Also telling is just how resource-constrained some of the most heavily afflicted countries really are. In 2010, Mozambique ranked 165 of 169 nations on the World Development Index of the United Nations Development Programme.28
The World Health Organization estimates the gross national income to be US$770 per capita in 2009, with male and female life expectancies of 47 and 51 years, respectively.29
An estimated 142 children under age 5 years will die per 1000 live births. The total expenditure on health per capita in 2009 was only $50 and represented only 5.7% of the national gross domestic product. Mozambique’s health workforce is one of the most under-capacitated in the world and nearly all HIV/AIDS care and treatment services are provided by nurses and técnicos de medicina (analogous to clinical officers in Anglophone Africa) rather than by physicians.21–24,27
To meet the needs in HIV care and treatment, effectively implement successful prevention programs, and integrate HIV into improved primary care programs, our experience suggests the need for sustained health workforce training and program support for decades to come.30
In contrast, more prosperous nations like Botswana are making steady and impressive progress towards achieving target metrics for cART coverage by national guidelines. The results indicate the relative maturity of their testing programs, comparative successes in effective linkage to care, and substantial proportions of eligible HIV-infected persons placed on cART. We used a number of sources to contrast Botswana and South Africa (comparatively higher income) and Zambia and Mozambique (low income) nations vis-à-vis cART coverage estimates, in the context of estimated national populations and likely numbers of HIV-infected persons.
Botswana () and Zambia () have succeeded in rapid scale-up with over half of eligible persons now on cART in both nations.26,31–37
Both have been more generously supported than have South Africa and Mozambique (). South Africa seems to have widespread coverage for high-access urban dwellers, but far less coverage for lower-access persons in rural or otherwise underserved communities; South Africa had reached 36.9% of infected persons eligible for cART by national standards in 2009, low, but a substantial increase from the 9.5% estimate in 2005 ().31–38
At the same time, South Africa has already achieved a high level of independence in managing its own HIV care and treatment programs.38
While the lag in achieving coverage in South Africa is due, in large part, to the AIDS-denialism viewpoint of the Mbeke government (1999–2008), the current South African Zuma administration is accelerating services at every level. Even though there has been consistent government support of cART in Mozambique (i.e, no AIDS denialism), only 29.7% of infected eligible persons were on cART in 2009 ().31–37
Furthermore, much of Mozambique’s challenge is in its rural regions with exceedingly limited infrastructures, workforce, and systems of drug delivery systems, data management, quality improvement, and transportation.30,39–43
Figure 1 Estimated national population, number of HIV infected persons, and antiretroviral coverage, 2005–2009, Botswana. Data from references 26, 31–37.
Figure 2 Estimated national population, number of HIV infected persons, and antiretroviral coverage, 2005–2009, Zambia. Data from references 31–37.
Figure 3 Estimated national population, number of HIV infected persons, and antiretroviral coverage, 2005–2009, South Africa. Data from references 31–38.
Figure 4 Estimated national population, number of HIV infected persons, and antiretroviral coverage, 2005–2009, Mozambique. Data from references 31–37.
Some nations lack even a fraction of the qualified health workers needed. The 2010 Report from the Mozambican Ministry of Health Human Resources Department states that of 1105 physicians working for the government, about 62% were concentrated in Maputo City and urbanized areas of Maputo Province, Beira (Sofala Province) and Nampula City (Nampula Province); these three cities host the nation’s three central hospitals.44
The remaining seven provinces shared 420 public sector physicians to cover two-thirds of Mozambique’s 21 million persons, corresponding to nearly 33,000 persons per doctor, compared to 10,000 persons per doctor in Maputo City, Beira and Nampula City. (Fewer than 1000 persons per doctor is the norm for high and high-middle income nations.) Shortages of nursing and other health staff are similarly serious; neighboring Malawi and Tanzania have similarly dismal population-to-doctor ratios that impede transition of HIV services to local management. Mozambique’s current rural-urban disparity may have actually increased since 2005 when 57% of physicians were found in the city of Maputo and Sofala (including Beira) and Nampula Provinces.45
In the face of this dire healthcare labor scenario in Mozambique, the timetable set for local control of PEPFAR programs is planned aggressively, despite current low treatment coverage rates, high loss to follow up, and poor levels of health infrastructures, health workforce capacitation, and programmatic integration. An excessively rapid timetable for transition to local management will not fit all circumstances and may well compromise those achievements that PEPFAR programs have nurtured in Mozambique and elsewhere to date.14,46,47,48