At Quelimane hospital, in Mozambique's central province of Zambezia, paediatrician Maria João Soromenho encounters a sobbing young mother and her one year-old daughter. The baby is skeletal, no bigger than a newborn, and shows few signs of life.

The medical staff suspects the child is HIV-positive and suggests to the mother that she takes a blood test, but she wants to leave the hospital and take the child with her. Soromenho fears the mother will go to a traditional healer and now the doctor, too, begins to cry, and pleads with the mother to leave the child behind for treatment. The mother agrees.

"If the child survives, the mother will be back with her other children," Soromenho told IRIN. If so, it would be a rare victory.

Despite concerted efforts to expand HIV/AIDS treatment and make lifesaving antiretroviral drugs (ARVs) available in every district of the country, the majority of Mozambicans eligible for medication are not coming for treatment.

While about 20 percent of eligible adults are on ARVs, only an estimated 5 percent of eligible children, or little more than 4,000 children, are on treatment, according to the United Nations Children's Fund (UNICEF).

This discrepancy between adults and children reflects the greater vulnerability of children to the disease. The average HIV-positive adult can often go for many years before needing to start an ARV regime. Most HIV-positive children, however, need quick access to treatment to survive.

Since this rarely happens, less than half of the 37,000 children expected to be born HIV-positive in Mozambique this year will live beyond the age of two.

Providing medication to the one in six Mozambican adults who are infected with HIV/AIDS is complicated enough in one of the world's poorest countries. The majority of the medical infrastructure is confined to the capital, Maputo, and although in the past year HIV/AIDS clinics have been established where previously only the most rudimentary health services existed, many of the 20 million population are still far from clinics.

Medical challenges

With a paucity of medical staff, the treatment of children introduces a new set of challenges. Few medical staff has the training or confidence to treat HIV-positive children, which requires specialized medical knowledge and supplies, such as AZT syrups and dry-blood testing materials, which are in any case in short supply. And mothers, fearing the stigma associated with HIV/AIDS, are still wary of having their children tested or treated for HIV/AIDS.

Perhaps most frustrating for doctors is the number of pregnant women who register at the HIV/AIDS clinic, but then never return with their children for follow-up appointments. "Pregnant mothers do the test, they test positive, they do the consultations, and they don’t come back," Núria Monfulleda, a Spanish doctor working in Zambezia and affiliated with Columbia University’s Internatio nal Centre for AIDS Care and Treatment Programmes (ICAP).
In Zambezia, 95 percent of pregnant mothers attending the clinic stop coming once their child is born. "So we are missing all the babies," another doctor working in the province told IRIN. "It means we are losing all our work."

About half the children who do get onto ARV treatment live in Maputo. In the rest of the country, the obstacles are proving overwhelming. In the populous Zambezia province, more people live with HIV/AIDS than in any other province in the country. Yet, with almost 4 million people and an HIV-prevalence of about 18 percent, only about 300 kids are on treatment. In some districts in the province no children are on treatment.

Last month, Monfulleda and her colleague Carles Miralles checked the patient database at the HIV/AIDS clinic at which they worked in Gurue, a town in northern Zambezia. During their daily consultations the doctors had rarely attended to children, and now, reviewing the clinic’s records, they learned why.

They found that of the 65 HIV-positive pregnant women who had been registered at the clinic since December, only five were still attending the clinic. The remainder had given birth and had never come back, making it impossible to evaluate the health of the new born babies.

"Many children die and we don’t know about it," Monfulleda said.

More disturbing for the doctors was that all the absent mothers were living in Gurue, close to the clinic, so the complications of distance, which still handicaps many rural Mozambicans from receiving medical treatment, was not a consideration for the mothers failure to return to the clinic.

The doctors dispatched volunteers to search for the missing mothers and found in some cases the babies born to the mothers had died, while in other instances the mothers had resorted to traditional healers for treatment. Other mothers, identified by a local official, denied being the woman named in the file and the remainder said they did not have the time as they had to travel each day to tend a distant patch of crops.

The imperatives of poverty

Public health officials often cite the stigma of HIV/AIDS as a decisive factor when women do not bring their children in for treatment, as it is not uncommon for a husband to blame the wife for bringing the disease into the family, and then cast her from the household.

But even a mother not hindered by stigma has other practical considerations to weigh-up against getting her child tested or treated for HIV/AIDS. A visit to the clinic is time away from growing food, or other daily chores necessary for survival. An HIV-positive mother, counselled that a child must come in for regular consultations, may instead wait until her child has fallen seriously ill. It’s a decision based on "If the baby looks healthy, it’s healthy," says Monfulleda.

The high child mortality rates, 152 babies per 1,000 live births are not expected to live to five-years-old, create an environment where some mothers consider an infected child a "lost cause", says UNICEF health and nutrition specialist Christiane Rudert.
"That child is not worth the time and energy and resources to go up and down to the clinic every month because she has five other children at home and her field to take care of", Rudert told IRIN.

Time may, in the end, be the crucial factor in expanding treatment to children. Many people, doctors said, have yet to see the benefits of ARVs. Once more people witness their neighbors, once on their deathbed, become suddenly better, treatment will be deemed as worthwhile.

But, almost a year after the national ARV rollout, mothers have yet to factor treatment into their daily cost-benefit analysis, or to trust that it will save the life of their children, or save themselves.

"It’s a struggle, between us and mothers, to convince them", says Soromenho, the paediatrician. "I cannot obligate them to do anything. I can only counsel".