Ambassador Randall Tobias' Visit to Mozambique

UNCLAS SECTION 01 OF 04 MAPUTO 000655

SIPDIS
DEPT FOR S/GAC AMB TOBIAS, AMB LANGE, AND WBRENCICK
DEPT PLEASE PASS TO USAID/GH/OHA AND USAID/AFR/SA
DEPT PLEASE PASS TO HHS/CDC and HHS/HRSA
E.O. 12958: N/A
TAGS: KHIV KSPR EAID PREL MZ HIV AIDS PEPFAR
SUBJECT: Ambassador Randall Tobias' Visit to Mozambique



1. Summary: US Global AIDS Coordinator Ambassador Randall Tobias
visited Mozambique April 28-30 to discuss the President's
Emergency Plan for AIDS Relief with government officials, key
implementing partners, and post's HIV-AIDS working group, and to
see first-hand the challenges and opportunities for Mozambique as
it confronts the HIV/AIDS pandemic. Ambassador Tobias was
accompanied by S/GAC's Director for Diplomatic Liaison William
Brencick and Press Officer Amy Black. Meetings were held with
the President, Minister of Foreign Affairs, and Minister of
Health, as well as a dinner with several other ministers and the
Executive Secretary of the National AIDS Council. A roundtable
discussion was held with bilateral and multilateral donors and a
reception with religious leaders and implementing partners. The
delegation also visited sites in Maputo and Xai-Xai that are
being supported through the USG and the Ministry of Health. The
visit provided an opportunity for all parties to gain a better
understanding of the Emergency Plan-- both what it is and what it
isn't-- and to address concerns from government and donors on
procurement and prevention policies. Press during the visit was
positive and included both TV and print journalism. End Summary.

Graca Machel on the HIV/AIDS Challenge in Mozambique
-------------- --------------

2. A meeting on April 28 with Graca Machel, president of the
Foundation for Community Development, a key USAID implementing
partner, and former First Lady and Minister of Education, served
as an excellent opportunity to discuss broad issues impacting
efforts to combat HIV/AIDS in Mozambique. Discussions ranged
from the need for greater leadership within the government to
more effective and cohesive use of prevention messages. Machel
noted that despite lower prevalence rates than neighboring
countries, Mozambique has yet to "turn the tide" and that there
was awareness that efforts have not been entirely effective. To
this end, she encouraged both more effective and cohesive use of
HIV/AIDS messages. In response to a question on Mozambique's
national leadership on HIV/AIDS, Machel described President
Chissano as "vocal" on HIV/AIDS, but stressed that the broader
leadership must become more actively engaged by talking publicly
about the issue. On the positive side, she said AIDS could serve
as bridge between various groups in the country and can thus be
used to address broader development issues. Turning to the issue
of Mozambique's limited human resource capacity and lack of
trained physicians, Tobias stressed that we must look beyond
physicians to provide treatment. Explaining his belief that "all
heath care is local"-- Tobias cited an example in Uganda where a
small number of doctors could be used effectively to train large
numbers of health professionals, thus increasing access to care
and treatment within the community.

Exchanges with Mission Team and Mozambican Partners
-------------- --------------

3. That afternoon, Ambassador Tobias met with post's interagency
working group on HIV/AIDS to discuss both USG and government of
Mozambique (GRM) efforts to combat HIV/AIDS and the broader
political/economic implications of the pandemic. The working
group highlighted the regional variance in prevalence rates, with
the central regions recording the highest rates; discussed the
historical reasons for Mozambique's lower prevalence rates than
neighboring countries and challenges for combating the epidemic
(such as limited human resources capacity and inadequate
infrastructure); and raised several issues regarding our
relationship with the Ministry of Health. A reception held later
that evening provided the delegation with an opportunity to
interact with our key implementing partners and religious
leaders. During remarks at the reception, Ambassador Tobias
stressed that combating HIV/AIDS is a priority for President Bush
and noted that the Emergency Plan should be seen as reflecting
not just the commitment of the USG, but of the American people.

Visit to the Field
--------------

4. On April 29, the delegation headed to Xai-Xai, the capital of
the southern province of Gaza. The delegation visited several
sites, including a provincial hospital that cares for clients
living with HIV/AIDS, malaria, TB and other diseases; a health
center that that has just begun to train staff providing PMTCT
and voluntary counseling and testing; and a center working with
orphans and vulnerable children (OVCs). Both centers are
supported by USG funding. The USG has recently begun activities
focused on OVCs with Emergency Plan funding. During the visit to
the health center, Ambassador Tobias was tested for HIV, which
sent an important message to the local community about the
importance of learning one's HIV status and reducing the stigma
associated with HIV/AIDS. (Note: MOH officials had been
informed that Ambassador Tobias would like to be tested during
the visit to help promote and de-stigmatize VCT services. Unlike
in Ethiopia, GRM officials were not receptive to being tested
publicly. Endnote.) Ambassador Tobias also had the opportunity
to meet with a group of persons living with AIDS. In addition to
having the opportunity to see the positive impact of USG funding,
the Xai-Xai visit highlighted several of the challenges and
opportunities to combating HIV/AID in Mozambique, including the
lack of human resource capacity and the strong tradition of
community involvement. Ambassador Tobias was the guest of honor
that evening at dinner hosted by Ambassador Helen La Lime that
included the Ministers of Health, Labor, Women and Social Action
Coordination, as well as the Executive Secretary of the National
AIDS Council and the Diplomatic Advisor to President Chissano.

Outreach to Other Donors
--------------

5. Bilateral and multilateral donors met with Ambassador Tobias
on the morning of April 30. Ambassador Tobias described the
Emergency Plan, noting that it represents a significant increase
in USG funding for HIV/AIDS and highlighted that the Plan's
resources are focused in the areas of HIV/AIDS prevention, care
and treatment. It was stressed that USG activities "fit" with
other donor activities and are developed within the MOH's
national plan. USG funding and the focused approach of our
programs should be used to leverage other donors to contribute in
areas not addressed through the Emergency Plan. Tobias stressed
that combating HIV/AIDS globally is one of President Bush's top
three priorities. While recognizing differences in each of the
focus countries, Tobias noted that many of the issues affecting
HIV/AIDS efforts were uniform, including: inadequate
infrastructure, lack of trained medical personnel, the need for
strong national leadership, and the impact of cultural factors.


6. Participants stressed the need for strong collaboration,
including integrating the Emergency Plan into the national health
system, and noted that significant donor support for HIV/AIDS
already existed. Two coordinating groups with the MOH and the
National AIDS Council (NAC) already exist, though several
participants expressed concern over the effectiveness of the NAC,
which has responsibility for policy coordination and prevention
programs. In addition, participants noted the need to broaden and
deepen leadership on HIV/AIDS. In response to a question by
Tobias about what could be achieved within one year, discussions
included examples of success stories (for example, UNICEF noted
the rapid increase in the number of women treated at PMTCT
centers, which was attributed to both integrated health centers
and rapid tests) and the need for a longer-term vision. Good
results were also cited from home-based/community care. The
UNAIDS representative voiced concerns with two aspects of the
Emergency Plan: 1) the perceived lack of emphasis on use of
condoms in prevention programs and 2) the exclusion of generics
in treatment. Ambassador Tobias responded that the Emergency
Plan's prevention programs included all elements of "ABC", with
condom distribution focused on high-risk groups. However, he
noted that results have been disappointing for prevention
programs that are based solely on broad-based condom
distribution. Thus, the Emergency Plan seeks new approaches and
emphasizes both delayed initiation of sexual activity and
faithfulness. The effectiveness of these two approaches has been
confirmed by recent studies. On generics, Ambassador Tobias
stressed that the principal concern is ensuring safe and
effective treatment, and that the definition of generic drugs
varied. He explained that generics, including those approved by
the WHO, have not gone through a formal regulatory process and
that the fundamental concerns for treatment are in infrastructure
and resistance.

Minister of Health Presentation
--------------

7. Later that day, Ambassador Tobias and delegation members met
with Minister of Health Songane, who then accompanied the
delegation to the Primeiro de Maio health center in Maputo,
Minister of Foreign Affairs and Cooperation Simao, and President
Chissano. The meeting with Minister of Health Songane included a
presentation by Ministry of Health officials on the MOH National
Strategic Plan for HIV/AIDS/STI and an open discussion on the
Emergency Plan and broader USG-MOH cooperation on HIV/AIDS. The
MOH presentation highlighted both the strong demand for services
and the current limitations (e.g., insufficient numbers of
hospitals, laboratories, and health professionals) in the supply
of services. A key concern of the MOH has been ensuring that the
Emergency Plan supports the MOH's strategy. Joanna Mangueira of
the National AIDS Council (NAC) noted that the NAC was receiving
USAID funding and was currently developing a national strategy.
During discussions with Songane and the other MOH officials, CDC
and USAID officials emphasized ways in which USG programs were
being developed to support the MOH strategy.


8. Following the meeting at the Ministry of Health, Songane
accompanied the delegation to Primeiro de Maio, a model VCT and
health center under the supervision of the Ministry of Health.
The clinic is supported by several donors and is a successful
example of how implementing partners can collaborate with the
government to strengthen service delivery. The center includes
VCT services provided by USG-funded Population Services
International (PSI). Clients who test positive are referred to
the neighboring treatment service that is supported by Medicins
sans Frontieres, Luxembourg. The health center also has an
integrated maternity ward and family planning services. Speaking
to a group of people living with AIDS at the center, Tobias
commended the activists for speaking out, noting that their
public efforts serve to encourage testing and reduce stigma
associated with the disease.

FM Simao Understands the Challenge
--------------

9. During the meeting with Minister of Foreign Affairs and
Cooperation, Minister Simao, a physician and former Minister of
Health, stated his appreciation for Mozambique's inclusion in the
Emergency Plan, saying that the program sent an important message
that Mozambique was not "left alone" to address the pandemic.
The visit was described by Simao as a "moral boost" to continue
the fight against HIV/AIDS. Simao described his greatest
concerns as the provision of drugs, since the disease affects the
most productive sectors of the economy, and stressed the need for
both regional coordination and strong leadership. Specifically,
he stated that government officials have the obligation to speak-
out publicly with the community. Simao was optimistic about
stabilizing prelvance levels, noting that there is a greater
value for life since the ending of the civil war in 1992.
Responding to concerns regarding the use of generics, Ambassador
Tobias noted that the issue is one of standards and ensuring the
safety of drugs, not intellectual property rights. The issue of
resistance from non-regulatory approved drugs is another concern.
Tobias stressed that the real constraining factor is medical
personnel and access to testing and treatment programs. Simao
noted the need for integrated health facilities, to which
Ambassador Tobias agreed, citing the positive example of the
Primeiro de Maio center.

President Chissano Active on HIV/AIDS, but Challenges Loom
-------------- --------------

10. Ambassador Tobias and the delegation finished the visit by
meeting with President Chissano, where Ambassador Tobias thanked
Chissano for his leadership on HIV/AIDS and answered questions on
the Emergency Plan. President Bush's personal interest and
commitment to combating HIV/AIDS was also highlighted. Of
particular interest to Chissano were the level of new funding
under the Emergency Plan and our policy regarding generics.
Ambassador Tobias explained our policy and addressed the
importance of both treatment and testing. Chissano noted the
challenges of increasing awareness about HIV/AIDS and
acknowledged that current message campaigns have not always been
effective. Citing illiteracy and traditional beliefs, Chissano
stated that various ways of explaining and presenting information
must be used, including the use of traditional healers. The
President also noted that there is an opportunity to halt the
disease, particularly given lower prevalence rates that other
countries in the region. However, the problem must be seen as
regional, describing the pandemic in Mozambique as a fire that
was fueled by the winds from other countries. A press briefing
followed the meeting with President Chissano.


11. Comment: The visit was successful in raising awareness of
the Emergency Plan and the President's commitment to combating
HIV/AIDS. Ambassador Tobias effectively addressed concerns about
the Emergency Plan's policies and programs for prevention and
treatment and assured all key partners of our commitment to a
collaborative effort to address the pandemic. Just as
importantly, Ambassador Tobias and the delegation were able to
meet with a wide range individuals, from high-level government
officials and donors to local activists, and to see first-hand
the limitations of Mozambique's health care system. For post,
the visit was an opportunity to highlight the positive impact of
USG funding and discuss key issues impacting the implementation
of our Emergency Plan programs. End Comment.
LA LIME