Antiretroviral therapy program expansion in Zambezia Province, Mozambique: geospatial mapping of community-based and health facility data for integrated health planning.

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 Zambézia 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

Multidimensional poverty in rural Mozambique: a new metric for evaluating public health interventions.

BACKGROUND: Poverty is a multidimensional phenomenon and unidimensional measurements have proven inadequate to the challenge of assessing its dynamics. Dynamics between poverty and public health intervention is among the most difficult yet important problems faced in development. We sought to demonstrate how multidimensional poverty measures can be utilized in the evaluation of public health interventions; and to create geospatial maps of poverty deprivation to aid implementers in prioritizing program planning. METHODS: Survey teams interviewed a representative sample of 3,749 female heads of household in 259 enumeration areas across Zambézia in August-September 2010. We estimated a multidimensional poverty index, which can be disaggregated into context-specific indicators. We produced an MPI comprised of 3 dimensions and 11 weighted indicators selected from the survey. Households were identified as "poor" if were deprived in >33% of indicators. Our MPI is an adjusted headcount, calculated by multiplying the proportion identified as poor (headcount) and the poverty gap (average deprivation). Geospatial visualizations of poverty deprivation were created as a contextual baseline for future evaluation. RESULTS: In our rural (96%) and urban (4%) interviewees, the 33% deprivation cut-off suggested 58.2% of households were poor (29.3% of urban vs. 59.5% of rural). Among the poor, households experienced an average deprivation of 46%; thus the MPI/adjusted headcount is 0.27 ( = 0.58×0.46). Of households where a local language was the primary language, 58.6% were considered poor versus Portuguese-speaking households where 73.5% were considered non-poor. Living standard is the dominant deprivation, followed by health, and then education. CONCLUSIONS: Multidimensional poverty measurement can be integrated into program design for public health interventions, and geospatial visualization helps examine the impact of intervention deployment within the context of distinct poverty conditions. Both permit program implementers to focus resources and critically explore linkages between poverty and its social determinants, thus deriving useful findings for evidence-based planning

Map of Maganja da Costa.

<p>*<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0109653#pone-0109653-g003" target="_blank">Figure 3A</a> shows the geographic locations of communities that reported community-based VCT activities and the percent testing HIV positive, in the time period between October 2011 and September 2012. *<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0109653#pone-0109653-g003" target="_blank">Figures 3B</a> shows the geographic locations of where patients live, that were newly enrolled into HIV care and treatment in the same time period between October 2011 and September 2012. The main hospital in the district capital providing ART services is marked with a 10 km radius (green) around the hospital, while the smaller peripheral health facility also currently providing ART services is marked in blue. Persons living in communities designated with a green dot enrolled in the ART site with 10 km radius in green. Persons living in communities designated with a blue dot enrolled in the ART site with a 10 km radius in blue. *<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0109653#pone-0109653-g003" target="_blank">Figures 3C</a> shows the locations of health facilities in each district currently providing ART (purple) and those slated for expansion of HIV care and treatment services in 2013 (light purple).</p

Map of Chinde.

<p>*<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0109653#pone-0109653-g004" target="_blank">Figure 4A</a> shows the geographic locations of communities that reported community-based VCT activities and the percent testing HIV positive, in the time period between October 2011 and September 2012. *<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0109653#pone-0109653-g004" target="_blank">Figures 4B</a> shows the geographic locations of where patients live, that were newly enrolled into HIV care and treatment in the same time period between October 2011 and September 2012. The main hospital in the district capital providing ART services is marked with a 10 km radius (green) around the hospital, while the smaller peripheral health facility also currently providing ART services is marked in blue. Persons living in communities designated with a green dot enrolled in the ART site with 10 km radius in green. Persons living in communities designated with a blue dot enrolled in the ART site with a 10 km radius in blue. *<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0109653#pone-0109653-g004" target="_blank">Figures 4C</a> shows the locations of health facilities in each district currently providing ART (purple) and those slated for expansion of HIV care and treatment services in 2013 (light purple).</p

Map of Mozambique, Zambézia Province with Districts of Ile, Maganja da Costa, and Chinde Highlighted.

<p>The Provincial Capital of Quelimane and District of Inhassunge also Represented.</p

Ogumaniha Community-Based Voluntary Counseling and Testing Campaigns: Ile, Maganja da Costa and Chinde Districts, October 2011–September 2012.

<p><b>*</b>District Prevalence Estimates are based on the percent of pregnant women testing HIV seropositive at antenatal care clinics (routine PMTCT data) from the districts main health facility for the period October 2011–September 2012.</p><p><b>**</b>Zambézia Province HIV prevalence as reported by INSIDA, 2009¹³.</p><p>Ogumaniha Community-Based Voluntary Counseling and Testing Campaigns: Ile, Maganja da Costa and Chinde Districts, October 2011–September 2012.</p

ART Coverage Estimates: Zambézia Province and Three Focus Districts, Ile, Maganja da Costa, and Chinde.

a<p>The Estimated Number of HIV Infected is calculated using the 2012 HIV prevalence estimates (<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0109653#pone-0109653-t002" target="_blank">Table 2</a>), as a proportion of estimated population.</p>b<p>The Estimated Number Eligible for ART is calculated by taking 28% of the Estimated Number of HIV Infected (Due to current lack of more detailed sub-regional data, 28% is the current Ministry of Health standard for calculating the estimated number eligible for ART. More detailed population-based surveys reaching the district and community level are planned to be conducted in late 2014).</p>c<p>Number of persons active and on ART as reported in the PEPFAR Annual Progress Report (APR) for the period October 2011–September 2012.</p>d<p>ART Coverage is defined as the Number Active on ART as of Sept 2012 (numerator) over the estimated number of HIV positive persons eligible for ART (denominator).</p><p>ART Coverage Estimates: Zambézia Province and Three Focus Districts, Ile, Maganja da Costa, and Chinde.</p

Smoothed Heat Map of Three Focus Districts: Morrumbala, Namacurra, and Alto Molócuè.

<p>*<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0108654#pone-0108654-g004" target="_blank">Figures 4a, 4b, and 4c</a> show heat map geographical representations of poverty by adjusted headcount with green being less deprived and red most deprived. (Circled Star represents location of district capital).</p

Respondent and Household Characteristics by Multidimensional Poverty Status, <i>Ogumaniha</i> 2010.

a<p>Continuous variables are reported as weighted estimates of median (interquartile range] and categorical variables are reported as weighted percentages, with each observation being weighted by the inverse of the household sampling probability.</p>b<p>‘Other Christian’ includes LDS Mormon and Jehovah’s Witness. ‘Other’ includes Spiritual, Traditional Religions, and Agnostic or Atheist.</p>c<p>Tests of associations (continuous) include Wilcoxon rank sum (continuous) and chi-squared test (categorical).</p>d<p>All percentages in the cross tabulations are row percentages. The final column presents column (overall) percentages.</p><p>*EA = enumeration area.</p><p>**Approximate exchange rate as of October 2013: $1 USD = 30 Meticais.</p><p>***VCT = voluntary counseling and testing (for HIV).</p><p>****ANC = antenatal clinic.</p><p>Respondent and Household Characteristics by Multidimensional Poverty Status, <i>Ogumaniha</i> 2010.</p