EGPAF is a global advocate for public policies benefitting women, children, and families living with and affected by HIV and AIDS. Advocacy efforts place a special emphasis on policies that ensure the availability of effective HIV prevention services for pregnant women and mothers and quality care and treatment for children and families affected by HIV and AIDS. EGPAF works with the Government of Mozambique, private partners, and other stakeholders to:
- Educate and mobilize communities about HIV/AIDS;
- Assist in the development of policies related to prevention of HIV; and
- Contribute to the creation of national strategies and guidelines associated with HIV/AIDS care and treatment.
Fortalecer Project: Technical Assistance to the Ministry of Health for HIV Services and Program Transition
Through the Fortalecer Project, EGPAF continues to support the Ministry of Health (MOH) to strengthen the implementation of prevention of mother-to-child transmission of HIV (PMTCT) and care and treatment services at more than 250 PMTCT and 67 antiretroviral therapy (ART) sites in four regions of Mozambique: Maputo, Gaza, Cabo Delgado, and Nampula. The project has the following objectives:
Strengthening the Basics: Provincial Health Systems Strengthening to Support High Quality HIV/AIDS Prevention, Care and Treatment Programs
- Increase access to and delivery of high-quality, cost-effective HIV prevention, care, and treatment services
- Build capacity of the health system at all levels to provide client-focused health services
- Strengthen data analysis and use to improve quality of service delivery and health management
- Ensure sustainable HIV prevention, care, and treatment service delivery through MOH and local partners; in 2012, two provinces were transitioned to EGPAFs local affiliate (Fundação Ariel Glaser)
The goal of this project is to build organizational and management capacity (including human resources management, planning, and financial management) in order to provide comprehensive HIV prevention, care, and treatment services within a strengthened health system in four provinces: Maputo, Gaza, Cabo Delgado, and Nampula. Specific activities include:
- Support of a working group with members from the Ministry of Health (MOH) Departments of Planning, Administration and Finance and EUROSIS (a private sector organization development firm)
- Developing a capacity assessment tool for Provincial Health Directorates (DPS)
- Conducting a preliminary capacity assessment of the DPS’s planning, financial, and administrative management capacities based on data, procedures, common practices, and expectations of the MOH/DPS
Helping Expand Antiretroviral Treatment for Families and Children (Project HEART)
Project HEART was launched in 2004 in Côte d’Ivoire, South Africa, Tanzania, and Zambia, and in 2006 in Mozambique. This eight-year project, funded through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. Centers for Disease Control and Prevention (CDC) saw dramatic results. In 2010, one out of every 10 PEPFAR-supported ART patients in sub-Saharan Africa received their treatment through Project HEART. By early 2012, more than one million men, women, and children received HIV care and support; more than 2.5 million pregnant women received HIV counseling and testing; more than 66,500 pediatric HIV infections were prevented; and more than half a million people started lifesaving antiretroviral therapy (ART). Working with a network of more than 215 international and local partners, Project HEART dramatically improved delivery of HIV/AIDS services and ultimately strengthened national health systems by:
- Supporting HIV prevention, care, and treatment services at more than 510 ART sites and 1,053 PMTCT sites throughout five countries
- Building the clinical, managerial, financial, and administrative capacity of local health providers and partners to more effectively provide HIV services
- Strengthening program and data quality
- Improving the technological and physical infrastructure of health facilities
- Providing sub-awards to local partners and Ministries of Health at the district and provincial/regional levels, in coordination with capacity building
Project HEART’s innovative practices – most notably using a decentralized district approach, scaling up performance-based financing, and piloting new, easy-to-use technology – have served as best practices that have been authorized and disseminated by Ministries of Health and other implementing partners.
Project HEART expanded EGPAF/Mozambique’s prevention of mother-to-child transmission of HIV (PMTCT) and care and treatment activities to include services in labor and delivery wards, postnatal care, child welfare clinics, inpatient pediatric wards, and support for the care and treatment of both adults and children. Approximately one-third of all PEPFAR-supported ART patients in Mozambique received their treatment through Project HEART. In fact, EGPAF/Mozambique exceeded initial project targets for patient enrollment in care and ART initiation by 27 percent.
Call to Action
With funding from the United States Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), EGPAF implemented the eight‐year Call to Action (CTA) project in 12 countries, including Mozambique (from 2004 through 2009). This project sought to improve access and expand care and support for quality prevention of mother-to-child transmission of HIV (PMTCT) services, while enhancing technical leadership and documenting successful program models. By project end, EGPAF had provided nearly four million women with access to PMTCT and antenatal care services.
Through the CTA PMTCT project in Mozambique, EGPAF initiated activities in Mozambique’s Nampula and Gaza provinces, supporting nine health centers and serving as an incremental partner to the Ministry of Health’s (MOH) national PMTCT roll-out program. By the end of 2009, with USAID’s support, EGPAF had expanded to support PMTCT services in the four provinces of Cabo Delgado, Nampula, Gaza, and Maputo to a total of 164 health facilities. With the closeout of the CTA project in 2009, EGPAF-supported PMTCT activities were transferred and expanded through the CDC Track 1.0-funded Project HEART, a multi-country EGPAF initiative funded through a cooperative agreement with CDC/PEPFAR.
Increasing Access to HIV Care and Treatment for Children and their Families
Under this agreement, UNICEF provided funding to expand HIV services to four additional districts in Cabo Delgado, and while these districts were eventually included in EGPAF’s flagship Project HEART program, UNICEF continued to provide integrated technical support tailored to the needs of the province. Activities implemented with UNICEF funds focused on building capacity within the Provincial Health Directorate (DPS) to both manage and scale up clinical services, with particular emphasis on prevention of mother-to-child transmission of HIV (PMTCT) and pediatric care and treatment services.
EGPAF strengthened nutritional and psychosocial support for HIV-infected children and their caregivers through technical support and training at the site and district levels. Once HIV services in Cabo Delgado also were funded by PEPFAR, UNICEF continued to fund certain distinct activities with the following specific objectives:
- Improving follow-up of HIV-exposed and HIV-infected infants and young children
- Improving access to quality HIV care and treatment services for HIV-infected infants and children
- Improving access to psychosocial support for children in care and treatment and their caregivers
By project end, the results of supported services in Cabo Delgado included:
Exploring Facilitators and Barriers to Participation of HIV-Exposed and HIV-Infected Children in Care and Treatment Services in Two Provinces in Mozambique
- The cumulative number of patients enrolled in care since the beginning of the program is 20,507, of which 1,274 were children (6.2%).
- A total of 7,907 persons initiated antiretroviral therapy (ART), of which 460 (5.8%) were children.
- In the 11 health facilities where EGPAF supported PMTCT services, a total of 337,176 pregnant women were counseled in antenatal care and of those 261,181 (77.5%) were tested.
Despite improvements in HIV pediatric care and treatment programs in Mozambique, engagement and retention of HIV-exposed and HIV-infected children in these services remain challenging. To explore the reasons behind these challenges, EGPAF conducted a qualitative study in August 2011 – January 2012 to identify barriers to HIV testing, enrollment into care, and follow-up services for HIV-exposed children in Mozambique.
Four participant groups―parents/caregivers with an HIV-exposed or infected child, grandmothers, healthcare professionals providing pediatric HIV services, and community leaders―were recruited from seven health facilities and surrounding communities in Maputo City, Maputo Province, and Cabo Delgado Province to participate in this qualitative study. Interviews and focus group discussions were conducted with these groups, and a resource inventory of pediatric services at these facilities was undertaken. Transcripts were transcribed and translated into Portuguese (for interviews conducted in local languages), and qualitative data was coded and analyzed.
Some of the most frequently reported barriers to engaging children in HIV services were alternative care-seeking due to perceptions of traditional or spiritual causes of disease, disbelief in positive test results, fear of death, and a general lack of willingness to attend facilities. In contrast, the facilitating factors most often cited by participant groups include children displaying visible illness, having hope for children’s future, perceptions that the facility was the appropriate place for HIV care and treatment, relationships with healthcare professionals, and institutional factors such as free services and medications and service integration. Further analysis will enhance our understanding of these factors, including the similarities and differences among participant groups and regions and any gaps or weaknesses in the provision of pediatric services at study facilities. Findings will result in recommendations for improving the engagement of children in HIV programs in Mozambique. Prior to this research, barriers and facilitators specific to engaging and maintaining Mozambican children in HIV care had not been systematically evaluated.
The abstract for this study was accepted to the 4th International Workshop on HIV Pediatrics in Washington, D.C. in July 2012. A manuscript to be submitted to a peer-reviewed journal is also being prepared.
Field Evaluation of Point of Care Technologies in Maternal and Child Health (MCH) Services and in the Prevention of Mother-to-Child Transmission of HIV (PMTCT) Program Project Period
Provision of optimal maternal child health services requires the availability of laboratory diagnostic capacity to identify maternal conditions that may negatively impact health without intervention. In Mozambique, most pregnant women will visit the antenatal clinics at least once, but many do not return for further visits. It is thus imperative to provide as many of the necessary laboratory services as possible during that initial visit. The development of point-of-care (POC) technologies for various laboratory tests provides the opportunity to conduct testing during the time of the visit, permitting implementation of necessary interventions during the patient’s visit.
Three POC laboratory tests that may significantly impact maternal child health include tests that screen for maternal anemia, syphilis, and CD4+ T-lymphocyte enumeration. Implementation of interventions based on abnormalities identified using these three tests can dramatically improve the health of the pregnant woman, as well as decrease the risk of morbidity and mortality to the infant, including the prevention of vertical transmission of HIV from mother to infant.
This study evaluated the feasibility and acceptability of introduction of three POC technologies for diagnosis of syphilis, hemoglobin, and CD4+ T-lymphocyte enumeration within the mother-to-child services. In addition, the study will assess the impact of the availability of test results on implementation of appropriate clinical responses to abnormal results, such as provision of supportive treatments for women identified with anemia, appropriate administration of antibiotics for syphilis infection, and initiation of antiretroviral therapy among HIV-positive pregnant women identified as eligible for treatment. Study findings will be used to guide optimal placement and usage of POC instruments to support maternal child health and PMTCT service delivery.
Reaching More in Need: PMTCT Enhancement through Expanded Implementation and Operations Research
(The Bill and Melinda Gates Foundation: 2006–2011)
The Bill and Melinda Gates Foundation funded this project, which was designed to expand access to prevention of mother-to-child transmission of HIV (PMTCT) services in 10 countries including Mozambique to allow EGPAF to fill critical gaps, ensure continued service delivery in resource-limited countries, and leverage other donor resources to increase access to PMTCT services. As part of these efforts, EGPAF/Mozambique implemented a research study to determine maternal seroconversion of HIV during the pregnancy and breastfeeding period, and to describe associated risk factors. Results of this study will contribute to designing prevention programs targeted for this population. The research was implemented from 2008 to 2011. Final analysis is ongoing, and final results are estimated to be available in early 2013.