The Mozambique HIV Testing and Counseling ‘Linkages Assessment’ Study was conducted in 2013-14 to ascertain what happens to people who are tested positive for HIV within the national health system. The study was initiated in collaboration with the MOH and donors to gain a better understanding of the proportion of new HIV positive patients who enroll in HIV care, the proportion of eligible HIV positive patients who initiate cART, and the proportion of those who are retained in treatment.
Investigators from the MOH Centro de Investigacao Operacional de Beira (CIOB) conducted a mixed-methods study in six districts of central Mozambique during a 12-month period from 2012-13 to describe the landscape of HIV testing and HIV care enrollment data. Within those six districts, all HIV positive enrollees in eight ART treatment facilities were followed to determine their outcomes. The investigators obtained testing data from national and provincial reports and compared them to clinic-based registries and pharmacy records of tests distributed and reported positives. They obtained enrollment data from the registry books at each of the facilities and retention data from review of patient charts selected randomly from the list all eligible enrolled patients. Charts of women in PMTCT Option B programs and children were excluded since their systems of HIV testing and care are substantially different than those for the general adult population. Interviews and focus group discussions were carried out with clinic directors, HIV providers, and patients, including patients who were lost to follow up.
The results demonstrated that the quality of HIV testing data is problematic. Over 46% of the 1,944 monthly HIV testing reports expected from the 89 health facilities were missing. Furthermore, many of the reports that were submitted did not report from all 13 sectors where HIV testing might have occurred, highlighting the likelihood that there is under-reporting of HIV-positives. Alternatively, missing reports for numbers of HIV positive adults registered in pre-ART or ART care were infrequent, with four of the six districts missing less than 5% of monthly reports. However, in three of the six districts, the number of reported registered HIV cases exceeded, by a large margin, the number of reported HIV positives for the same period.
After in-depth visits to each district and to many of the facilities with missing data, new estimates of people determined to be HIV positive and registered for pre-ART care were made based on review of primary data sources, cross-checking with pharmacy records of test distribution, and conservative imputation methods. The new estimates for HIV positives were over twice the number of officially reported HIV positives (33,228 vs 15,028); the new estimates for numbers of individuals registered in pre-ART changed less than 10%. Using the improved data, the number of registered HIV positives in pre-ART care was 75% of the number of HIV positives identified during the same 12 month study period – with a large variation between districts (45% to 92%).
The national norm is to open patient charts for all registered HIV patients. However, of the registered patients, only 60% of pre-ART patient charts and 66% of ART charts were located at the facility where they had registered for care – again with a large variation between facilities (41% to 91% of ART charts found at each facility). Among the patients whose charts were located, only 37% of them had evidence of having had a clinic visit to a provider or an ARV pick up at the pharmacy within 90 days prior to the study team’s chart review. Variation in retention between the eight sites was between 8% and 62%.