is possible,” Milagre said.

There has been some success. By March of this year, more than 676,000 patients were enrolled on ART, up from 308,000 in 2012.

When he took over three years ago as the program officer for care and treatment in Chibuto District, Armindo Thay Carlos said about 3,000 people in the district were enrolled in treatment, which could only be accessed at two health centers.

“It was a very painful situation,” he said of Chibuto, a quiet district about 200 kilometers north of the capital, Maputo. “I remember when I came here, there were patients who used to sleep here, because it was one of the only health centers. Waiting for the next day to do their consultations and then to go back to their homes located at more than 150 kilometers.”

Now 16 health centers offer HIV services and the number of patients on treatment has more than doubled to 7,000. “Basically, the whole district is now covered with the capability to provide treatment,” Thay said.

He credits the government with introducing the national plan, which helped spur the provision of HIV services, but acknowledged that PEPFAR through its provincial partner, the Elizabeth Glaser Pediatric AIDS Foundation, were ultimately responsible for the expansion of services.

That’s the story across Mozambique, where PEPFAR supports nearly 620,000 of the people currently on treatment.

But in both Maputo and in PEPFAR’s head offices in Washington, D.C., there was a growing recognition that if transmission continues at its current rate, it would outpace both PEPFAR’s logistical and financial ability to enroll people in treatment. Already, new guidelines the country looks likely to adopt will swell the number of people eligible for treatment to 1.2 million. And those standards are still below newly released World Health Organization guidelines, which call for all HIV patients to be enrolled on ART as soon as they are diagnosed.

Kebba Jobarteh, the U.S. Centers for Disease Control and Prevention’s care and treatment branch chief in the country, said the PEPFAR team realized, “if we don’t do something right now, then we run out of resources and the problem becomes bigger and bigger and impossible to manage.”

Targeting communities at the greatest risk

Under the new strategy, which was introduced internationally in December last year, PEPFAR will flood areas that have the highest rate of new infections with additional resources and programs — what Jobarteh called “every innovative, evidence-driven intervention we can think of for treatment, transmission, prevention and communication.” Basically, an even more robust version of what has happened in Chibuto over the past three years.

The program will simultaneously target communities at the greatest risk of transmitting, including sex workers and men who have sex with men.

“Given the way the epidemic is transmitted, it makes a lot of sense to focus on high prevalence areas with high density of HIV-infected individuals,” Jobarteh said. “Trying to massively scale up treatment and effective evidence-based prevention interventions in order to maximally drive down transmission.”

A reduction in transmission would eventually allow Mozambique to achieve an HIV tipping point — more people enrolled in a year on treatment than acquire the virus — rendering the epidemic more manageable and, ultimately, leading to its end.

PEPFAR’s new approach has its skeptics. There are few places in Mozambique that do not have a generalized epidemic — that is, at least one percent of the population is HIV-positive. In addition, the population is incredibly fluid, as people move in search of jobs or education.

José Enrique Zelaya Bonilla, the UNAIDS country coordinator, said he is “not sure if, in a country like Mozambique, we would need to do that,” alluding to PEPFAR’s new strategy and arguing that nearly all of the country could benefit from scaled-up services. But then conceded, “Unfortunately, resources are not enough and there’s a need to focus.”

The PEPFAR team in Maputo is quick to point out they will remain in all but a handful of the sites they currently support, even if some do not fall in the new priority districts. Dubbed “maintenance” districts, they just won’t see the same accelerated response in services.

Silvia Matitimel Mikusova, the senior technical adviser for Elizabeth Glaser, said they would see virtually no change in the work they’re doing in Gaza Province, which includes Chibuto. Nine of the province’s 12 districts were marked for acceleration. “There are three very small districts with scattered populations and very few people living there that are nonpriority,” she said. “But still, we have the high maintenance sites in nonpriority districts. We will continue to provide support to HIV services.”

There are 38 PEPFAR-supported sites in the country that are currently providing treatment to less than 30 patients apiece, totaling about 1,000 people. PEPFAR officials said they would be pulling out of those locations by the end of 2017 and passing services off to someone else — most likely the government.

Mozambique’s health officials have largely gotten behind the plan, though the National AIDS Council’s Milagre still harbors some doubts. “Changing in a country like Mozambique entails training people,” he said. “Then changing the paradigm in the operations. And therefore, it’s very expensive.”

With PEPFAR footing much of the bill for the country’s response, Milagre said they ultimately cannot afford to be against the plan. He pointed to a marked reduction in international support for the country’s AIDS program over the past 10 years, which he attributes to both the downturn in the international economy, but also a reprioritization of global health priorities.

At the same time, PEPFAR has actually increased its investment in the country, earmarking more than $330 million for Mozambique in the coming fiscal year, up from $277 million last year. That means the country’s HIV response is even more dependent on PEPFAR, along with the Global Fund, than ever before.

“We have to identify and prioritize and in that we agree with the Americans,” Milagre said. “Through that process, we believe that if we can continue, we can very soon control our epidemic.”

Reporting for this story was supported by a grant from the independent International Reporting Project.

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