No abstract

BackgroundHigh rates of attrition are stymying Mozambique’s national HIV Program’s efforts to achieve 80% treatment coverage. In response, Mozambique implemented a national pilot of Community Adherence and Support Groups (CASG). CASG is a model in which antiretroviral therapy (ART) patients form groups of up to six patients. On a rotating basis one CASG group member collects ART medications at the health facility for all group members, and distributes those medications to the other members in the community. Patients also visit their health facility bi-annually to receive clinical services.MethodsA matched retrospective cohort study was implemented using routinely collected patient-level data in 68 health facilities with electronic data systems and CASG programs. A total of 129,938 adult ART patients were registered in those facilities. Of the 129,938 patients on ART, 6,760 were CASG members. A propensity score matched analysis was performed to assess differences in mortality and loss to follow-up (LTFU) between matched CASG and non-CASG members. Propensity scores were estimated using a random-effects logistic regression model. The following covariates where included in the model: sex, educational status, WHO stage, year of ART initiation, age, CASG eligibility, CD4 cell count category, weight, and employment status.ResultsNon-CASG participants had higher LTFU rates (HR 2.356; p = 0.04) than matched CASG participants; however, there were no significant mortality differences between CASG and non-CASG participants. Compared with the full cohort of non-CASG members, CASG members were more likely to be female (74% vs. 68%), tended to have a lower median CD4 counts at ART initiation (183 cells/m3 vs. 200cells/m3) and be less likely to have a secondary school education (15% vs. 23%).ConclusionART patients enrolled in CASG were significantly less likely to be LTFU compared to matched patients who did not join CASG. CASG appears to be an effective strategy to decrease LTFU in Mozambique’s national ART program.

Mobile health clinics can markedly decrease clients' transportation time and cost to access antiretroviral therapy (ART) and other health services in rural areas, potentially improving use. Close coordination with community leaders and regularly scheduled visits by the mobile clinics are critical.

Performance-based financing (PBF) is a mechanism by which health providers are paid on the basis of outputs or results delivered. A PBF program was implemented on the provision of HIV, prevention of mother-to child HIV transmission (PMTCT), and maternal/child health (MCH) services in two provinces of Mozambique. A retrospective case–control study design was used in which PBF provinces were matched with control provinces to evaluate the impact of PBF on 18 indicators. Due to regional heterogeneity, we evaluated the intervention sites (North and South) separately. Beginning January 2011, 11 quarters (33 months or 2.75 years) of data from 134 facilities after matching (84 in the North and 50 in the South) were used. Our econometric framework employed a multi-period, multi-group difference-in-differences model on data that was matched using propensity scoring. The regression design employed a generalized linear mixed model with both fixed and random effects, fitted using the seemingly unrelated regression technique. PBF resulted in positive impacts on MCH, PMTCT and paediatric HIV program outcomes. The majority of the 18 indicators responded to PBF (77% in the North and 66% in the South), with at least half of the indicators demonstrating a statistically significant increase in average output of more than 50% relative to baseline. Excluding pregnant women, the majority of adult HIV treatment indicators did not respond to PBF. On average, it took 18 months (six quarters) of implementation for PBF to take effect, and impact was generally sustained thereafter. Indicators were not sensitive to price, but were inversely correlated to the level of effort associated with marginal output. No negative impacts on incentivized indicators nor spill-over effects on non-incentivized indicators were observed. The PBF program in Mozambique has produced large, sustained increases in the provision of PMTCT, paediatric HIV and MCH services. Our results demonstrate that PBF is an effective strategy for driving down the HIV epidemic and advancing MCH care service delivery as compared with input financing alone.

Initiation of ART at earlier disease stages in later calendar years might explain observed declines in mortality. Retention interventions are needed to address trends of increasing LTFU overall and the high LTFU among Option B+ pregnant women specifically. Further expansion of CASG could help reduce LTFU.