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Improving Health through Evidence-based Local Solutions Around the World
Tailoring Local Solutions to Control the HIV Epidemic in Mozambique
It was, Paula Manual thought, a routine antenatal appointment at a local clinic. It wasn’t. The 27-year-old mother of two emerged with an unexpected diagnosis: HIV positive. The community sprang into action to help.
After the visit, the clinic assigned her a “mentor mother,” who coached Paula through the emotional process of disclosing her diagnosis to her husband, Armando. A community health worker and lay counselor together visited the couple at their home, testing Armando and their two children. Armando tested positive, while the two children were negative. That was not the end of it. “When I took the HIV test, the mentor mother gave me all the support so that I could continue with the treatment and actively participate in the prenatal consultations,” said Armando, who is taking antiretroviral therapy (ART). “Because of that, my wife and I had a healthy baby.”
Credit the Christian Council of Mozambique (CCM), a community-based organization in Sofala province that deploys community health workers to link patients and health facilities, even bringing services directly to families when the need arises. CCM’s partnerships with health facilities ensure high-quality and empathetic counseling and clinical care. During Paula’s pregnancy, the family received frequent visits from their mentor mother, who offered consultative and emotional support to both Paula and Armando. Once their son was born, the couple administered medicine to their newborn and brought him to at-risk child consultations.
CCM can provide these crucial services thanks to technical and financial support from the Abt-led USAID Efficiencies for Clinical HIV Outcomes (ECHO) project, which began in 2019 when many of those living with HIV were abandoning treatment and identifying them was a challenge. ECHO supports basic care and treatment for people living with HIV and strengthens community capacity for outreach, treatment, and counseling.
This collaboration shows how community-level localization works. ECHO partners directly with CCM and other community-based organizations to train and deploy mentor mothers and community health workers. We also support these organizations on administrative functions—from budgeting to human resources activities to prepare for eventual direct donor funding.
The results were remarkable as treatment drop-outs and mother-to-child transmission rates declined precipitously from 2019 to 2022. In Sofala, where CCM operates, patient drop-outs plummeted from 15 percent to 1.4 percent of Sofala’s active patients per quarter. Across ECHO-supported provinces, we saw these quarterly numbers fall from 15 percent to just 1.7 percent. Positivity rates for at-risk children whose mothers were diagnosed with HIV dropped by nearly 50 percent, from 5 percent to 2.6 percent.
At the community level, ECHO empowers health workers to test eligible members of their community, engage in follow-up to ensure that at-risk patients start and maintain treatment, and connect with their family members and sexual partners to offer them testing services. The strategies require an immense level of trust, and community-based organizations are well placed for this work.
ECHO isn’t working only with community organizations in its localization approach. It also collaborates with local government entities trying to control the HIV epidemic, such as the Provincial Health Directorates (DPS), Provincial Health Services (SPS), and the Ministry of Health (MOH). ECHO’s collaboration with the SPS, notably, is evolving towards local self-sufficiency. The project has transitioned from providing simple in-kind grants to these local health departments to standard grants, which come with robust procurement, financial management, and technical support that is embedded directly in SPS offices and offers a path toward greater stability and autonomy.
ECHO also worked with the MOH to implement differentiated service delivery models, a recognition that patients in different situations need different care. The models include intensive and non-intensive models. Intensive models require monthly visits to health facilities while non-intensive models allow patients with stable health conditions to visit facilities less often.
A key change was expansion of three- and six-month drug distribution and community-based distribution. The COVID-19 threat and concerns about crowded health facilities prompted a change in the requirement that limited ART prescriptions to one month of medicine. Many patients simply couldn’t get to distant facilities monthly. When the MOH considered expanding a policy to allow more patients to get three months of prescriptions at once, ECHO provided crucial clinical evidence that supported the case for expanding the popular policy. Years later, the MOH is now transitioning patients to six-month distribution after seeing the model’s great success.
The results were dramatic. Enrollment in the six-month program in Tete skyrocketed from 172 to 17,112 in about eight months. A six-month supply led to an 83 percent decline in unnecessary clinic visits, a reduction in overcrowding at facilities, and a lightening of the load for overworked staff.
More importantly, after just a few months of offering differentiated services, ART adherence shot up and the number of treatment dropouts plummeted to record lows. In early 2020, for example, three-month retention was just 78 percent in Tete province and 70 percent in Niassa. By July 2022, that figure shot up to 99 percent in Tete and 96 percent in Niassa. Both provinces also saw steep drops in patients leaving treatment. In a single quarter, the number plunged 94 percent, from 10,210 to 632, in Tete, and 70 percent, from 2,175 to 648, in Niassa.
More patients staying on treatment means more people living productive and healthy lives with a greatly reduced chance of passing HIV to others. All of this shows the strengthened capacity of Mozambique’s national and provincial government entities and community-based institutions and workers to lead efforts to stem the spread of HIV.
LEARN MORE: Controlling the HIV Epidemic in Mozambique | Caught Between HIV+ and Climate Change: Mozambique’s Cyclone Victims Maintain Treatment Through Community Support
PROJECT: Efficiencies for Clinical HIV Outcomes
CLIENT: U.S. Agency for International Development (USAID)
We work with communities and the local government to make our approach effective. We set a goal of hiring at least 50 percent women and achieved it. We collaborated with local leaders to hire people from the community where we are supporting larval source management. Homeowners are more receptive to community members rather than strangers coming into their homes.
The good news is that the data show that over time, larval and pupal density have dropped. This means fewer immature mosquitos are making it to adulthood where they can infect people. But unanswered questions remain. For example, other factors, like environment or weather, could have played a role in the density reduction. But it’s likely the intervention was effective because through our surveillance, we found higher larval densities in nearby locations where there was no intervention.
Has larval source management reduced malaria cases and mortality, the ultimate goal? It's too soon to tell. However, our work in Ethiopia is paving the way for the global response to An. stephensi, which is critical, considering some estimate this mosquito has the potential to put upwards of 120 million additional people at risk of the disease.
That’s not the end of our sleuthing. PMI VectorLink conducted modeling to predict where the vector’s presence could spread from the areas in Ethiopia that provide a suitable climate for its survival. The modeling will have to evolve as the mosquito’s behavior changes, particularly because this mosquito species is adaptable and might continue to change. “That’s why this vector is such a challenge,” says Matt Kirby, PMI VectorLink Entomology Director. “It’s less predictable than the more established malaria vectors in Africa.”
Our entomologists worldwide are on the case, keeping tabs on this new threat with national malaria programs in dozens of countries under PMI VectorLink and the new PMI Evolve project. And we will adapt our approaches as needed to protect communities and make further progress toward eliminating the malaria scourge.
LEARN MORE: Climate Change, Malaria, & Data: Getting Ahead of the Spread | Spotlight On: Climate and Health
PROJECT: U.S. President’s Malaria Initiative VectorLink Project
CLIENT: U.S. Agency for International Development (USAID)