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Geographical focusing: an intervention to address increased risk for sexually transmitted diseases during repatriation and resettlement in post-war Mozambique
  1. B De Hulsters1,
  2. A Barreto2,
  3. R Bastos2,
  4. A Noya2,
  5. E Folgosa3,
  6. L Fransen4
  1. 1Former technical assistant European Commission, Mozambique
  2. 2National STD and AIDS Control Programme, Mozambique
  3. 3National Reference Laboratory Microbiology, Faculty of Medicine, Eduardo Mondlane University, Mozambique
  4. 4Health, AIDS and Population, DGDEV, European Commission, Belgium
  1. Correspondence to:
 Dr Brigitte De Hulsters, International Centre for Reproductive Health, University Hospital, De Pintelaan 185 P3, B-9000 Gent, Belgium;

Statistics from

Countries in the early post-war phase face population movements contributing to increased vulnerability for sexually transmitted diseases (STD) and HIV. Mozambique chose geographically focused interventions to control STD spread in the first post-war years.

Mozambique was one of the poorest countries in the world in 1993 with per capita GNP of US$63 and life expectancy of 48 years.1

Seventeen years of civil war and economic crisis destabilised the country causing massive population movements towards urban areas and neighbouring countries. Between 1992 and 1995, an estimated 1.7 million refugees from Malawi, Zimbabwe, Tanzania, Zambia, and Swaziland returned, soldiers were demobilised, and internally displaced people resettled.2 The war destroyed the health infrastructure, especially in rural areas, precluding provision of STD services and effective primary health care (PHC).3

Vulnerable groups and populations of the areas through which the refugees were returning, were considered particularly vulnerable to the risk of STD/HIV.4

The National STD/AIDS Control Programme, supported by the European Commission, decided to focus STD/HIV interventions at the PHC level in the areas most affected by population movements.

Four studies carried out between 1987–92 showed HIV seroprevalence rates of 3.2%–4.6% in displaced populations, higher than the 1.2% of the general population.

Very high STD prevalence rates (51%) were demonstrated in pregnant women attending PHC services for antenatal care.5 Displaced populations showed lower awareness of condoms than the general population.6

Fifteen districts in five provinces were selected on the basis of existing population health facilities and projected influx of people.2 PHC services were strengthened overcoming the existing shortages of staff, drugs, and materials. Clinical, laboratory, and health education skills of over 100 PHC workers in these priority districts were upgraded through training. Drugs for STD treatment, condoms, and educational materials were delivered. An existing popular health education initiative using theatre groups expanded, reaching over 100 000 people in local languages.

Difficulties encountered were mostly related to the destabilisation due to the war, such as transport problems, demotivation and relocations of health staff, parallel drug and treatment markets, and poor condom availability. Nevertheless, significant progress was noted. One major achievement was the increase in STD patient attendance, quadrupling in one province and doubling or tripling in others. The number of contacts reached also increased significantly: in 1992, 4.5% of STD patients were contacts, in 1993 9%, and in 1994 20.8%. Another achievement was increased condom distribution, from 2.5 million in 1993 to 5 million in 1994.

Geographical focusing of interventions in early post-war Mozambique showed significant impact on STD attendance, proving the feasibility of introducing STD care in difficult circumstances. Strengthening 15 districts provided the basis for improvement of the STD programme in other areas and enhanced general functioning of PHC centres in the initial priority districts. Improved supervision, in turn improving clinical, laboratory, and educational activities, was subsequently expanded to other districts. The use of syndromic management protocols contributed positively to STD management throughout the country.

Focusing interventions in areas with especially vulnerable populations, combined with an integrated approach to STD/HIV control, may have contributed to the control of the spread of STD and HIV in early post-war Mozambique.


Grant: European Commission, DG VIII/8, contract No RPR-MOZ-003.

The authors would like to thank all those who contributed to this letter and especially Kathy Attawell for her assistance in editing this report and Professor Marleen Temmerman of Ghent University for her encouragement and assistance.


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