Analysis of routinely collected data from a subset of HIV care and treatment clinics in Mozambique documents the rapid scale-up HIV care and treatment services in the country during the 2003–2009 period. The majority of adult patients enrolled in care and those who initiated ART were women (65.4% and 62.8%, respectively), a slightly higher proportion than in the larger HIV epidemic in Mozambique (57%).10
This may reflect higher testing and referral rates for women in Mozambique. For example, at least 10.5% of women included in this analysis were pregnant at enrollment, likely reflecting availability of PMTCT programs and linkages between PMTCT programs and HIV care. Children were also enrolled and initiated on ART, however, only a small proportion of children initiating ART (15.5%) were <1 year old. This is likely due to very high death rates, only recent availability of early infant diagnostic tests, and enrollment before new guidelines which recommend that all HIV-infected infants younger than 1 year be initiated on ART irrespective of HIV disease stage.11
Additionally, a high proportion of children were severely malnourished at enrollment and ART initiation.
We observed high rates of nonretention among ART adult patients at 12 months (27%), although they were similar to those described in a systematic review of 39 cohorts from sub-Saharan Africa [median attrition at 12 months was 23% (range 7%–45%)].12
Among children on ART, 21% were LTFU at 12 months, which was higher than those reported in other cohorts.13,14
High rates of LTFU were observed among patients enrolled in care who had not initiated ART, especially among a substantial proportion of patients who despite being ART eligible at enrollment were not initiated on ART. The high proportion of 1-year LTFU in this group (81% in adults and 71% in children) may have hindered initiation of ART and could also represent a substantial number of unascertained deaths.15–17
For example, a recent study conducted in South Africa with 44,844 patients enrolled in HIV care observed that 23% of eligible patients died before starting ART with a median time to death of 92 (IQR: 33–216) days.18
Some of the LTFU could also be due to overburdened clinics (due to waiting times and prioritization of ART patients to receive adherence support and outreach services), undocumented transfer of patients to other facilities,19
or due to patients not completing the nonclinical national requirements to start ART (ie, failing to attend 3 ART readiness pretreatment counseling sessions and disclosing HIV status to a treatment partner). Our findings around LTFU underscore the importance of conducting active tracing of all patients enrolled in HIV care to engage pre-ART patients in HIV care to help ensure timely ART initiation20
and reduce the risk of mortality and morbidity.21,22
The recent changes in ART initiation guidelines in Mozambique [CD4 count <250 cells/µL (vs. the previous <200 cells/µL), WHO stage IV and WHO stage III, and CD4 count <350 cells/µL] will likely result in a 10% increase in the number of eligible patients at enrollment into care. Nevertheless, additional efforts at the community and clinic levels will be needed to ensure that this larger population of ART eligible patients do in fact start ART earlier.
Among those who initiated ART, we also observed a relatively high proportion of patients initiating ART at advanced stages of HIV disease (CD4 count <100 cells/µL or WHO stage IV), although 21% had missing WHO stage and CD4 count at ART initiation. Late ART initiation has been associated with high early mortality rates in sub-Saharan Africa.22,23
A cross-sectional study from a clinic in rural Uganda observed that 40% of the 2,311 patients initiating ART were late presenters and found that male sex, lower education level, and unemployment, among other factors, were associated with a higher likelihood of late ART initiation.24
A recent analysis of 268 HIV care clinics in sub-Saharan Africa found both program level factors (provider to patient ratio, adherence support services, linkages with PMTCT programs, and outreach services) and AIDS knowledge and testing coverage in the general population to be important determinants of low median CD4 counts in populations of persons initiating ART.20
In addition to diminishing the successes of scale-up and its future potential to save lives, the problem of late ART initiation also adds significant burden and costs to care,25
and missed opportunities for secondary HIV prevention due to late diagnosis.26–29
It is therefore critical to understand more about the upstream determinants of late ART initiation (eg, determinants of HIV testing and late diagnosis among HIV-positive persons).
The 12-month reported mortality rate of 5% of adults and 7% of children who initiated ART in this study are very high, and almost certainly underestimated due to high numbers of persons LTFU, among whom death rates have been shown to be quite high in sub-Saharan African scale-up programs.19,21
Application of a recently described method which attempts to correct mortality estimates for LTFU suggest that the true 12-month mortality rate among patients initiating ART in our study population is probably closer to 13% and 14%, for adults and children, respectively. Taken together, these data underscore that efforts are urgently needed in Mozambique to identify and enroll patients at earlier stages of HIV infection.
The strengths of our study include the fact that the data were derived from routine clinical care from multiple HIV care and treatment clinics from a variety of facility types and from various regions in the country. It also includes information on adult and pediatric patients on ART and those in HIV care. This analysis included 55,014 patients from 28 sites in 5 Mozambican provinces, which represent one-fourth of the approximately 229,000 patients who ever initiated ART in Mozambique across more than 200 sites.6,30
The study also has limitations that motivate caution in interpretation of the findings. First, the clinics included in this analysis were selected for establishment of electronic database and are therefore not representative of all clinics providing HIV care and treatment in Mozambique. Second, some children <18 months who had not yet initiated ART may have been entered into the database with unknown HIV infection status, overestimating the number of HIV-infected children who were receiving care at these sites. Finally, an important limitation is the quality of the data that were derived from service programs including a large proportion of missing date and inability to validate the information. Despite periodic data quality assessments, there was a high proportion of patients with missing data on WHO stage (32.7% and 33.7%) and CD4 cell count (43.9% and 35.1%) at enrollment in HIV care and ART initiation, respectively. This precluded us from assessing their ART eligibility status, among other things. The reasons for these missing data may include the following: lack of clinical staging, poor documentation of information in the medical chart, poor data entry, lack of CD4 cell count testing (including reagent shortages or machine downtime), or some combination of these factors. Although missing data are a common challenge in large scale service delivery programs, it nonetheless limits the ability to accurately determine a variety of estimates and examine determinants of key outcomes,31
requiring the use of missing data methods such as multiple imputation32
(for an example of this technique for baseline CD4 cell count in HIV scale-up). Focused efforts to improve data quality are ongoing and will be critical to provide further insights into HIV care and treatment scale-up in the future. The importance of obtaining complete information during clinical assessments and documentation of all findings in medical records must be emphasized during the training of health care workers.
In conclusion, our analysis documents the success in the enrollment of large numbers of patient in HIV care and on ART. However, several challenges remain. These include high rates of loss to follow-up and death and initiation of ART in the advanced stages of HIV disease among both adults and children. Further efforts are also needed to ensure that accurate and complete data are obtained on all individuals enrolled in the HIV programs. When possible, future analyses of HIV scale-up programs should include an analysis of patients from the pre-ART phase of care, even if key clinical data may be missing on a large proportion of patients.