3. General situation of HIV/AIDS in Mozambique

3.1 General statistics

The first case of HIV/AIDS in Mozambique was officially notified in 1986. The first governmental reaction was in 1988 with the establishment of four sentinel surveys in Maputo, Beira, Chimoio and Tete. These posts were established to monitor the evolution of the HIV/AIDS epidemic. The observation methods are those established worldwide for this epidemic, which consist of sampling pregnant women aged 15-49 years attending prenatal consultants. This method is believed to produce reliable results in southern Africa, where the main form of transmission is through heterosexual relations (World Population Bureau, 2002; CNCS, 1999). Details of the survey method may be found in CNCS (2003) and World Population Bureau (2002). At the same time, a multi-sector technical group (TG) composed of researchers at the Ministry of Health, the Ministry of Agriculture, the Ministry of Finance, the National Statistics Institute, the Eduardo Mondlane University and the Center for Population Studies was established. The task of the TG is to analyse the data of prevalence and demography, and evaluate the impact of the epidemic on population growth and the economy.

The general results of the monitoring show an increased prevalence since the first statistics were produced. The figures increased dramatically from the total accumulated of 662 confirmed cases by the end of 1992 to 10863 cases in 1998. These figures, however, may be associated with the expansion of the diagnosis network, which improved in the same period. The last surveillance report presents a national prevalence of 13.6 percent in 2002. The central region (Manica, Sofala and Tete) was reported to have reached the highest level in 2000 (17 percent), after which its prevalence indices remained stable. The southern (13-17 percent in 2000 and 2002) and northern (6-9 percent in 2000 and 2002) regions are said to be in an increasing phase (Figure 5).

Currently there are 36 sentinel surveys covering all the regions (Figure 3) with particular emphasis on rural areas (district level). The 2002 statistics include all the sentinel survey posts (sample size of 10,788 pregnant women) and, in general, they report higher prevalence indices in large towns compared to rural districts. In regional terms, the central region, which includes Manica and Sofala, has the highest prevalence indices, followed by the southern region. The low prevalence in the northern region is attributed to reduced accessibility, low urbanization and low interaction with neighbouring countries. Population movements during the war period, particularly the refugees returning from Zimbabwe and Malawi, the presence of development corridors (highway, railway and pipeline) and the consequent movement of trucks (truck drivers spending nights in district towns) and people doing business across the border, are indicated as among the most important causes of high prevalence in the central region (CNCS, 1999). Migratory work to South Africa is the main characteristic of southern Mozambique, and is indicated as the main reason for an increasing prevalence. Unprotected extramarital sex (EMS) and commercial sex (CS) are generalized in all the regions (of the 1.6 million men who practised EMS, 23 percent was commercial sex and 70 percent did not use a condom). EMS and CS are indicated as the main reason for infection and spread of the virus among Mozambican families (CNCS, 1999).

Because the 36 sentinel survey posts did not cover all the districts, certain criteria had to be adopted to estimate district prevalence. These criteria include:

1. similarity to population movements

2. accessibility among districts

3. similarity of the health facilities

4. existence of population groups with high risk of HIV infection

5. similarities in cultural, social, economic and educational levels

6.

Table 3. Prevalence indices by province and region, estimated from the 2002 survey in 36 sentinels with a sample size of 10,788 pregnant women (CNCS, 2003)

Figure 3

Distribution of the districts and the location of HIV/AIDS sentinel posts in 2002 (CNCS, 2003)

The province of Sofala presented the highest prevalence index (26.5 percent) (Table 3). The sentinel located in the urban hospital of Beira (Ponta Gêa) presented the highest prevalence (37.5 percent) among all sentinels in the country. The other two sentinels located in the suburbs of Beira presented 29.3 (Chingussura) and 27 percent (Munhava) prevalence, while the only sentinel located in a rural area presented only 12 percent (Caia). Based on the criteria presented above, the other districts of Sofala were estimated to have the prevalence indicated in Table 4. These criteria resulted in the districts along the Beira corridor (Dondo and Nhamatanda) and within easy accessibility having the highest indices and those located far from the urban centres and with difficult accessibility having low prevalence. It is believed, however, that increasing accessibility to districts like Caia, after reconstruction of the EN1 highway from Inchope to Caia, the construction of the bridge over the Zambezi river and the establishment of the agricultural investments in Marromeu, bringing migrant labour from other regions, will tend to increase HIV/AIDS in the districts of northern Sofala.

Table 4. Estimated HIV/AIDS prevalence in the districts of Sofala (compiled from CNCS, 2003)

District	Reference sentinel post	Prevalence (%)
Buzi	Chingussura (Beira suburb)	29.3
Caia	Caia_	12.0
Chemba	Caia (rural district)	12.0
Cheringoma	Caia (rural district)	12.0
Chibabava	Mossurize (rural district)*	10.3
Dondo	Chingussura (Beira suburb)	29.3
Gorongosa	Barue (rural district)*	16.7
Machanga	Mabote (rural district)**	12.7
Marínguè	Barue (rural district)*	16.7
Marromeu	Caia (rural district)	12.0
Muanza	Caia (rural district)	12.0
Nhamatanda	Chingussura (Beira suburb)	29.3

^_ Caia is the only district with a sentinel

^* districts of the neighbouring Manica province

^** district of the neighbouring Inhambane province

Figure 4

Estimated HIV/AIDS prevalence in the districts of Sofala province in 2002 (adapted from CNCS, 2003)

Figure 5

Map of HIV/AIDS prevalence index, Mozambique

3.2 Institutional involvement

The Government of Mozambique has been increasing interest in fighting the HIV/AIDS epidemics through different ways. In 1994, Mozambique signed the Paris Declaration, in which the signatory countries promised to fight HIV/AIDS, respect the rights and reduce the discrimination of people living with the infection. The Maputo Central Hospital was also nominated the Day-Hospital, to assist people living with AIDS. The interministerial commission that became the National Council for AIDS (CNCS) was created in 1999. The Council's function is to coordinate government efforts to fight the epidemics. Within this effort, civil society, the mass media, schools and traditional leaders play an important role as it has been recognized that HIV/AIDS is a matter of concern for all society.

In 1999 there were more than 58 national and international organizations, including community organizations, working for the prevention, treatment and care and mitigation of this epidemic. Data from CNCS (CNCS, 2003, online) show that most of these organizations are involved in prevention through awareness campaigns (speeches, theatre, radio and TV programmes, etc.) and the distribution of condoms to high-risk population groups.

So far, few organizations work for treatment, as the cost of medication is high (USD200-300 per year) and few people may have access (Tembe, 2004, personal communication). There are a number of organizations that work to care for those with HIV/AIDS infection to help improve their quality of life. Religious organizations such as the Catholic Church, and community organizations such as "Kubatana", are among the organizations that care about those infected by the virus. Their main task consists of reducing discrimination, a visiting programme, the provision of goods and opportunities for treatment and improved food. Mitigation actions and caring for orphans are also taken care of by a number of organizations at different levels.

An analysis of the structure of the cost of the organizations involved with HIV/AIDS shows that of the total amount spent in programmes and projects, only 20 percent goes to the direct benefit of the people living with HIV/AIDS, with the remaining 80 percent being spent on salaries and training. Eighty-six percent of the total amount spent on HIV/AIDS programmes and projects is provided by international aid agencies, 11 percent by the Mozambique Government and only 3 percent by service providers (CNCS, 1999).

3.3 The forestry/agricultural sector

The forestry sector is represented in CNCS by the Ministry of Agriculture and Rural Development (MADER) representative, who is based at the Rural Extension Service. The contact person has the responsibility to provide information on the epidemic to the employees of MADER. However, it seems that this contact person has no real role in the inclusion of the HIV/AIDS analysis in the agricultural programme. In fact, few programmes include HIV/AIDS impacts explicitly in their activities. There are, however, actions taken in other perspectives, such as food security, gender-based programming and development of labour-saving production techniques, which can contribute to the mitigation of the effects of HIV/AIDS.

Community forestry has contributed significantly with an increased participation of rural communities in forestry activities, particularly the generation of income from such activities. Community participation in forestry has been enforced by the Forest Regulation (DNFFB, 2002b) and is part of PARPA. Although the community forestry unit of the Mozambique forest department does not explicitly include HIV/AIDS activities, its activities may contribute to the mitigation of the impacts by increasing opportunities for rural people to increase income from forestry activities, and the channelling of revenues collected by the forestry sector to the communities involved in the management of these resources.

3.4 Local and indigenous knowledge institutions

The social structure and organization vary greatly throughout the country and provide the basis for the life pattern of the community in general through a set of rules and beliefs. These may affect the people's perception of the epidemic and the response reaction in the case of infection. For instance, polygamy in rural areas is believed to be a healthy practice, which reduces extra-marital relations at the same time that it provides an opportunity for a higher number of productive members within a household, thus reducing vulnerability and increasing food security. However, should the polygamous husband die, the household disintegrates and the quality of life of the survivors may be even worse that that of the monogamous household. Some traditional beliefs can prevent people from using condoms, while other beliefs also prevent ill people from seeking hospital treatment or taking any kind of medicines, thus increasing the vulnerability of these people to infections and reducing their chance to overcome the effects of HIV/AIDS-associated illnesses.

The use of medicinal plants for the treatment of opportunistic infections is among the most positive uses of local knowledge.

The use of plants for treatment of various diseases is commonly controlled by the Association of Traditional Healers of Mozambique (Associação dos Médicos Tradicionais de Moçambique - AMETRAMO), which has also been in partnership with some HIV/AIDS projects and programmes to help prevent contamination from sharing cutting objects, the distribution of condoms and the use of medicinal plants for patients with scarce resources.

The national policy on the use and exploitation of medicinal plants in Mozambique is still being prepared. Meanwhile, several people have been involved in collecting and selling medicinal plants for national and trans-national markets.

3.5 Impacts on household and community

It was estimated that between 1998 and 1999, 30-60 thousand families were affected by HIV/AIDS (CNCS, 1999). The impact will greatly depend on family size and structure, and, in general, the household's structure will disintegrate as well as the resource distribution, income and quality of life of the survivors, among others. Poor households tend to have large families, with an elevated number of children, with few working adults to support them, thus reducing significantly the per capita income.

The duration of the disease produces the highest impact. Medical expenses and the need for care increase with time, thus reducing household savings and the time allocated by the other household members to perform other household activities including income-generating activities. Because of the extended duration of the illness, when the ill person dies the household's savings are exhausted, thus increasing the household's vulnerability, especially for children. Apart from the loss due to medical expenses, relatives of the deceased man expropriate all remaining goods, such as the house and land, leaving the woman and children in extremely poor circumstances.

Orphans and children are the main victims of HIV/AIDS. In 1998, it was estimated that about 73,000 children were infected from their mothers and 120,000 children were orphans. Most of the infected children will die before the age of five while the quality of life of the orphans will be reduced. In Mozambique, generally, orphans are cared for by relatives, thus putting stress on already limited resources. Most of the orphans drop from school to take care of ill relatives and to engage in production activities such as selling goods on the street, agriculture and pasture, to sustain themselves. Female orphans may also engage in commercial sex (CNCS, 1999).

Most of the Mozambican population is rural. Subsistence agriculture is the most important activity. The impact of HIV/AIDS on the community may be reflected by a reduction in the ability to produce food; it may also affect the provision of teaching and health care, among other basic services. Community services may be affected because of infection of trained personnel, on the one hand, and also because of the increasing number of people seeking health care, which can surpass the capacity of existing infrastructure. The time spent caring for the ill person, but not working, affects household income and food security. On the other hand, the amount spent in preventing, caring and mitigating the impacts of HIV/AIDS might have been spent in community development actions (CNCS, 1999).