US embassy cable - 04MAPUTO655

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