Antiretroviral Therapy Program Expansion in Zambézia Province, Mozambique: Geospatial Mapping of Community-Based and Health Facility Data for Integrated Health Planning

Mozambique: Geospatial Mapping of Community-Based and Health Facility Data for Integrated Health Planning. PLoS ONE 9(10): e109653. doi:10.1371/journal.pone.0109653 Antiretroviral Therapy Program Expansion in Zambe zia Province, Mozambique: Geospatial Mapping of Community-Based and Health Facility Data for Integrated Health Planning Troy D. Moon 0 Ezequiel B. Ossemane 0 Ann F. Green 0 Elise e Ndatimana 0 Eurico Jose 0 Charlotte P. Buehler 0 C. William Wester 0 Sten H. Vermund 0 Omo Olupona 0 Kebede Deribe, Brighton, Ethiopia 0 1 Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America , 2 Friends in Global Health , LLC , Maputo, Mozambique, 3 World Vision, Maputo , Mozambique Objective: To generate maps reflecting the intersection of community-based Voluntary Counseling and Testing (VCT) delivery points with facility-based HIV program demographic information collected at the district level in three districts (Ile, Maganja da Costa and Chinde) of Zambe zia Province, Mozambique; in order to guide planning decisions about antiretroviral therapy (ART) program expansion. Methods: Program information was harvested from two separate open source databases maintained for community-based VCT and facility-based HIV care and treatment monitoring from October 2011 to September 2012. Maps were created using ArcGIS 10.1. Travel distance by foot within a 10 km radius is generally considered a tolerable distance in Mozambique for purposes of adherence and retention planning. Results: Community-based VCT activities in each of three districts were clustered within geographic proximity to clinics providing ART, within communities with easier transportation access, and/or near the homes of VCT volunteers. Community HIV testing results yielded HIV seropositivity rates in some regions that were incongruent with the Ministry of Health's estimates for the entire district (2-13% vs. 2% in Ile, 2-54% vs. 11.5% in Maganja da Costa, and 23-43% vs. 14.4% in Chinde). All 3 districts revealed gaps in regional disbursement of community-based VCT activities as well as access to clinics offering ART. Conclusions: Use of geospatial mapping in the context of program planning and monitoring allowed for characterizing the location and size of each district's HIV population. In extremely resource limited and logistically challenging settings, maps are valuable tools for informing evidence-based decisions in planning program expansion, including ART. - Data Availability: The authors confirm that all data underlying the findings are fully available without restriction. Data belongs to the government of Mozambique. It is being collected through a consortium project funded by USAID in which World Vision is the leader. Data are available upon request to World Vision International and the National Bioethics Committee for Health, Maputo, Mozambique. Requests for data can be made to Omo Olopuna, Chief of the World Vision Ogumaniha Consortium: . Funding: This research has been supported by the United States Agency for International Development, Strengthening Communities through Integrated Programs under the terms of Cooperative Agreement #656A000900014100 to World Vision and by the Presidents Emergency Plan for AIDS Relief, through the Centers for Disease Control and Prevention under the terms of Cooperative Agreements U2GPS000631 and 1U2GGH000812 to Vanderbilt University. Research training was supported by the National Institutes of Health, AIDS International Training and Research Program grant D43TW001035. The findings and conclusions in this report are those of the authors and do not necessarily represent the official positions of USAID, CDC or the NIH. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: Please note that co-author Sten H. Vermund MD, PhD, is a PLOS ONE Editorial Board member. This does not alter the authors adherence to all PLOS ONE policies on sharing data and materials. In recent years, the worlds governments have galvanized unprecedented support towards the scale-up of HIV care and treatment. International programs such as the Presidents Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria have provided funding and technical assistance for the successful initiation of large numbers of patients on antiretroviral therapy (ART) in sub-Saharan Africa and elsewhere. [14] The absolute number of persons with access to and initiating ART is unprecedented (.10 million as of late 2013), yet key challenges remain to be addressed as to the quality of services. Gaps include suboptimal awareness of personal HIV status, late enrollment into HIV care and treatment, poor adherence and retention strategies, minimal psychosocial support initiatives, limited diagnostics of opportunistic infections, depleted human resources for health, inadequate integration of HIV services, and needs for health system strengthening. [1,410] Each of these requires thoughtful, efficient, and evidence-based health planning in order to have the desired impact. Mozambique ranked 185 of 187 nations on the 2012 Human Development Index of the United Nations Development Program and was one of the original 15 PEPFAR focus countries. [11,12] An estimated 2009 national adult HIV prevalence of 11.5% (,1.4 million HIV-infected persons aged 1549) ranked it among the most heavily HIV-afflicted nations in the world. [13] The magnitude of this epidemic is especially evident in Zambezia Province, Mozambiques second largest province and home to 3.8 million persons. [5,6,13] While Mozambique ranks among the poorest of the poor nations, Zambezia Province consistently ranks among Mozambiques bottommost performing provinces with low literacy rates, poor maternal and child health (MCH) indices, and high rates of tuberculosis, malaria, and malnutrition. [1418] More HIV-infected persons (,275,000) live in Zambezia than in any other province, representing 20% of Mozambiques HIVinfected adolescents/adults as of 2009 [13,19]. Estimating ART coverage rates for program planning purposes has been difficult, mainly due to weaknesses in HIV surveillance systems and in calculating HIV prevalence at a local site level. From 1988 to 2009, Mozambique relied on bi-annual serosurveys conducted at sentinel antenatal care (ANC) clinics (limited to 34 PMTCT clinics per province) for HIV prevalence estimates. [20] In 2009, Mozambique implemented its first and only population based National HIV epidemiologic survey, to date. [13] While confidence in these methods of determining HIV prevalence has increased, they continue to be limited to providing estimates for national and regional levels only, and do not provide estimates for the district or site level. Recently, there has been increasing interest in the use of routine site level PMTCT data to supplement or replace ANC sentinel surveillance an (...truncated)