© Tomás Munita

MSF IN MOZAMBIQUE 2001-2010 :Ten years of HIV projects

Introduction
In the late 1990s, the introduction of antiretroviral (ARV)
treatment transformed AIDS from a death sentence toa chronic lifelong disease. However, the extremely highcost of ARV drugs meant that treatment was restricted
to people in richer parts of the world, and the millions ofpeople suffering from the disease in places like Africa
remained untreated. National and international decision
makers actively refrained from embarking on the fightagainst HIV/AIDS, believing that an insufficient budget
and a scarcity of both technical means and human resources would lead to inadequate HIV care and management. Their fear was that this would ultimately lead to theemergence of widespread drug-resistant strains of thevirus, which would exacerbate an already dire situation.
Médecins Sans Frontières (MSF) – determined that theplight of people with HIV/AIDS in African countries would
not be ignored – has been working with HIV in Mozambique since 2001, where it has been helping the Ministryof Health develop a comprehensive plan for widespread
provision of ARV treatment. During the first few years,
around half of all patients on treatment were supported
by MSF. MSF’s objectives were to demonstrate that it was
feasible to provide ARV services in low-resource settings,
to explore possible modes of operation and to help create a national capacity for treating people with HIV/AIDS.
At the time, the organisation of the Mozambican healthsystem needed to be adapted to allow the development ofcomprehensive ARV treatment programmes, in terms ofhuman resources (both numbers and skills), laboratory
capacity, technical means, and the overall managementof HIV/AIDS. MSF has spent a total of 58 million Euros on
its HIV/AIDS activities in Mozambique since 2001, of which
the majority comes from private funding.

12

http ://www.misau.gov.mz/pt/hiv_sida/programa_de_tratamento_
antiretroviral_tarv/dados_tarv_nacionais.

© Tomás Munita

The number of patients on treatment has risen dramatically over the last few years. At the end of August 2010,
more than 200,000 patients were on ARV treatment inMozambique1, of whom more than 33,000 were being
treated with the assistance of MSF. The growing numberof patients on treatment shows that the scale-up and provision of ARV treatment is indeed possible in a country
like Mozambique. MSF has helped to put HIV/AIDS firmly
on the national health agenda and, along with the Ministry of Health, has developed innovative strategies for HIV
care and management. This report details MSF’s workand achievements in Mozambique in the field of HIV/AIDS
over the last ten years, as well as pointing to the challenges that lie ahead.

Five sites, three contexts
MSF made the decision to invest in a number of projects based in different locations, in order to be able to explore
innovative solutions adapted to specific contexts and population groups.

Lichinga
AngoniaTete

The sites where MSF has been active can be classified
into three main categories :Urban context
MSF started its HIV/AIDS activities in the Chamanculo
and Mavalane districts of Maputo in late 2001. The
Maputo metropolitan area is one of the most prevalentareas of HIV/AIDS in the world, partly due to its
large migrant population, which includes miners,
commercial sex workers and economic refugees.
MSF is currently supporting five health centres in the
Chamanculo district and four health centres in the
Mavalane district.

Semi-urban context
Maputo (Mavalane andChamanculo districts)

MSF has been working in the city of Tete and its
surrounding districts since 2001 Tete is enjoying an
economic boom, driven by the discovery of reserves ofnatural resources in the region, which have attracted
large numbers of migrants. The influx of people hascreated a breeding ground for the burgeoning HIV/AIDS
epidemic. In 2007, ARV treatment was decentralised
from hospitals to health centres, and MSF’s project
was extended to two more districts. Project activities
were subsequently reoriented towards training,supervision and running mobile teams. As of 2011,
the project will focus on the implementation andmonitoring of a number of community-based patientgroups which are aimed at empowering patients topartly manage the disease by themselves.

Rural context
MSF works in rural Angonia (in central Mozambique)and Lichinga (in the north of the country). Rural areas
characteristically have a lower HIV prevalence thanurban areas, but have more severe shortages of healthstaff. This shortage contributes to the very limitedaccess to health & HIV/AIDS services for people living
in rural contexts.
3How MSF’s HIV activities have evolved
Over the years, MSF’s activities in Mozambique have evolved and changed. This evolution can be characterised in five main
steps, from an initial period when ART implementation in low-income countries was widely considered unfeasible, to the current situation where the Ministry of Health is developing the capacity to take over a complete set of HIV/AIDS interventions withpartner support.

Initiation (2001-2002)
This was the period when treatment first became
available for HIV/AIDS patients in Mozambique. Curative care mainly involved treating and preventing opportunistic infections, and treating sexually transmitted infections. HIV/AIDS programmes at this time were
reinforced by the development of Voluntary Counselling and Testing (VCT) centres, which have played an
important role in persuading individuals to take HIV
tests and in reducing the stigma associated with thedisease. The VCT centres were supplemented by information, education and communication services.
Prevention of mother-to-child transmission (PMTCT)
was also being piloted. This era provided MSF with theleverage to lobby for the adaptation and scaling up of
ART programmes in Mozambique.

special attention paid to tuberculosis (TB) co-infections.
The programmes were complemented by measures
to tackle issues such as shortages of health staff
and drug procurement issues, as well as improving
laboratory capacity. Psychosocial activities were also
extended, with lay counsellors providing support toVCT activities and helping patients adhere to theirtreatment. During this period, the price of HIV drugs
plunged dramatically from US$10,000 per patient per
year to just US$100 per patient per year, enabling
many more people to start receiving treatment.

Scale-up and decentralisation (2005-2008)
As patient numbers increased, hospitals became overwhelmed and waiting lists were introduced. This createdan obstacle to guaranteeing good quality treatment. It
also became harder to start people on treatment, especially in peripheral areas where there were no hospitals
close by. As the number of patients grew, moving HIV
care and treatment from hospitals to primary healthclinics became a necessity. As a result, the Ministry of
Health launched an ambitious plan in 2006 to expand thenational capacity to provide ARV treatment, and to decentralise patient cohorts from hospital to health centre
level. Between 2005 and 2008, the number of treatmentsites for HIV/AIDS rose from 20 to 220.

Curative care and implementation of ARV
treatment (2002-2005)
MSF started providing free ARV treatment inMozambique in 2002. The treatment programmes
were developed in line with the Ministry of Healthprotocol, and also drew on MSF’s experience inother African settings. The programmes establisheda standard package for HIV care and treatment, with

Number of Patients on ART 2002 - 2010
250,000
200,000
150,000
100,000
50,000
0
2002

2003

2004

2005

2006

MSF in collaboration with Ministry of Health

4

2007

2008

2009

Ministry of Health / others

2010Quality consolidation (2007-2009)
A variety of activities were conducted to improve thequality of services provided to people living with HIV/
AIDS. MSF was progressively moving away fromdirect, hands-on treatment, towards adopting a role
which included technical support, human resource
strengthening and the integration of activities with the
Ministry of Health’s workforce and guidelines. This
resulted in initiatives that included training medical
personnel to handle difficult cases and deal with side
effects, and developing innovative models of care,such as Community ARV Treatment Groups, whereby
patients were enabled to help manage their own
treatment of the disease.

Phase-out preparation and reorientation of
HIV/AIDS activities (2009 onwards)
MSF’s project support in Tete, Angonia and Lichinga will be handed over to the Ministry of Health in2010 and 2011. However, MSF will still be involvedin the Tete province, implementing and monitoring
community ARV treatment groups. MSF’s medical
activities in Chamanculo and Mavalane will carryon, and MSF will continue to work with the Mozambican health system to address the challenges thatlie ahead. Particular focus areas include improving
PMTCT services, integrating TB and HIV services,
creating one-stop services for pregnant women, andimplementing new WHO protocols.

Isabel Maria Francisco, 43

5© Tomás Munita“My name is Isabel Maria Francisco and I am 43 years old and HIV-positive. For two years I have beenworking with MSF as a counselor to prevent Mother-to-Child Transmission of HIV in Maputo city. In
the past, I suffered a lot from discrimination in my community but now things are changing. People havestarted to understand that HIV/AIDS can be treated.”Addressing the HIV problem :progress and innovation
HIV prevalence among the adult population in Mozambique is estimated at 11.5 percent in a recent Ministry of Healthstudy2. Although there is currently no cure for HIV/AIDS, adherence to ARV treatment helps slow progression of thedisease to a near halt, enabling people to live longer, healthier lives. MSF’s comprehensive HIV/AIDS programmes offer : HIV testing, with pre and post-test counselling ; the treatment and prevention of opportunistic infections ; paediatricdiagnosis and treatment ; the prevention of mother-to-child transmission ; and the provision of ARV treatment for people
in the advanced clinical stages of the disease. At the end of August 2010, more than 33,000 people in Mozambique werebeing treated for HIV/AIDS with MSF’s assistance.

2

INSIDA,

Support to HIV-positive children
and mothers
HIV prevention of mother-to-child transmission(PMTCT)The vast majority of children with HIV have been infected by their mothers, either in the womb or in thecourse of childbirth or breastfeeding. Working to prevent this transmission from mother to child is crucial,
yet access to PMTCT treatment remains extremely
limited nationwide, especially in rural areas, wheretraditional home-based deliveries remain the norm.
MSF is involved in helping Ministry of Health staff
improve the quality of PMTCT treatment, and has put
in place a strategy to improve treatment adherence
among HIV-positive pregnant women. A one-stop
service has simplified procedures for women who
come for consultations.

Treatment
Treating babies who are born with HIV as early as
possible is known to have a significant impact on
reducing mortality. An increasing number of babies
and children receive ARV treatment in Mozambique.
Between 2003 and 2009, the number of children receiving ARV treatment increased from 300 to 13,510(representing an increase of 0.3 percent to 19 percent
of all children in need of treatment)3. Yet 47,000 out ofan estimated 147,700 HIV-infected children4 were still
without ARV treatment in 2009.

Counselling for children© Niklas Bergstrand

Children treated by MSF receive counselling sessions
in which their HIV-positive status is explained anddiscussed in a sensitive manner. HIV infection and its
consequences are also explored through fairytales anddrama sessions based on local folklore and African an-

62

INSIDA, 2009 Relatório Preliminar sobre a Prevalência da Infecção por
HIV, July 2010. NOTE : Prior to this study, official sources estimated the HIVprevalence to be at 16%.

3

UNGASS – The United Nations General Assembly Special Session dedicatedto HIV/AIDS. Progress report, 2010. Mozambique.
Impacto Demográfico do HIV/SIDA em Moçambique. September 2008.

4

Management of co-infections
The weakened immune systems of HIV-positive people
make them prone to ‘opportunistic’ infections such as
TB, which remains the leading cause of death amongpeople with HIV. MSF is supporting the Ministry of Healthin TB activities in five projects throughout the country,
by enhancing laboratory capacity, providing training
and technical support to health staff, and introducing
measures to reduce the risk of infection in healthfacilities. MSF is also working to raise awareness of
HIV/TB co-infection, providing counselling sessions to
discuss the transmission and symptoms of HIV/TB andrunning patient support groups.
In Angonia, MSF has developed a model whereby designated community members are responsible for checking that HIV patients are taking their TB medication regularly and in the correct way. These community members, also known as ‘DOTS volunteers’, play a supportrole for TB-infected HIV patients ; they are responsiblefor identifying and referring people with suspected TBinfection to the health centre, and also trace defaulting
patients. The introduction of the DOTS volunteers meansthat the patients do not need to visit the health centres asoften, therefore reducing the burden on the health services and the financial and economic cost to the patients.

Patient empowerment and a reduced
burden on the health system
MSF is increasingly working on developing models ofcare whereby patients are empowered to manage thedisease in part by themselves.
In MSF’s project in Tete, patients are divided into groups ofabout six, all of whom live near each other. Each month, thegroup chooses one person to go to the health centre andcollect the ARV refills for the rest of the group. The representative usually takes the opportunity to have a medical
check-up while they are there. On their return, the representative distributes the ARV drugs to other group-members, who confirm that they have received the medication bysigning a document. The representative also checks that all
the members of the group have been adhering to treatment,so that this information can be relayed to the health centre.
This model of care has a number of distinct advantages.

It has led to a reduced burden on healthcare services, as
fewer patients need to queue up at the health centre to gettheir medication. It has the potential to facilitate the scalingup of ARV treatment. It also makes it simpler for patients inremote areas to obtain their ARV refills, as they only haveto pay for transport for the designated group leader, anddo not need to sacrifice a day’s work each month to travelto the health centre. Finally it enables group members to
support each other in overcoming problems related to thestigma associated with HIV/AIDS. The model has been
accepted as national policy by the Ministry of Health who isplanning to introduce it nationwide.

© Niklas Bergstrand

imals. MSF-supported health facilities have been mademore child-friendly with the introduction of educational
tools, colourful wall paintings and playgrounds. The
improved quality of care for children has facilitated thescaling up of treatment for this age-group.

Margarida Smith was diagnosed with HIV in2006 and is the leader of two patient groups.

‘I live in a village outside the city of Tete. Other
people know that I’m HIV-positive, but I’m notworried or ashamed of my disease. MSF encouraged me to help others with HIV. I am now
the leader of one of MSF’s HIV patient groups. My
role is to collect medication at the health centre
and distribute it to the others in the group. Before, each member used to pay 100 meticais totravel to the health centre and back. Now, eachmember pays me seven meticais, and I bringthe medication to their house. The patients in thegroup appreciate this, because many don’t haveenough money to travel to the health centre. It’s
great to be able to help others to take care of theirillness. I’m taking medication, but I am healthy
and working like other people. I want other HIVpositive people to join me and enjoy life.’
7

Expert patients
A number of patients who have demonstrated good
adherence to their treatment and a commitment to helping
other HIV-positive people have been encouraged by MSF
to assist in the areas of health promotion and prevention,
tracing defaulting patients, providing adherence support,
and leading support groups and therapeutic educationalsessions. These expert patients’ have played an importantrole in breaking down taboos and showing that it is possible
to live a normal life as an HIV-positive person. They havecontributed to reducing the stigma that surrounded thedisease during the early years of HIV treatment.

Psychological support
Patients who are anxious or depressed often find it hardto adapt and adhere to their treatment. To help tackle
the adverse effects of negative emotions, MSF offers
psychological support to patients. Those suffering fromdepression and anxiety are seen by a psychologist andoffered psychotherapy. Patient support groups, where
patients can share emotions and experiences with theirpeers, also provide an additional means of support.

Strengthening health information
systems
MSF has developed the FUCHIA system, a database tool
which enables analysis of the HIV cohort. MSF has also
developed an adherence card system, containing thepersonal data of each patient, as a means of improving
the routine monitoring and tracing of patients, and of
identifying problem areas that may lead to patientsdelaying or dropping out of treatment.

Reinforcing drug supply
MSF has supported improvements in the drug supply
chain, mainly through construction and building
upgrades, but also by providing staff with training on stock
management and drug consumption. In instances when
there have been drug shortages in the national system,
MSF has provided support in the purchase of drugs andmedical material.

Tackling Human Resources
Shortages
In order to address shortages of staff, MSF has developeda system of task shifting, whereby non-clinical tasks are
re-allocated from doctors to nurses, and from nurses tolay workers. This allows doctors to focus on providing
hospital care for inpatients and the most complicatedcases, while supervising clinics via mobile teams, andhanding over some of the clinical management of patientsto nurses. Nurses no longer exclusively support doctors,
but are able to independently assess patients, diagnose
and treat opportunistic infections, and initiate and monitor

8

ARV treatment. Lay workers are able to provide testing
and counselling, to provide treatment adherence support,
and to assist with general clinical support.
MSF has also developed a number of other innovative
approaches, in partnership with the Ministry of Health, forattracting and retaining health workers. These include :• “Retired but not tired” : This scheme aims to reintegrate
retired nurses and clinicians into the health service on
health facility contracts funded by MSF.
• Reducing attrition on health staff : HIV is a growing
cause of falling numbers among health staff. As aresult, MSF provides ARV treatment for all its healthworkers who are infected with HIV/AIDS.
• Bridging contracts for newly graduated staff : Newly
graduated and appointed staff members often have to
wait up to 18 months before receiving their first salary.
Bridging contracts, in the form of a cash advance by
MSF, mean that new staff are not forced to quit theirjobs through financial hardship.
• Expatriate staff : MSF helps to plug the humanresources gap by employing expatriate staff for
specific periods of time in specific locations. In 2008,
international medical doctors represented morethan 26 percent of all medical doctors working inMozambique5.

Contributing to Developmentof National Policy
MSF and the Ministry of Health has been working together
on developing planning and policy in the field of HIV/AIDS and on the development of innovative approaches.
Through these collaborations, MSF has contributed to
the larger national policy development process, as in
the development of clinical protocols and drug regimen
guidelines.
MSF has taken an active part in technical working groups,
sharing and discussing key lessons learnt with otherstakeholders. MSF helped to found – and is currently
on the board of – NAIMA+, which is a network of nongovernmental organisations working on health and HIV/AIDS in Mozambique, and which acts as a link between
NGO work and government decisions.

5

Mozambican Ministry of Health, Human Resources report, December 2008

© Tomás Munita

Remaining challenges for Mozambique
In addition to bringing HIV/AIDS onto the national political scene, MSF has played a significant part in exploring innovative
ways to provide comprehensive HIV/AIDS care services in resource-limited settings. In most cases, national authorities
and other stakeholders acknowledge the positive impact of these strategies.
However, MSF’s model of care is not a prescriptive cure for all problems, and there are some significant remaining challenges
to be addressed on a national level. More than 350,000 people in Mozambique are in need of ARV treatment but do not haveaccess to it6, which equates to two-thirds of all HIV-positive Mozambicans not receiving the treatment they need.
Below are some specific problem areas that need to be addressed in the future.

Funding6

Relatório de P

MSF has recently started to observe a worrying turnaround among the international donor community. After
years of political willingness and financial commitment tocombat HIV/AIDS, donors are now either flatlining, reducing or withdrawing their funding for HIV, thus abandoning
those who are still in dire need of lifesaving treatment.
Donors have increasingly voiced concerns regarding
the cost, sustainability and relative priority of HIV/AIDS,
against the background of an ostensible lack of funds.
This donor retreat will not make the numbers of people
in need of lifesaving treatment simply disappear. Instead
they are likely to increase, with a resulting impact on families, communities and the healthcare system as a whole.
If funding is not forthcoming, it will also be impossible toimplement the new, improved WHO guidelines, which
recommend improved drug regimens and earlier initiation of treatment.

The global economic crisis, which began in 2008, is expected to result in a decrease in support to Mozambique’s
general health budget from US$85 million in 2010 to
US$70 million in 2012, which is certain to have an impact
on HIV care and treatment. Although countries like Italy
and Canada will increase their funding for the health sector in Mozambique, France and Finland, for example, plan
to discontinue their support in 2011. The Global Fund, thelargest international contributor to the fight against HIV/
AIDS, is also facing a funding shortfall, which will makeit a lot harder to drum up support for the scale-up of HIV
treatment.7 As of 2010, the US will decrease direct support
for ARV treatment by 15 percent8.
6
7
8

Relatório de Progresso de Actividades de Combate ao HIV e SIDA –Iº Semestre de 2010, June 2010 and WHO website, www.who.int
Mozambique’s Mid Term Expenditure Framework (MTEF) for 2009-2011 forthe health sector, all funding included.
2009-2014 PEPFAR II Partnership Framework, August 20109

Barriers to accessing treatment
HIV-infected people continue to face major barriers in theiraccess to services, even in a context of free treatment. Although figures from December 2009 show that every district in the country now has at least one site where patients
can access ARV treatment, many patients still face long andexpensive journeys to their nearest health facility.
The proportion of patients defaulting from treatment needs
to be reduced. The main reasons for abandoning treatment
include clinical staff lacking the time to provide effective
counselling, the cost of making monthly trips to distantclinics, and lengthy waiting times for clinical consultations
and obtaining drugs at the pharmacy.

Human resources gap
Efforts to increase patients’ access to treatment andmaintain and improve the quality of care are coming
up against a wall due to the severe shortage of healthworkers. With only 3 doctors and 143 nurses per 100,000
people, Mozambique has one of the lowest workforce per
population ratios in the world9.
Understaffed facilities are overwhelmed by patient numbers, health workers are put under pressure, and patientsend up waiting in long queues. Low staff salaries lead topoor motivation, short working hours, and frequent absenteeism amongst staff. The main cause of health worker
attrition is death, with a significant proportion attributable
to HIV/AIDS10. Apart from increasing the health workforce,a challenge for the next few years will be to implement
measures such as task shifting amongst staff in order tomake optimal use of the available resources.

Drug availability and procurement
ARV drugs are provided by the Ministry of Health in morethan 220 health centres. Drug procurement remains oneof the main weaknesses of Mozambique’s public healthsystem, which affects HIV/AIDS services. The main causes
are inappropriate orders, delays in the procurement andverification chain, and insufficient staffing and infrastructure. For example, since 2008, there have been significant
delays in the disbursements of grants by the Global Fund,which have resulted in drug stock-outs and delays in the
procurement.

Resistance to TB drugs
More and more people with HIV/AIDS are contracting drugresistant forms of TB, either as a result of treatment failure
or by coming directly into contact with the resistant formof the TB bacteria. The rapid rise in drug-resistant strains,particularly in southern Africa, is a major cause for alarm. A
2007 survey showed the prevalence of multi drug-resistant
TB in Mozambique to be 3.4% among new cases and 12.5%
among re-treatment cases.11 The rise of drug-resistant
9
10
11

10

WHO, World Health Report, 2006
MSF, Help Wanted report, 2007
WHO document: «Country Cooperation Strategy: Republic of Mozambique 2009 - 2013

strains poses a serious problem, due to a lack of available
treatment and diagnostics, complicated treatment procedures, expensive drugs, and serious side-effects which
frequently result in patients defaulting from treatment.

Luis Júnior Mariquele, 38

Luis Júnior Mariquele is a38-year-old Mozambican who
lives in Mateque, in Maputo
province. Mariquele and hiswife are both HIV-positive,
and have been receiving ARV treatment throughMSF for the last eight years. Luis remembers
what his life was like before starting ARV treatment :“I frequently used to get sick, and lost a lot ofweight. One time I spent five days at the Central
Hospital of Maputo. I could not even speak – I
was unconscious. My family thought I was dead,but the doctor verified that I was still alive because my heart was still beating,” says Luis.
But everything changed when the doctor put him
on ARV treatment.

“Antiretroviral drugs have changed my life fromnegative to positive. Without them, I would not
be on this planet. I have not had a single major
health problem since I started taking them. They
have saved my life,” he says.

José Carlos, 44“My name is José Carlos andI am 44 years old. I was diagnosed as HIV-positive in 2008.
In the same year I started antiretroviral treatment (ART) in
the Malhangalene Health Centre. Before
starting treatment, I used to feel physically weak
and tired. Nowadays I live an active, normal
life. I believe it is important for people to knowthat HIV-positive people can work and practicesports like I do.”Conclusion
The situation in Mozambique today is very different fromten years ago, when MSF began treating HIV patients in the
country. The cost of HIV drugs has dropped enormously,
the number of people on treatment is increasing eachday, the quality of treatment and care is improving, andthere is less stigma associated with the disease.

© Tomás Munita

Yet many challenges remain. Two-thirds of Mozambicans
who need ARV treatment are still unable to get the
medicines that would save their lives. Although MSF
will be handing over some of its project activities tolocal health authorities in the near future, MSF willremain in Mozambique and will continue to work with
the Mozambican health sector to address the many
challenges that lie ahead.

11© Benjamin Bechet12© layout : www.okidokidesign.net