Integration of HIV/AIDS treatment into primary health care in Mozambique: A health system strengthening approach

Context:

Mozambique initiated national scale-up of anti-retroviral treatment (ART) in 2004 through a vertical “day hospital” model using large separate facilities in population centers. Thousands were placed on ART quickly. However, constraints soon became apparent: a) day hospitals were reaching capacity, b) HIV/AIDS resources did not strengthen the wider system, c) linkages with key services, such as TB treatment and antenatal care, were weak, d) loss to follow-up was a growing challenge, and e) geographic coverage was limited.

Approach:

In 2006, the Ministry of Health and Health Alliance International, a U.S.-base NGO, initiated an effort in two provinces to integrate ART into the existing primary health care system through health units distributed across 23 districts. Integration included, a) placing ART services in existing units, b) retraining existing workers, c) strengthening laboratories, testing, and referral linkages, e) expanding testing in TB wards, f) integrating HIV and antenatal services, and e) improving district-level management.

Outcomes and Challenges:

By December 2007, treatment was available in 60 facilities in 23 districts across the two provinces; 17,000 patients were on ART; and 80,000 enrolled in the program. Loss to follow-up improved dramatically, average time from testing to ART initiation declined, and treatment adherence was best at integrated sites. The integrated approach led to greater investment in laboratories, infrastructure, and human resources which strengthened the PHC system.

Key recommendations:

To improve ART scale-up and strengthen health systems, NGOs, donors, and Ministries should support ART integration into national primary health care systems and avoid vertical scale-up models.