The spectre of HIV looms large over Mozambique. More than 2 million Mozambicans are estimated to be living with the disease, and only just over half are on treatment. Increasing this coverage will be a serious challenge: it’s not just that many won’t test for the disease, they won’t even talk about it.
“People are afraid,” Francisco Mbofana, president of the National Council for Combating Aids (Conselho Nacional do Combate ao Sida, CNCS), told Zitamar News. “There is still a misconception that a person with HIV should be isolated to prevent the spread of the virus … It is because of this discrimination that many people prefer to pretend that they are well just to be welcomed in families, either avoiding treatment or taking it in secret, which does not always work.”
The normalisation of HIV status within Mozambican society is one the last major barriers to controlling the epidemic, now that testing and treatment is available for free at around 1400 public health facilities across the country. Anyone living with virus, regardless what stage it is at, is eligible for antiretroviral drugs, or ARVs.
Political and economic leaders speaking out about how HIV has affected them or their families could go a long way to addressing the stigma around the disease, as has been shown in other countries, but there is no public discourse in Mozambique.
“We have cases of leaders infected with the virus, who live normally because they follow the treatment,” said Mbofana. “They could very well appear in public and encourage people, but it has not been easy because discrimination on the basis of this disease is not just a matter of small communities – it is a problem of our society as a whole.”
CNCS has worked with musicians and actors on their national TV and Radio awareness campaigns, and is working with traditional and religious leaders – authority figures who have in the past been known to discourage patients from taking ARVs – to try to change attitudes at a community level.
“We will continue to educate until the disease is seen in the same way as diabetes or high blood pressure. This is our challenge,” said Mbofana
Keeping girls in school
But tackling HIV means more than changing attitude towards the disease in Mozambique; it requires changing attitudes towards women.
The spread of HIV among adolescent girls and young women – the group most at risk to new infection – is closely linked to low education rates, poverty and domestic violence.
Keeping girls in school through educational subsidies, offering cash transfers to vulnerable women, and support to parents – as well as improving understanding of and access to contraceptives, Pre-Exposure Prophylaxis and HIV treatment – have all been shown to be effective in the reducing infection rates in this group, according to the DREAMS initiative – an $385 million partnership between the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), Johnson & Johnson, Bill & Melinda Gates Foundation, Girl Effect, Gilead Sciences, and ViiV Healthcare.
In Mozambique, this also mean looking at ways to tackle child marriage or the practise in urban and peri-urban areas of young girls sleeping with older men – known as ‘ministerios’ – who help sponsor, or fund, specific needs in their lives, such as healthcare or education.
If girls can find economic empowerment and take control of their reproductive health, “we can decrease the need for sponsorships and…the likelihood of young women having these relationships with potentially older and multiple sexual partners,” said Benjamin Isquith, division chief for HIV and Aids at the US Agency for International Development (USAID) in Mozambique.
US AID is also is also working out how to make sure that these sexual partners regularly test for HIV – and those that test positive stick to a treatment programme.
“Retention and adherence is really important because if you take your meds every day consistently, you can make the virus more or less go to sleep – you are virally suppressed and then you won’t be able to transmit the virus, which is the goal,” Isquith said.
But treatment retention is low in Mozambique, particularly among men. Around 30% of people who start treatment drop out after 12 months, according to CNCS statistics.
Poor retention rates are a concern not only because it increases the risk of the disease spreading, but increases the likelihood of patients becoming resistance to first line drugs.
There are many reasons people stop treatment: some because after a few months of taking medication they feel better, others because of the long distances to get to clinics – or the poor services they receive when they are there, with long queues and dismissive staff. Others stop because of the stigma that comes with taking ARVs.
PEPFAR has been working with the government on various initiatives to make it easier for men to access services, whether through workplace testing, testing as part of the voluntary medical male circumcision programme, or through offering more male-friendly services at clinics or extended clinic opening hours.
Once patients have been regularly taking treatment for six months, other treatment options are open to them, such as multi-month scripting, community ART distribution, or visits by mobile brigades to bring drugs directly to them.
Mozambique is still aiming for the United Nation’s 90-90-90 goals – a concept introduced in 2013 that by 2020, 90% of the people infected with HIV should be diagnosed; 90% of the people who are diagnosed should be on ARVs, and 90% of those on ARVs will be virally suppressed, the state when the virus in an HIV-positive person’s blood is reduced to an undetectable level.
Mozambique is currently around 57-54-72, according to PEPFAR estimates in September 2018.
It won’t hit its 90-90-90 target by 2020, “but it could by 2023”, says Isquith.
In the meantime, PEPFAR plans to get more than 300,000 more people on treatment by the end of September 2019, which will increase treatment coverage to around 80%.
It has stepped up its funding to Mozambique to help meet this target. Last year’s annual budget was $394 million, the programme’s largest contribution to Mozambique since its inception in 2003.
However, domestically CNCS faces a funding crunch. Mozambique’s financial crisis has meant swingeing cuts to the health budget, which have meant doctors’ and nurses’ salaries, and medical suppliers, have gone unpaid, affecting services across the country.
CNCS only receives around MZN 150 million a year from the government, so is heavily reliant on external funding to support its programmes, Mbofana told Zitamar.
“[But] what has happened lately is that resources for prevention and awareness-raising activities for social change have been shrinking globally, and this has an impact at the national level,” says Mbofana.
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