Alicic 1

Zero HIV/AIDS Cases by 2019: A Goal Report for Mozambique

Hana Alicic Dr. Danuta Kasprzyk Honors 391 A 1 June 2012

Alicic 2 Epidemiology: Over the course of 16 years, Mozambique suffered through a civil war that led to the deaths of 1 million of its citizens.1 The peace that followed was broken by a new and potentially more devastating disaster that threatens over 1.4 million Mozambicans today: HIV.2 In 2009, 11.5% of all adults aged 15-49 were infected with the virus and 74,000 deaths occurred in that year alone.3 Though incidence peaked at 1.8% in 2001 and has since tapered off to a rate of approximately 1.1%, the epidemic does not show signs of slowing.4 Successfully ending the transmission of HIV will require a deep understanding of the dynamics of the virus transmission. HIV may be spread primarily via heterosexual contact, but the factors behind its transmission extend beyond sexual intercourse to include biology, behavior, economics, and social norms.5,6 Geographic and societal differences in rates of infection, hidden by the overall prevalence values, reflect the complexity of factors influencing transmission. For 2009, USAID identified these differences by noting high rates in urban areas (15.9 percent) compared to rural areas (9.2 percent); along transportation corridors; and among women (13.1 percent) compared with men (9.2 percent).2 Mozambiques different regions also show greatly contrasting rates of infection; a 2009 survey found that while the north had a prevalence of 8%, the central region showed and 18% prevalence and the south showed a still greater 21% prevalence.2 These differing rates of prevalence can likely be attributed to movements of populations. In the central region, the 18% prevalence likely results from the return of approximately 2 million refugees, temporarily living in neighboring countries with high HIV rates, following the end of the civil war as well as movement on transport corridors linking Mozambique to Zimbabwe and Malawi.6 The souths

Alicic 3 high prevalence rates likely result from men working in the mines of South Africa for long periods of time.6 The correlation of these mens extended absences to high rates of HIV is the product of behavioral norms as well as gender inequalities. With a wife at home in Mozambique and another wife or partner in South Africa, migrant miners regularly expose both themselves and their partners to infection. Therefore, even within marriages, women are left vulnerable to infection, leading one former prostitute to state that a woman with a husband is in much more danger than a girl in a brothel.7 Concurrent sexual partnerships such as this have been identified as increasing risk of infection by introducing new pathways for transmission (a phenomenon though to be a major driver of the continued spread of HIV in Africa) and are common throughout Mozambique.8 Other high-risk activities include widow cleansing (a male relative has sex with the wife of a deceased family member), early sexual initiation, intergenerational and transactional sex, and the practice of dry sex.9 The individuals most as risk due to these practices are female are most often young. Women are at greatly increased risk for contracting HIV due to the interplay of a number of factors including social norms, poverty, and lack of education. Though the higher prevalence of HIV among women likely results in part from female biology and susceptibility to the disease, it is assuredly exacerbated by a multitude of cultural and social factors.9 In essence, women receive insufficient education, leaving them unable to support themselves economically and reliant on men for survival. Already in a subservient position to males, women are left with little influence in protecting their own general health, much less their sexual or reproductive health. Poverty that impedes girls from attaining basic needs like food and school fees has been identified as the driving factor behind girls vulnerability.10 In some cases, girls are used to

Alicic 4 generate income for the family via prostitution.10 Others take on affluent sugar daddies, resulting in polygamous relationships and the exposure of larger numbers of people to infection.11 Because females engaging in transactional sex and more likely to have unprotected, concurrent partnerships with older men, they are more vulnerable to HIV infection. Overall, multiple partners, transactional sex, and intergenerational sex common in Mozambique greatly contribute to the disproportionate infection levels among Mozambican women.11 Increasingly common, rape of women and especially girls is linked to the spread of HIV/AIDS.12 The culmination of these factors is the fact that the majority of HIV-positive adults are women. The disparity is especially visible in those 20-24 years of age: in this cohort, 22% of women and only 7% of men are infected.14 Since women are often infected at earlier ages, females lose more life years than men.12 Similarly at risk are young people. Half of Mozambiques population is under the age of 15, so any risky behaviors or lifestyle choices among the youth greatly impact the epidemic as a whole; the highest infection rates in the country are seen among those 20 to 24 years of age (18.3% in 2003).2,15 Among pregnant women, prevalence levels remained at a relatively constant 15% from 2002 to 2009.2 Approximately 85 babies are infected with HIV by their mothers each day, either through pregnancy, delivery, or breastfeeding.16 Commonly carried out for 18 to 24 months in Mozambique due to the cost of alternatives, breastfeeding carries a 15% risk of transmission.16 As a result of high rates of infection, Mozambique is home to 670,000 orphans as well as 130,000 HIV-positive children ages 0 to 14.2,3 Most of these children reside in areas most drastically affected by the epidemic and while such most were once taken in by extended family networks, the AIDS epidemic has strained families so that they are no longer able to do so.2

Alicic 5 Continuing the cycle of infection, orphaned children remain without a caretaker and often leave school to earn money or care for siblings, leaving them vulnerable to exploitation and possibly to infection.2 Though rates of HIV infection in Mozambique appear relatively low when compared to those of neighboring countries, these countries once had similar statistics during the early and mid 1990s but later experienced great expansions of the epidemic.12 Perhaps Mozambique is currently faced with a window of opportunity that can be taken advantage of in order to prevent the devastation seen in other south African countries.12 Treatment coverage, goals, costs: With poor roads, limited means of transportation and a scarcity of clinics leaving over 60% of the population unable to access health services, many Mozambicans remain undiagnosed and untreated.12 In spite of these barriers, the number of people with access to antiretroviral therapy (ART) has been gradually expanding. The country has set a goal of universal access, or coverage of over 80%, by 2015, but considerable improvements are left to be made.17 Only one third (170,198) of the 570,000 who needed ART in 2009 had access to the therapy; by 2011, the number had increased to 51.7%.12,17 Among children, the number able to access ART lags behind that of adults, posing an important threat to the goal of universal access. Though the 20% coverage of children with ART by the end of 2011 was an improvement over the 14% coverage seen in 2009, increasing commitment to treating children is required.17, 18 Among adults receiving ART, in 2009 63% were women while 37% were men.18 Coverage, much like the epidemiology of the disease, remains uneven throughout the country, with adult coverage in the countrys north and center at approximately 30% and coverage in the south at 65%.2

Alicic 6 Much progress has been made since the creation of the first National Strategic Plan to Combat HIV/AIDS (the National PEN of 2000-2002), which focused mainly on prevention due to the high cost of ARV treatment.14 Subsequent plans have included efforts to spread ART. The second PEN II of 2005-2009, for example, placed new emphasis on the care and treatment of people living with HIV.14 The coverage of HIV treatment, though still low, reflects, as one Doctors Without Borders coordinator states, an increase in awareness among the population.19 This may be due to new trends in ART treatment including decentralization and integration into the health network system so that more HIV-positive individuals are able to access treatment.2 In May 2009, ART services were provided in 216 health centers throughout Mozambiques 11 provinces, though many remained unable to access services and the expansion strained the limited health infrastructure.20 These expansions of treatment are irreplaceable in fighting the epidemic and though prevention efforts can be very successful, they cannot end the transmission of HIV unless coupled with treatment. In 2004, the Ministry of Healths ART expansion program was largely funded by outside sources in a movement that likely saved tens of thousands of lives and hundreds of thousands of disability-adjusted life-years.20 PEPFARs contribution in 2010 led to the treatment of 138,800 individuals with ART (PEPFAR). Of the $41.85 million spent on care and treatment in 2008, 21.237 million was spent on ART.18 Since the first line drugs used to treat HIV/AIDS cost $140 per person per year, approximately $80 million would be needed to treat the 570,000 in need of ART.6 This expansion of treatment is unlikely to occur, however, as the $1 billion pledged by America over the next five years will not account for the increasing need for expanded treatment.21 Furthermore, ensuing Mozambiques ability to treat its citizens is

Alicic 7 blocked by multiple factors including a lack of human resources, poor infrastructure and relatively centralized access to care, high stigma, poverty, and limited education.20 Similarly to many other African countries, Mozambique faces a significant lack of human resources. The civil war of the late 20th century destroyed much of the public health infrastructure, leaving the country vulnerable to the AIDS epidemic. There are currently only 4 doctors and 21 nurses per 100,000 people, an extremely low rate even when compared to neighboring counties (South Africa, for instance, has a 1:215 nurse to patient ratio compared to Mozambiques 1:5000 ratio).12,20 Rural hospitals are normally staffed by one doctor while rural health centers are staffed by one or two heath staff; in the Zambezia province, one or two physicians are expected to serve 150,000-400,000 people so that most services are ultimately delivered by clinical staff and nurses.20 In some cases, clinicians see as many as 70 patients in one morning.22 The situation is not projected to improve as current production of health care workers is far too low to achieve sustainability in a primary health care program focused on increasing the number of persons accessing the system.20 From 2004 to 2006, the amount spent on human resources and retention did not change despite and increasing need for a national response to the epidemic.14 Because sustaining treatment in Mozambique will require the transition of services from emergency foreign partners to local authorities, the increased training of health care workers is crucial.20 One potential idea is the creation of schools to train nurses and other health care workers that target women, thus increasing the number of human resources and providing women with economic opportunity. The lack of health care personnel leads to significant weaknesses in treatment. One UN employee framed the problem succinctly when he stated that when we have a physician only twice a week, things get complicated.15 The burden placed on those currently employed can be

Alicic 8 great, with low salaries and poor living conditions often decreasing morale and performance.20 Furthering the problem, only 11,000 of the 17,000 health care workers in Mozambique are trained and the ability to provide accurate information on AIDS and to treat opportunistic infections remains low, suggesting the need for continued education.12 Overworked health care staff and poor access to health facilities hinder the development of patient-centered care and strong relationships between patients and providers.22 As a result of such factors, users of HIV/AIDS services perceive them to be low-quality and mistrust remains an important issue in the population.12 One tactic to mitigate the impact of low number of personnel uses a strategy once employed in Thailand so as to increase the number of women on the Pill: nurses and other health care workers could be trained to prescribe ART so as to increase ease of access.7 Mozambiques government has recognized the impact of low human resources and has put in place a goal of training 2,267 health workers and supporting the increase of community health workers between 2009 and 2013.2 The goal has already seen successes, with 757 health workers trained in 2010 alone.2 Identifying ways to increase the sense of ownership that health care staff and Mozambicans in general have about their heath will only increase the sustainability of those changes currently being made to the health care system.20 For the treatment of AIDS to be successful, a much greater emphasis must be placed on training and educating health care workers. Though expansions of clinics have occurred throughout Mozambique, poor infrastructure and centralized care continue hamper the expansion of treatment. Because travel distances to access ART services can be over 100 km, bringing care and treatment closer to those who need it is key improving adherence rates since.20 The concentration of resources in urban centers (such as Maputo) leads to the neglect of those in rural areas. Mozambique has recognized that the

Alicic 9 number of people lost to follow up on ART is beginning to become an issue and indicates the need for greater understanding of peoples access and use of health service facilities.14 Laboratories similarly suffer from poor infrastructure and as a result are often limited in their diagnostics ability and are at times are ineffectual. Because of Mozambiques centralized system and poor supply chain management, stock-outs are commonplace and patients are often unable to attain essential supplies and medicines.20 Additional barriers to treatment surround the issues of stigma, poverty, and education. The stigma surrounding AIDS delay or prevent many from accessing treatment so that testing and treatment only occur in later progressions of the disease.20 Reduction of stigma may occur by increasing access through treatment scale-up.20 Social support for the ill and increased campaigns for awareness could also effectively reduce stigma. Due to weaknesses in the education system, new ways must be identified to educate patients about their disease and to encourage adherence to treatment.20 Mozambique has recognized the systemic barriers to access and has invested in public health infrastructuresupply chain procurement systems, and country health information systems.2 One potential solution to current barriers in treatment is a modified directly observed therapy (mDOT) system in which peers are employed and supervise the administering of medications. In one study using mDOT in the administering of highly active antiretroviral therapy (HAART), adherence averaged 98% when such a system was used.22 If peers are trained to provide accurate information about AIDS, ensure adherence, and enhanced access for patients, the issues of poor infrastructure, lack of health care workers, stigma, and education can all be addressed. Combining mDOT with other support interventions, especially community support, could further bolster its impact.22,23 For the effective treatment of AIDS patients in Mozambique

Alicic 10 to take place, innovative programs that address multiple health system barriers, monitor adherence, and elicit national support to control HIV/AIDS must first be put into place.22 Bolstering the administration of ART is crucial to reaching the goal of zero transmissions: treatment reduces by 96% the odds that an HIV-positive person will transmit the virus to a sexual partner.40 Furthermore, treatment can result in economic returns of 87% to 287% by increasing productivity, decreasing the number of orphans, and averting medical care.40 The expansion of ART treatment will require continued funding as well as education campaigns to increase knowledge, more human resources capacity, decentralized and improved infrastructure, and community support. Prevention: Mozambiques government has attributed the nations recent declines in incidence to a focus on prevention efforts. With the release of the National Strategic Plan III came the Strategy for the Acceleration of Prevention of HIV Infection (2009-2010), a plan consisting in part of eight priority areas: biosafety, counseling and testing, sexually transmitted infections, male circumcision, prevention of mother to child transmission, condoms, most at risk populations, and treatment.2 While successes did occur in the targeted areas, gaps nevertheless continue. Pushing back against the preventative efforts, the effects of stigma, discrimination, and gender roles further add to the struggle with AIDS. Biosafety, specifically the ensuring of a safe blood supply, has increased from 2007 to 2011, with quality assurance of tested blood increasing from 35.5% in 2007 to 69.4% in 2011.17 Reducing the prevalence of HIV in blood supplies remains a challenge as the prevalence in the population is high and the recruitment of low-risk donors is difficult.17

Alicic 11 Testing and counseling, by informing individuals of their HIV status and providing them with needed aid, help to both minimize the spread of the virus and to increase education and behavior change. They are the gateway to treatment. Prevention programs providing testing and counseling to Mozambicans increased their reach from 1.1 million people in 2009 to 2,961,099 in 2011.2,17 Though approximately 88% of men and women in urban areas know where testing occurs, in 2010 only 17% of women and 9% of men 15-49 had been tested and received results, indicating a need to reemphasize the importance of knowing ones HIV status.17 As testing is seen as the responsibility of women, more women than men have accessed testing services.15 One potential method of further expanding coverage is Mozambiques Community Counseling and Testing for Health strategy, which relies on trained community members to disseminate messages about health education.17 The hope is that by increasing community ownership, counseling messages will be more effective and stigma will be reduced. Testing and counseling serve as opportunities to both educate on sexual and reproductive health and, if needed, to refer patients to needed treatment for tuberculosis, malaria, diabetes, and, crucially, STIs. STIs, very prevalent in the population, facilitate the transmission of HIV, and HIV in turn increases the difficulty of treating some STIs.5 At any given time, 11% of Africans suffer from untreated bacterial genital infections.7 One 2007-2008 study showed a high prevalence of STIs in HIV-positive individuals during their first care visits, with 86.8% of men and 94.8% of women infected with the herpes simplex virus-2.9 Acknowledging the positive correlation between STI infection and HIV infection, Mozambique has directed its attention to the prevention, detection and treatment on STIs. Diagnosis and treatment remains limited, however, due to a lack of human resources and medicine.17 STIs may constitute an underutilized aspect of

Alicic 12 prevention, as public health experts widely acknowledge that one of the most cost-effective ways to treat HIV is to provide free checkups and treatment forSTDs.7 Male circumcision constitutes another biomedical intervention, one that is hugely effective and that could reduce the risk of HIV transmission by 58%.25 Though 40,280 Mozambican men were counseled and circumcised from 2010 to 2011, the creation of a strategy for male circumcision remains a challenge.17 By circumcising 80% of men and newborn males by 2015, Mozambique could prevent 300,000 adult HIV infections from 2009-2025 and save over $1.5 billion.26 As with many aspects of the AIDS epidemic in Mozambique, circumcision rates vary from province to province. While the number of circumcised men stands at 59.5% of males 15-49 nationwide, variation across provinces results in local rates ranging from 8-21% to 88-95%.26 Targeting those provinces with the lowest rates and encouraging continued circumcisions among provinces already engaging in the practice would prove a boon to the prevention of HIV infection. In hopes of preventing HIV infection in a new generation, Mozambique places an emphasis on the prevention of mother to child transmission (PMTCT). Without such services, 25-48% of pregnant would pass the virus on to their children either during pregnant, childbirth, or breastfeeding.9 Since Mozambique lies fourth on the list of 16 countries contributing 60% of the global number of women living with HIV, PMTCT constitutes vital part of preventing the transmission of HIV.17 As a result, the expansion of PMTCT services has become a priority so that prophylaxis and treatment regimens to pregnant women as well as better follow-up with exposed infants can occur.2 Via ART, infants can be protected from infection at each stage of their early development. When given to a woman during pregnancy and delivery and to an infant after birth,

Alicic 13 antiretroviral prophylaxis sharply reduce[s] the likelihood of a mother passing HIV on to her baby.16 Increasing recognition has also been given to the effectiveness of prophylaxis in reducing HIV transmission during breastfeeding.17 Highlighting Mozambiques stress on PMTCT, in 2011 the nation set the goal of reducing the number of new infections to 5%, achieving 90% coverage of women with services, and ensuring that 30% of HIV-positive mothers had access to ART by 2015.17 Such efforts have been seeing increasing success. While only 4,641 pregnant women received counseling and testing in 2002, the number increased to 366,281 women in 2007 (each year saw an average total of 800,000 pregnancies.)16 By the end of 2010, 86% of health facilities had access to PMTCT services.17 Access to ART, however, remains an issue: of the 65,963 HIV-positive women eligible for ART in 2010, only 6,944 received the therapy.17 Though the number increased to 8,643 in 2011, considerable work remains to be done.17 Though much improvement remains before the goals of 90% coverage and 30% access goal are reached, the situation has drastically improved when compared to a decade ago. Part of the success of testing may be attributed to the Ministry of Healths (MOH) opt-out approach to testing, which by making testing routine increases its frequency.16 Because early detection of infection is vital to the health of an HIV-exposed child, the MOH plans to expand the use of necessary PCR tests.16 An additional strategy for the PMTCT is increasing womens access to and utilization of birth control so as to minimize unwanted pregnancies do not occur in the first place. Another key aspect of prevention is the use of condoms. In one study, a third of Mozambican teenagers had not practices abstinence in the past month, indicating the need for the emphasis on the c of the ABC model.27 Their use is also vital because 10.3% of Mozambican couples are discordant and each year 10-12% of discordant couples will transmit HIV to the

Alicic 14 negative partner.5 One study found that the percentage of people aged 15-49 who had more than one sexual partner in the past 12 months reporting the use of a condom during last sexual intercourse was only 22% for men and 23% for women.18 Despite being one of the simplest forms of preventing infection, their use remains inconsistent. This low rate of use may be in part due to a belief that relationships based on ideals like love and trust will not require the use of condoms. Additionally, if women are valued for their ability to produce children and to please their husbands, condom use may not occur even when fear of infection exists. Additional barriers may be due to positions of clergy members: in one study a pastor stated that he would not educate his congregation about condoms because using a condom is sinful always.28 While most as risk populations are defined youth in and out of school, long-distance truck drivers, women with low levels of education, migrant workers and their wives, sex workers and their clients, police, military, people with STDs, street children and orphans, and PLWHA, the term serves as a catch-all phrase than encompasses more targeted forms of intervention within subgroups.12 Two key groups are youth and women. Mozambique is a youthful nation: approximately half of the population is under the age of 15.15 Due to the early imitation of sex among youth, the benefits of delayed sexual initiation and condom use are especially important for adolescents.9,18 Furthering the need for programs targeting youth is the fact that Mozambicans tend to underestimate personal risk markedly.9 Currently, the ABC model of modifying personal behavior is used in campaigning to youth: the model centers around reducing sex among teens (abstinence), reducing the number of partners and encouraging monogamy (be faithful) and promoting correct and consistent condom use.9 Prevention efforts occur both within schools and without. The Ministry of Education and Culture has created a strategy to define key areas for curriculum surrounding HIV/AIDS,

Alicic 15 including life skills education.29 Corners of counseling also exist in schools with the aim of providing information and condoms as well as other services.17 The efficacy of these efforts is questionable, though, as in one study only 53% of children 10-14 years of age knew what AIDS was.30 Efforts outside of schools include mobile units stocked with educational and communication materials, community theaters that raise awareness about topics relevant to HIV/AIDS, and the child-to-child media network that, in all 11 provinces, involve children and youth in developing and presenting TV and radio programs.29 One barrier to dispersing information is the fact that many Mozambicans live in rural areas where over half of the population is illiterate and over half of households do not own a radio.29 In these areas, drama, music, and interpersonal communication are the most effective means of communication.29 Youth-friendly service venues have been increasingly successfully, reaching 13 million youth 10 to 24 years of age in 2007 and 3.6 million in 2008.2 Though the level of knowledge among youth has increased in recent years, significant behavioral changes have not followed suit, indicating the need for more programs to effectively encourage youth to adopt health changes in behavior.29 Any such change must be reinforced by a society that encourages the attitudes and practices. Orphans, a significant subset of youth, are at increased risk for contracting HIV due to higher levels of poverty and lower levels of education. The ratio of orphans to non-orphans attending school was 0.91 in 2008, up from 0.47 in 2003.18 However, support for orphans falls short of current needs and should be increased so as to decrease vulnerability among the population.12 Because so many HIV infections occur among women, prevention efforts must address the factors leaving them vulnerable, including lack of education, lack of economic opportunity,

Alicic 16 and social norms. Mozambique tripled elementary school enrollment from 2 million to 6 million students from 2005 to 2009, and such efforts must be paired with an emphasis encouraging girls to attend school.1 Doing so will not only increase their ability to become self-sustaining, but will teach them to read and write so that they are able to read materials about HIV, STIs, and reproductive health. Additionally, economic opportunities must be presented to women. Warning girls of the dangers of dating older men can also be an effective preventative tool: when schoolchildren were shown a video describing the dangers associated with teenage girls dating older men, girls increasingly began dating their peers.7 Perhaps the most challenging status quo to break in hopes of encouraging prevention will be the low position of women. Improving the status of women will require a large paradigm shift, but, as one village leader in Malawi states, We need to join hands in guiding our youths properly. The church, the schools, the clergy, and the community should indeed join hands to fight against HIV/AIDS. United we stand, divided we fall.10 Such a change might begin with the creation of laws and policies to encourage rights for women. Laws might include the raising of the legal marrying age, illegalizing spousal rape, and an increase in legal tools providing medical and legal assistance to sex workers.15 another solution, which addresses the role of churches in society, is to include church activists in outreach programs so as to increase communication between those providing health care services and those using them.28 Key aspects of prevention necessary in reaching zero transmissions vary widely an include: the treatment of STIs, male circumcision, targeting and education of youth and women, condom use, PMTCT, and increased community support of topics ranging from condom usage, counseling, and womens rights.

Alicic 17 Political climate and commitments for funding: Political support for the movement to fight HIV/AIDS exists throughout Mozambique and has for much of the epidemic. Beginning with prevention programs in the mid-1980s and transitioning to a National AIDS Council in 2000, the nation addressed the disease relatively early in its rise.6 National Strategic Plans have been released every four years since 2000, with the third plan (for 2010-2014) creating programs based on studies carried out within the country and as a result consisting of appropriate priorities.2 The government has also endorsed the Declaration of Commitment on HIV/AIDS adopted by the UN General Assembly in June 2001, and the UN Millennium Development Goal to halt and reverse the spread of HIV by 2015.12 The countrys National AIDS Council has stated that most government officials and leaders are committed to the national response against HIV/AIDS and that the work of these figures is both notable and commendable17 Despite political support of thoroughly addressing the AIDS epidemic, the government itself has not been able to finance a response. Donor assistance first helped Mozambique recover following a 15 year civil war and aid to the country continues.1 In 2008, 96% of Mozambiques HIV/AIDS expenditures came from direct external funding, with 3% coming from public funds and 1% coming from private funds.17 The $269 million that PEPFAR donated to Mozambique in 2010 totals to more than the total budget of Mozambiques health care system.32 This dependence stems from Mozambiques continually high poverty rate, which though decreasing is still one of the worlds highest, with 54% of the country living below the poverty line.31 The vast majority of those funds goes towards prevention, care, treatment, and programs management, leaving gaps in areas such as human resources and orphans and vulnerable children.17 As a result, Mozambiques response is almost completely based on external funds.

Alicic 18 This dependence on outside sources brings up concerns as to how sustainable the countrys programs to combat HIV/AIDS are. Due to the dependence of external funds, current budget cuts to major donors could prove detrimental to Mozambique. As of March 15,2012, Mozambique was a grant recipient of the Global Fund to Fight AIDS, Tuberculosis, and Malaria.33 However, recent budget cuts to the Global Fund likely mean that the amount received will be less than necessary.34 This has raised concerns that treatment may now be greatly hindered, with the Executive Director of the National Network to Support People Living with HIV/AIDS stating that The consequences would be disastrous. Many people will lose their lives due to lack of treatment and others will have to stop the treatment, risking life and developing resistance to the therapy.35 Since PEPFARs inception in 2004, the United States has donated $1.3 billion to combating HIV/AIDS in Mozambique, with 70% of those currently on ART receiving the treatment as a result of US funds.36 Recent reaffirmations of continued funding in Mozambique were made by the United States Global AIDS.Coordinator.36 However, the Presidents budget for 2013 proposes a cut to PEPFAR of $562.9 million, or 12.3%, a policy that would result in an 18% cut in funding in Mozambique for 2013.38,40 With the advent of new, effective prevention methods and Mozambiques recent decline in incidence, removing funding now will greatly hamper the accomplishment of a realistic goal. MSFs team leader in Mozambique has recognized the need for continued funding and has stated that Sadly, despite its noteworthy efforts, Mozambique cannot make it without further commitment from international backers.19 Budget and Prognosis:

Alicic 19 Though Mozambique has had a strong, positive reaction to the HIV/AIDS epidemic and is continually working on the strengthening of the response, I do not believe that the milestone of 0% HIV incidence by 2019 is a realistic one, mainly due to a lack of needed funds. However, with continued funding and improvement of treatment and prevention methods, the goal may occur within the next twenty years. There are a few areas that I believe are crucial to address to successfully eradicated HIV/AIDS. With regard to treatment, the widespread use of ART must occur but can only happen after educational campaigns, human resources, and infrastructure have been strengthened. With regard to prevention, increased funding and support of Mozambiques Strategy for the Acceleration of Prevention of HIV Infection will provide support for widely varied and effective methods of prevention. In terms of budget, a few costs are relatively simple to calculate. Assuming a goal of reaching 0% transmission by 2025 (a date chosen as more realistic than the 2019 goal), the total cost of circumcision between now (2012) and 2025 will be approximately $366 million dollars.26 Using the calculation noted in the treatment section above, the cost of expanding ART to all who need it would total approximately $80 million per year, or $1.04 billion dollars between now and 2025. The treatment of STIs becomes more complicated to calculate. Assuming that approximately 525,000 people in 2011 were infected with either vaginal discharge, urethral discharge, genital ulcers, or syphilis (and ignoring other STIs that doubtlessly exist) and assuming that the cost of drugs and treatment is approximately $17.80 (an average for low income countries), treatment for one year should cost approximately $9,345,000.17,39 This estimate is low not only because it includes a limited number of STIs, but because it assumes that each infected individual will only be treated once. Other costs are similarly difficult to calculate. In 2008, Mozambique spent an overall of $38.543 million on prevention.18 Of this, $4.581

Alicic 20 million was used for social and behavioral change and $4.481 was used for testing and counselling.18 Because many of the factors crucial to prevention are related to these two areas (namely addressing at-risk populations, providing counseling and testing, and likely providing condoms), I would argue for the doubling of funds in both of these areas. This would result in a total spending in social and behavioral change and testing and counseling of $18.124 million dollars each year, or $2.35 billion dollars from now until 2025. Additional funds would be needed to strengthen human resources and infrastructure. Though this budget does not include all factors related to ending the HIV/AIDS epidemic, with a grand total of well over $43.755 from now until 2025, it does reflect the immense funds and dedication necessary to end the transmission of HIV/AIDS in Mozambique.

Alicic 21 References 1. "A Peaceful Climb From Poverty." USAID: From the American People. Nov 2009. <http://www.usaid.gov/press/frontlines/fl_nov09/pm1_poverty091119.html>. 2. Mozambique HIV/AIDS Health Profile. May 2011. <http://www.usaid.gov/our_work/global_health/aids/Countries/africa/mozambique_profil e.pdf>. 3. "Mozambique: HIV/AIDS Assets and Strategic Focus." Centers for Disease Control and Prevention. 27 Mar 2012. <http://www.cdc.gov/globalaids/Global-HIV-AIDS-atCDC/countries/Mozambique/>. 4. Mozambique Epidemiological Fact Sheet on HIV and AIDS. WHO, UNAIDS, UNICEF, Feb 2009. <http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_MZ.pdf>. 5. "Mozambique Positive Prevention (PP) Program." Positive Prevention. 2011. Web. <http://positiveprevention.ucsf.edu/CDROM/HTML/PDF/moz-PP-slides-Eng2011.PDF>. 6. Summary Country Profile For HIV/AIDS Treatment Scale-Up. WHO, 2005. Web. <http://www.who.int/3by5/support/june2005_moz.pdf>. 7. Kristof, Nicholas D, and Sheryl WuDunn. Half the Sky: Turning Oppression into Opportunity for Women Worldwide. New York: Alfred A. Knopf, 2010. 8. "Behavioral Interventions: Multiple and Concurrent Sexual Partnerships." USAID. Mar 2011. <http://www.aidstarone.com/focus_areas/prevention/pkb/emerging_areas/multiple_and_c oncurrent_sexual_partnerships>. 9. Audet et al. BMC International Health and Human Rights 2010, 10:15 http://www.biomedcentral.com/1472-698X/10/15 10. Underwood, Carol, Joanna Skinner, Nadia Osman, and Hilary Schwandt. "Structural Determinants of Adolescent Girls Vulnerability to HIV: Views from Community Members in Botswana, Malawi, and Mozambique." Social Science and Medicine 73.2 (2011): 343-50. 11. Mozambique. UNESCO. HIV/AIDS Prevention and Care in Mozambique, A Socio-Cultural Approach. Maputo, 2002. 12. Economic Commission for Africa. Mozambique: The Challenge of HIV/AIDS Treatment and Care. <http://www.uneca.org/chga/doc/mozambique.pdf>. 14. Mozambique. Republic of Mozambique National AIDS Council. Universal Declaration of Commitment on HIV and AIDS. 2008. Print. 15. IPPDF, UNFPA, The Global Coalition on Women and AIDS. Report Card: HIV Prevention for Girls and Young Women. IPPDF, UNFPA, The Global Coalition on Women and AIDS. 16. "Preventing Mother-to-child Transmission." UNICEF Mozambique. <http://www.unicef.org/mozambique/hiv_aids_2968.html>. 17. Mozambique. Republic of Mozambique National AIDS Council. GARPR (2012 Global AIDS Response Progress Report) For the Period 2010 - 2011 MOZAMBIQUE. Mar. 2012. 18. Global report: "Annex 2: Country Progress Indicators." UNAIDS Report on the Global AIDS Epidemic 2010. UNAIDS. <http://www.unaids.org/globalreport/global_report.htm>. 19 "Mozambique: A Long Fight Against HIV/AIDS But an Uncertain Outcome." Doctors

Alicic 22 Without Borders. 16 Mar 2011. <http://www.doctorswithoutborders.org/news/article.cfm?id=5105>. 20. Moon, Troy et al. "Lessons Learned While Implementing an HIV/AIDS Care and Treatment Program in Rural Mozambique." Retrovirology: Research and Treatment (2010). 21. "High Costs of HIV Medication Cause 'Terrible Dilemma' in Mozambique." PBS. 23 Nov. 2010. <http://www.pbs.org/newshour/bb/health/july-dec10/mozambique_11-23.html>. 22 Pearson, Cynthia R., Mark Micek, Jane M. Simoni, Eduardo Matediana, Diane Martin, and Stephen Gloyd. "Modified Directly Observed Therapy to Facilitate Highly Active Antiretroviral Therapy Adherence in Beira, Mozambique: Development and Implementation." Journal of Acquired Immune Deficiency Syndromes 43 (2006). Print. 23. Randomized control: Pearson CR, Micek MA, Simoni JM, Hoff PD, Matediana E, Martin DP et al. Randomized control trial of peer-delivered, modified directly observed therapy for HAART in Mozambique. J Acquir Immune Defic Syndr. 2007 Oct 1;46(2):238-44. 25 Medicalnews: "Biomedical Prevention Is Key To Reducing Transmission Of HIV Infection." Medical News Today. MediLexicon International, 08 Aug. 2008. <http://www.medicalnewstoday.com/articles/117316.php> 26 Circum: USA. UNAID. The Potential Cost and Impact of Expanding Male Circumcision in Mozambique. <http://www.malecircumcision.org/programs/documents/Mozambique11209.pdf>. 27. Planes, Montserra et al"Perceived Acceptance of Condom Use by Partners, Close Friends, and Parents of Spanish and Mozambican Heterosexual Adolescents." Journal of Transcultural Nursing (2011). 28. Pfeiffer, James. "Condom SocialMarketing, Pentecostalism, and Structural Adjustment InMozambique: A Clash of AIDS Prevention Messages." Medical Anthropology Quarterly 18. 29. "Preventing Infection among Young People." UNICEF Mozambique. <http://www.unicef.org/mozambique/hiv_aids_2970.html>. 30. "HIV Prevention Programme in Schools." UNICEF Mozambique. <http://www.unicef.org/mozambique/hiv_aids_5032.html>. 31. "USAID Africa: Mozambique." USAID Africa. Web. 02 June 2012. <http://www.usaid.gov/locations/sub-saharan_africa/countries/mozambique/index.html>. 32. Block, Melissa. "In Mozambique, A Fight To Keep Babies HIV-Free." NPR. NPR, 06 July 2011. <http://www.npr.org/2011/07/06/137536170/in-mozambique-a-fight-to-keepbabies-hiv-free>. 33. "Global Fund to Fight AIDS, Tuberculosis and Malaria - HIV/AIDS Grant Recipient." The Kaiser Family Foundation. <http://www.globalhealthfacts.org/data/topic/map.aspx?ind=56>. 34. "CORRECTED: Fund Fighting Killer Diseases Cuts Jobs, to Focus on 20 Countries."Reuters. 2 May 2012. Web. <http://www.reuters.com/article/2012/05/02/usglobalfund-idUSBRE84113Y20120502>. 35. Funding cuts: "Funding Cuts Threaten HIV Gains in Mozambique: Activists." AFP, 2 Dec. 2011. <http://www.google.com/hostednews/afp/article/ALeqM5jeNLV9v2E7z82qMG3rqnKfTOxTQ?docId=CNG.d3100a537f0497eaa934258620b0f483.b1>. 36: "Mozambique: U.S. Reaffirms Support for Fight Against HIV/Aids." AllAfrica. Dec. 2011. <http://allafrica.com/stories/201112080154.html>. 38. Mazzotta, Meredith. Science Speaks: HIV and TB News. 18 Apr. 2012. Web.

Alicic 23 <http://sciencespeaksblog.org/2012/04/18/evidence-grows-global-fund-financial-slackand-proposed-cuts-to-pepfar-are-hurting-progress-against-aids-2/#axzz1wYyaXAbl>. 39. Terris-Prestholt F, Vyas S, Kumaranayake L, Mayaud P, Watts C. The Costs of Treating Curable Sexually Transmitted Infections in Low- and Middle-Income Countries: A Systematic Review. Sex Transm Dis. 2006 Oct;33(10 Suppl):S153-66. 40. "Averting Deaths, Lowering Costs, and Beginning to End the HIV/AIDS Epidemic." Apr. 2012.<http://www.amfar.org/uploadedFiles/_amfar.org/In_The_Community/Publications /Pepfar-Investment-April-2012.pdf>.