Patient-level database informs HIV response in Mozambique

By supporting the Mozambican health authorities to manage and analyze one of the largest HIV patient-level databases of Southern Africa, the U.S. Centers for Disease Control and Prevention (CDC) is enabling Mozambique to make informed decisions along the path to epidemic control.

Since the inception of the U.S. President´s Emergency Plan for AIDS Relief (PEPFAR) in Mozambique in 2004, CDC has worked with the Ministry of Health (MOH) to help expand access to life-saving HIV treatment services across the country. From less than 5,000 patients receiving HIV treatment in 2003, Mozambique remarkably surpassed 1.2 million patients in 2019. But the success of this continued expansion of services has not come without challenges, including those related to managing patient-level information at such a large scale.

In Mozambique, the primary health sector relies on paper-based registers for recording patients’ information at the health-facility level. And it is in these clinics that most of the people living with HIV access HIV services, including antiretroviral treatment (ART). To ensure timely access to quality program and clinical data, CDC has been working in coordination with USAID, PEPFAR’s implementing partners, and the MOH to establish an electronic patient-tracking system (EPTS) in these facilities, specifically in the ones that have a high volume of patients receiving ART.

This system captures demographic information, such as age, sex, or occupation, and detailed clinical data, such as the point when the patient was first diagnosed with HIV, when ART was initiated, dates of clinical appointments and treatment pick-ups at the pharmacy, and laboratory test results, including viral load and CD4 count monitoring.

“After a patient visits a health provider, the data is retrospectively introduced in the system by data clerks that work in the health facility,” explains CDC epidemiologist Alex Cox, noting that, when combined, the data from the health facilities utilizing EPTS “form one of the largest longitudinal patient-level HIV databases in the Southern Africa region.”

This database, which is known as MOZART, has expanded since 2011 and now includes approximately 90 percent of the patients receiving ART in the country (representing more than 600 clinics). To strengthen country ownership, CDC transferred the database to the Mozambican National Institute of Health (INS, in its Portuguese acronym) in 2017, which also coincided with the launch of the National Health Observatory (NHO), a national center that integrates different data sources to continuously monitor population health and well-being.

To assist with MOZART’s data analysis to monitor the HIV epidemic, CDC also initiated a technical collaboration with the INS focused on improving the data management system and creating new tools that make the database easier to use.

“Since the database had been around for a long time, the data management processes were outdated,” says Cox, explaining that “it could take weeks to do one analysis because we were using a software that was not prepared to analyze such a large dataset.”

To address this challenge, technical assistance from CDC headquarters was provided over the last two years to build capacity among CDC-Mozambique and INS staff in the use of this powerful data management software.

“This changed our ability to make use of the information at a much faster pace,” Cox emphasizes. “We were very successful in reducing the amount of time it takes to merge the data, clean it and extract it from the database for analysis.”

In addition, the technical cooperation opened space for new data analysis to be jointly conducted by CDC and INS, including a bulletin on patients´ retention on ART and GIS maps with information on patients´ CD4 counts for a national HIV atlas. Other projects will include creating visualizations and analysis of data on ART patients that are considered lost to follow-up.

Improving the national ART retention rate, which currently stands at approximately 70 percent after one year of treatment initiation, is a top priority for Mozambique to progress towards epidemic control. To that end, MOZART will be useful to better understand the characteristics of the patients discontinuing ART and to inform public health interventions that can address this critical challenge.

“This is also helpful to understand if the types of people that we are losing are changing over time, and if our interventions are having an impact on retaining new patients and reducing loss to follow-up,” Cox explains.

Another important use of MOZART is to assess how well the national HIV-related policies and guidelines are being implemented. For example, by analyzing patients´ viral load test results and changes in ART regimens, CDC and INS are currently working to understand if clinicians are correctly implementing the MOH´s guidelines for changing patients to second-line treatment regimens. Delays in changing ART regimens may compromise the effectiveness of ART and increase the risk of HIV transmission.

These and other analyses are being presented on the NHO´s HIV Platform, which is jointly led by the MOH and the INS and involves multiple partners working to control the epidemic in Mozambique. The platform also generates and promotes the use of scientific evidence to formulate new policies that will reduce health inequities and improve the health and well-being of Mozambicans, particularly those living with HIV.

Thanks to MOZART, INS, MOH, and CDC now possess an extraordinary analytical capacity, enabling a more effective response to the HIV epidemic in Mozambique.