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Mozambique is a large country situated on the southeastern coast of Africa. To the north lie Tanzania and Malawi; Zambia lies to the northwest; Zimbabwe lies to the west; and Swaziland and South Africa lie to the south. Mozambique has a 1500 mile shoreline on the Indian Ocean.

This country of just under 20 million people is divided into 10 provinces. Maputo, the capital, lies on the southern coast. The majority of the population lives below the poverty level, and foreign aid comprises much of the country’s budget.

A former colony of Portugal — which controlled of the country for nearly five centuries — Mozambique won independence in 1975, a decade after most other European colonies in Africa had gained autonomy. Portuguese is the official language.

From 1977 to 1992, nearly 1 million Mozambicans died from famine and fighting in conflicts between the ruling Front for the Liberation of Mozambique and the Mozambique National Resistance, a group of rebels funded by South Africa. Though a U.N.-negotiated ceasefire formally ended the fighting in 1992, the countryside remains riddled with landmines.

The face of HIV

AIDS is the leading cause of death for adult Mozambicans and fifth for children under 5. The country has the 10th-highest HIV rate in the world. The first case of AIDS in Mozambique was a Haitian doctor who was diagnosed in 1986 and died three days later.

According to the U.S. Centers for Disease Control and Prevention, the epidemic in Mozambique mainly strikes in areas where there is poverty and limited health care services and in corridors through which large numbers of people pass.

Infection rates in the north are lowest — 8 percent, according to the World Health Organization; in the south, the rate is about 15 percent. The situation is most dire in the central part of the country, where WHO estimates the epidemic afflicts 17 percent of the population. WHO attributes the high rate, in part, to the return of about 2 million refugees from neighboring countries with high HIV rates.

Jay Knott has witnessed the disease’s toll on families. After the death of one or both parents, the responsibility to take care of the family often falls on the oldest child. “I’ve seen countless households headed by 12-year-old girls and 13-year-old boys taking care of younger siblings,” said Knott, director of the U.S. Agency for International Development in Mozambique and coordinator of the interagency working group there for the President’s Emergency Plan for AIDS Relief (PEPFAR), a five-year, $15 billion U.S. initiative to fight AIDS abroad.

He added that 20 to 30 percent of the patients visited by nongovernmental organizations (NGOs) working in HIV/AIDS programs die within four to six months.

Challenges to fighting the HIV epidemic

In July 2006, Mozambique’s minister of health, Dr. Ivo Garrido, told a panel at the Washington, D.C.–based Center for Strategic and International Studies that his country’s main problem is that the health service network is not extensive enough.

WHO considers anyone living farther than five miles from a health clinic not to be covered by health services, according to Garrido. In Mozambique, that includes half of the population. “We still have nine-month pregnant ladies walking 30, 40, 50 kilometers [18 1/2 to 31 miles] just to reach the first health unit to deliver” their babies, he said.

According to the U.S. State Department’s Office of the Global AIDS Coordinator (OGAC), there are only about 650 doctors in the whole country, 270 of whom are in Maputo. As a result, some districts have only one doctor for every 70,000 people. Garrido noted that the number of doctors in his entire country is less than a large hospital in Washington, D.C., would employ.

Garrido also pointed out that 85 percent of the health clinics in Mozambique do not have electricity or clean water, so providing adequate, sanitary care proves extremely difficult.

Another challenge is that other medical ailments divert resources that could otherwise be used to combat HIV. Leprosy, a disease that has been virtually wiped out in the United States — in 2002 the Centers for Disease Control and Prevention reported only 96 cases — represents a major health problem in Mozambique, which is one of five countries that together account for 90 percent of leprosy cases worldwide. Diseases such as malaria and tuberculosis — which often strike AIDS patients — are also still very prevalent.

Mozambican government response

The Mozambican government’s commitment to fighting HIV/AIDS is strong, but resources are lacking. Mozambique spends only $28 a year per person on health care, according to UNAIDS, the Joint United Nations Program on HIV/AIDS; the U.S. spends $2,548 per capita.

Soon after independence was declared in 1975, the government created the National Health Service. In 1988, the government established several HIV/AIDS control programs, including an epidemiology surveillance program to track trends.

In 2000, the government created the National AIDS Council, which now administers what Garrido called his country’s “AIDS business.” With representatives from government agencies, the private sector, civil society and NGOs, the council sets general HIV/AIDS policy for the country and distributes donor funds.

Currently, the ministry of health’s focus is on sustaining programs after PEPFAR leaves. “We are trying to have a model of HIV care that is standardized and simplified,” Garrido said, “so that different kinds of health workers can work on it.”

U.S. government response

Prevention programs received the most funding in fiscal 2005, according to OGAC’s Web site. Just under $20 million — or 38 percent of funding allocated for prevention, care and treatment programs — was earmarked for prevention, with two areas receiving the most funding. Prevention of mother-to-child transmission was appropriated $5.6 million, while the “A,” or “Abstinence,” and “B,” or “Be Faithful” components of the so-called ABC approach received $4.7 million. The amount appropriated for condoms (the “C” of the ABC approach) is not itemized in the funding breakdown.

Care programs, including palliative health care, counseling and testing were allocated $14.9 million, or 28.5 percent of prevention, care and treatment funding. Treatment received $17.5 million, or 33.5 percent.

According to Knott, of USAID, part of PEPFAR funding goes toward renovation of health clinics and — in the future — construction of facilities. “We don’t want to create a shiny new room in a decrepit hospital simply for HIV/AIDS sufferers,” he said.

As in many of PEPFAR’s “focus countries,” treatment in Mozambique seems to be a successful area. In 2005, more than $13 million was appropriated for antiretroviral (ARV) drugs and services. ARV drugs have largely transformed HIV/AIDS from a fatal condition to a manageable illness.

In 2003, before PEPFAR came to Mozambique, 200 to 300 people were receiving ARV treatments there, according to Knott. Current estimates place the number of Mozambicans receiving ARVs today at 20,000 to 21,000. “That’s an increase that’s geometric,” he said, “in a country with one of the most woeful public health systems I’ve seen. That’s not enough; we need to do more, but it’s a small victory that’s worth celebrating.”

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