The antiretroviral treatment lottery

If you are an HIV-positive Mozambican in need of antiretroviral treatment (ART), life can resemble a lottery, in which your chances of accessing the life-prolonging medication depend on the region, or even the district, where you live.

If you live in Maputo, the nation's capital, you may be in luck. Of the 32,000 Mozambicans receiving treatment by December 2006, 40 percent were living in the capital; just one percent were living in the northern province of Niassa.

As of August 2006, according to government data, 60.5 percent of people accessing ART were living in the south of the country, 32 percent in the central region, and 7.5 percent in the north.

These figures do not reflect the geographical reality of HIV prevalence in Mozambique. Infection rates are actually higher in the central region - 20.4 percent - than in the south, where prevalence is estimated at 18.1 percent; prevalence in the north, at 9.3 percent, is the lowest.

The imbalances reflect the obstacles to making treatment available in the country's most remote districts, which are mainly in the northern and central provinces.

The amount of money pouring into Mozambique to combat AIDS does not match its capacity to absorb and spend those funds

Just as economic development has been concentrated in the south, most hospitals and health professionals are also based in the three southern provinces: Maputo, Gaza and Inhambane.

"We need additional personnel to expand services in places where access to HIV/AIDS services is poor," said Dr Alfredo Mac-Arthur Junior, head of the epidemiology and endemic diseases department at the Ministry of Health.

Regional inequalities are also evident in the capacity to conduct a CD4 count (which measures the strength of the immune system), an essential requirement for starting patients on ART and monitoring their progress. Of the 10 laboratories in Mozambique that do CD4 count testing, six are in the south.

"We need to create a large centre for testing in each region of the country," said Jose Casanovas, a pharmacist at the Viral Immuno-diagnostic Unit at the Eduardo Mondlane University Medical School, in Maputo.

Laboratory technicians could be better utilised if they were spread around, added Casanovas, who estimated that he had conducted over a thousand CD4 tests in the last five years.

UNAIDS put the number of people in Mozambique currently in need of ART at 230,000. The government failed to meet a target of reaching 55,000 people - 3,500 of them children - with treatment by the end of 2006, but there have been some improvements.

Between July 2005 and 2006, the number of people on treatment rose by 54 percent, with a greater increase in the northern and central regions than in the south. In October 2006, Prime Minister Luisa Diogo announced that ART would be expanded from 80 district capitals to 128 in 2007.

Poor absorption of resources

As in the rest of Africa, a national ART programme for Mozambique was only a dream until a few years ago. Since then, various international commitments and declarations, combined with an influx of international donor funds, have meant that financial support is no longer the principal barrier to rolling out the treatment.

According to government estimates, contributions for ART and health-system strengthening from the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank, and the Clinton Foundation will total more than US$300 million in 2007. In addition, the United States government, through the President's Emergency Plan for AIDS Relief, had invested $94 million in Mozambique's AIDS response by September 2006. United Nations agencies and non-governmental organisations (NGOs) have donated further resources.

But the amount of money pouring into Mozambique to combat AIDS does not match its capacity to absorb and spend those funds. The numerous donors multiply the need for reports, monitoring, evaluations and visits, overloading weak public institutions and local NGOs.

In April 2006, the government and seven principal donors - Canada, Denmark, Great Britain, Ireland, Sweden, the World Bank, and the Global Fund - created a common fund, managed by the National Council to Fight AIDS (CNCS), to channel money into Mozambique's AIDS fight. The goal is to reduce overlapping efforts, simplify reporting and accounting procedures, and encourage group visits to projects.

Ivo Correia, UNAIDS project coordinator, complained that international donor agencies, NGOs, and the government all shared the same goals but competed to produce the best results and failed to communicate with one another. "It's a war of flags," he said.

Meanwhile, the government's decision to make AIDS a national priority has paralleled the development of civil society groups and a multitude of NGOs, which are still gaining experience and exploring independence in their interactions with government.

"The partnership between the government and civil society is inefficient," said Ana David, national coordinator of the Mozambican network of AIDS organisations (Monaso), which has more than 300 members.

Monaso has developed courses to help its affiliates improve their management and project-monitoring skills but, according to Diogo Milagre, vice-executive secretary of CNCS, many NGOs still lack efficient accounting systems. CNCS has contracted two international accounting firms to evaluate the financial management of local NGOs.

dm/ks/he