Maputo, Mozambique — With a shortage of physicians in this country of 22 million and less than a quarter of adults aware of their HIV status, Mozambique’s health officials knew they had to come up with a new strategy to expand access to HIV counseling and testing services. People were being diagnosed late in the course of their illness, and individuals and couples lacked the knowledge they needed to prevent transmission of the virus.
In 2007, with the help of Jhpiego and funding from the President’s Emergency Plan for Aids Relief (PEPFAR), through the Centers for Disease Control and Prevention, the Ministry of Health (MOH) and National AIDS Commission decided on a plan that would enable HIV-positive people to receive care before they fell ill. Through this plan, Mozambicans could take advantage of the prevention benefits of counseling and testing.
The plan centered on training lay counselors, chosen from local nongovernment and faith-based organizations, to provide counseling and testing in the community. The counselors had to be able to read and write in Portuguese, speak the relevant local language for their geographic area and have at least a seventh grade education. They went through two weeks of classroom training plus a four-week practicum with an experienced counselor.
Cesar Francisco Mauinje, from Maputo Province, was among the counselors in the pilot project. “The first one to benefit from the program was me. When I was trained as a community counselor, I learned so much about HIV,” said Mauinje. “I had to let go of many taboos and myths in order to participate in this program…. When we started with the pilot [project], the communities had many doubts about whether counseling and testing was really going to be good for them. They were resistant. But later, as we kept working with them, they came to see the huge benefits to them, and they welcomed us.”
During the pilot phase, 9,094 people were counseled and 8,975 tested; 11.2 percent tested positive and were referred to health units for HIV clinical care. Given the tremendous success of the pilot project, the MOH decided to expand the Home and Community Counseling and Testing for Health program nationwide.
With that move forward, a network of trained lay counselors linked underserved communities in Mozambique with the formal health system. This collaborative effort has expanded critical services rapidly, without further straining the MOH’s already scarce resources.
To date, 230,592 Mozambicans have been counseled and tested for HIV. That’s significant progress in a country where 11.5 percent of adults and 13.5 percent of pregnant women are living with HIV, among the highest prevalence rates in the world.
To appreciate the achievements of this nationwide program, it’s important to know that as recently as 2003 only three percent of adults had ever been tested for HIV. The program is among 36 that will be highlighted at the 2nd Global Forum on Human Resources for Health in Bangkok, Thailand in January 2011.
The MOH favors integrated programs and quickly recognized the role community counselors could play in assessing the health care status of the people they serve. Since beginning this initiative, community counselors have taken on greater responsibilities. They were asked to also check for tuberculosis and educate residents on hypertension, malaria and diarrheal diseases.
“This program has helped us break many taboos in the community,” said Julião Fenias Boane, Coordinator of the Christian Council in Cabo Delgado Province, one of the participating nongovernmental organizations (NGOs). “For example, many people still thought that an HIV diagnosis meant that the person would die soon. This program has helped change that. Also, in our communities there has been a taboo regarding epilepsy. People thought that children with seizures could not go to school. But the counselors help explain that children with epilepsy can indeed participate in the community.”
The Home and Community Counseling and Testing for Health program has since been expanded to all 10 provinces of Mozambique. There are 163 counselors and 11 supervisors working with the Jhpiego-supported NGOs. Between September 2008 and August 2010, they provided health and HIV education and counseling to 307,756 people. Of those, 230,592 were tested for HIV, many of them as couples or families.
The counselors also referred 47,212 people to government health facilities for suspicion of tuberculosis based on screening questions, elevated blood pressure, HIV testing and a variety of other health problems, ranging from fever and diarrhea to seizure disorders.
This program demonstrates that NGOs can effectively partner with government health systems to expand the health workforce and provide lifesaving services at scale, increasing access for rural communities. The goal now is to continue to expand the program while strengthening follow-up systems to ensure that clients referred to the health units get the diagnostic and care services they need.
“For us as a congregation, it [the program] was a tremendous leap forward because it gave us the chance to save lives. Each person counseled and tested started to take care not just of themselves but of others, according to their serostatus,” said Sister Susana of the Franciscan Sisters in Maputo Province. “When we detect HIV early it ensures that people can live longer and healthier lives. [This program] also helped us to work much, much closer with the health system, including not just the health facilities but also the district and provincial health authorities. By talking to people as families rather than individuals we can break the fear of learning their HIV status.
“It helps unite the families. They are stronger and they can take precautions for their health. For couples it helps them to support each other. It breaks the silence.”