With 1.6 million people infected by HIV, or over one in ten adults, Mozambique has one of the highest HIV prevalence in the world. To tackle this public health crisis, the Mozambican government last year launched an ambitious acceleration plan that aims at doubling the number of its HIV positive citizens on ARV treatment.
But this comes with challenges: not only 610.163 people need to be on treatment, but those already taking ARV need to be able to stay in care for the rest of their lives. MSF, in collaboration with health authorities, launched community models of care that have been helping with patient retention.
It’s 7am, and Cacilda Fumo is on a mission: rescuing a patient who abandoned his anti-retroviral treatment (ARV). Supported by crutches, the 53-year-old ambles slowly down the alleys of Xiquelene informal market, among precarious constructions made of bricks and zinc plates.
She slaloms around dirty water and mud flows, proudly wearing a green t-shirt screaming “GAAC”, the portuguese acronym for the Community ART Group (CAG) of HIV positive patients like her that she belongs to.
'My brother abandoned treatment'
Cacilda is like a mentor for the members of hers and other groups, and, as a community counsellor, she takes to heart the wellbeing of other CAG members.
So today Maria João* turned to her to seek help. “My brother abandoned treatment and no longer goes to the medical consultations. I was told that he fell very sick several times recently. His wife died of AIDS and he is living alone right now, I’m not sure where. His son gave up on him because he doesn’t want stay on treatment,” explains the worried sister.
Indeed, Cacilda remembers him. “He participated in a couple of CAG meetings in the community, but suddenly he disappeared,” she comments.
The clinic, the community and now his sister told Cacilda that he is not reachable by mobile phone. So she takes the card identification of the patient with his physical address, given to her by his sister, and goes on a search.
A lot of individual support
From April to July 2014, 5,544 patients on ART from the three health centres in the districts of Kamaxaquene and Kamavota in Maputo dropped out of care. Reasons differ: some drown their despair in alcohol, some misunderstand tests results showing that their treatment is working so well that the virus is undetectable in their blood; because they feel better, they believe that don’t need treatment anymore.
This is where a counsellor’s role is crucial: in a country like Mozambique where most people are not used to having to take drugs every day to tackle a chronic disease, it takes a lot of individual support to provide the patient education that will make them realize that, although HIV can be controlled by modern medication, it cannot be cured but requires a lifelong, daily treatment.
“Unfortunately some people don’t accept they need to go back on treatment and react aggressively. When they feel better they give up ART, but when they get worse they get back on treatment. Unfortunately some of them may die,” explains Cacilda.
'Why did you miss treatment for so long?'
After walking for four hours under the scorching sun along the alleys of Xiquelene market, the two women finally find Maria’s brother in a “senta baixo”, a traditional beer hall. Maria knocks at the zinc door that opens with a grinding sound. Her brother Ernesto is here, drunk in front of his glass of beer, sitting in a chair with other customers in a dark corner.
Maria approaches him. He keeps silent, he is surprised. Then Cacilda takes the card identification of the patient and gently tells him: we are here to help you. Why you are here and why did you miss treatment for so long?
“I gave up because during my last medical consultation the doctor told me that I should take daily injections for two years as I had tuberculosis. I got scared!”, explains Ernesto Valoi.
'The choice is his'
Cacilda intervenes. “I am here to advise you to restart the treatment for living better. Look at me: I’ve been on ART for over ten years, and I’m doing great! God always gives us a hand when we need help, but it is our choice to accept or not”, concludes Cacilda referring to part of the Bible. Ernesto listens to the two women, nods. He now understands: the choice is his to make. Back to treatment, for his own good. He is not alone anymore in his battle against HIV: his sister found him, his counsellor is here for him.
Ernesto restarted the treatment two days after Cacilda found him and is following the regimen so far.
*The name has been omitted as requested by the interviewee.
MSF invented the Community Art Groups in 2008 in Mozambique, in Tete province, which has since then been adopted as national guideline by the MoH and is currently being rolled out throughout the country. Other countries in the region are also copying the model: South Africa, Lesotho, Zimbabwe and Malawi.
This programme encourages patient self-management within a community based peer support network. It was designed to reduce both the need for patients to attend clinics every month to collect ART and the burden on the health facilities. In this programme, groups of patients were established, with patients taking turns to collect antiretroviral medicines for group members.
This means that each group member attends the clinic at least once every six months. Group members have assumed four functions: to collect and deliver ART each month to other members in the community; to provide community-based adherence support and treatment outcome monitoring; to establish a community-based treatment social support network; and to ensure each group member has a clinical consultation at least once every six months.