1. Image courtesy of Wikimedia user “Thisisbossi” under CC-BY-SA license Dr Sam Phiri Executive Director, Lighthouse Trust Universal Access to HIV services – Malawian perspective

2. Presentation outline Malawi HIV response: case study towards universal access TB and HIV partnership – national level example TB and HIV partnership – clinic level example –Lighthouse Trust initiative Challenges *

3. HIV and AIDS Situation In Malawi Current statistics: –Population – 13 Million –12% HIV prevalence among 15-49 years –900, 000 pe living with HIV/AIDS Impact of AIDS: –About 70,000 adult and child deaths annually –700,000 orphans directly related to AIDS ART program progress –1.7 million people tested in 2010 –~406 sites providing ART –345, 598 patients ever started ART (63 % coverage) –250, 987 alive and on ART as of Dec, 2010

4. Malawi National HIV and AIDS Response Prevention and behaviour changePrevention and behaviour change Treatment, care and supportTreatment, care and support Impact mitigationImpact mitigation Mainstreaming and decentralisationMainstreaming and decentralisation Research, monitoring and evaluationResearch, monitoring and evaluation Resource mobilisation and utilisationResource mobilisation and utilisation –Main funding from Global Fund Policy and PartnershipsPolicy and Partnerships

5. Guiding principles of the Extended National Action Framework High-level government commitment, national leadership and ownership Three Ones (coordinating, framework and M&E plan) Multi-sectoral and multi-stakeholder partnerships Greater involvement of people living with AIDS (GIPA) Human Right Gender Evidence-based interventions Public health approach Community empowerment approach: Good governance, transparency and accountability

6. ART Scale Up Plans (2004-2005) and (2006-2010): main elements for the public sector Phased selection of facilities Free ART to HIV-positive eligible patients One first-line ART regimen only “Lamivudine + Stavudine + Nevirapine” “Push” system of ART supply to facilities Standardized system of monitoring/reporting Quarterly structured supervision

7. The Goal for 2006-2010 YearNew patients on ART each year Cumulative patients ever started on ART 200520,000 37,840 200635,00070,000 200740,000110,000 200845,000155,000 200945,000200,000 201045,000245,000

8. Progress in cumulative patients alive on ART in public and private sector

9. National outcomes (cumulative analysis) December 2010 Number% Enrolled to ART345, 598 Alive on ART250, 98773 Dead40, 21112 Lost to Follow Up53, 28115 Stopped ART1, 350<1

11. Malawi’s response to new WHO recommendations Eligibility –Stage 3 or 4 –CD4+ cell < 350 –PMTCT Option B+ - All pregnant and lactating HIV infected women Regimen Tenofovir + Lamivudine + Efavirenz (TDF – 300 + 3TC 300 + EFV 600) single FDC Challenge –Round 10 application to Global fund not successful Phased approach –Maintain current regimen except New pregnant and lactating women New TB/HIV co-infected patients First line alternative for severe lipodystrophy

12. Cost implications for the new WHO recommendations

13. Common ground: WHO-recommended collaborative TB/HIV activities A. Establish a mechanism for collaboration –TB/HIV coordinating bodies –HIV surveillance among TB patients –TB/HIV co-planning –TB/HIV monitoring and evaluation B. Decrease the burden of TB in PLWHA –Intensified TB case finding –Isoniazid preventive therapy –TB infection control C. Decrease the burden of HIV in TB patients –HIV testing and counselling –HIV preventive methods –Cotrimoxazole preventive therapy –HIV/AIDS care and support –Antiretroviral therapy to TB patients.

14. Infection with HIV Infection with TB Sub-Saharan Africa TB/HIV Co-infection

15. TB / HIV interaction in Malawi

16. TB/HIV co-infection in Malawi 60% of TB/HIV co-infected patients did not get on ART 27,000 TB patients per year but case detection <50% (51,000 estim. cases) 66% TB patients HIV + 16% TB case-fatality

17. National Level Collaboration: Malawi National TB control programme (NTP) and the National AIDS Commission (NAC) collaborate closely at national policy level NTP and NAC funded separately with their own directorates ART M&E strategy based on previous TB M&E supervision and tools TB program weakened by focus on HIV care Closer service integration could benefit both

18. Clinic level integration & coordination: Lighthouse and Martin Preuss Clinics WHO Centre of Excellence 2 clinics: –HTC– 4, 000 clients/month –ART service provision > 10,000 patient visits/month > 15,000 patients ART –Integrated TB, FP, STI, and PMTCT –Home- and community-based care –Capacity building National trainers in HTC, ART, palliative care Supports MOH in supervision, mentoring and coaching

19. Partnership Principles for TB/HIV at MPC Partnership with MoH –Policy support from National TB Program –Policy Support from Department of HIV and AIDS –Supplies and support from District Health Office Partnership with other institutions –Baobab Health Trust Electronic Data System Staff training & education –Ownership and buy-in Space for service provision –Lighthouse and District Health Office

20. Martin Preuss Centre Malawi’s first integrated TB/HIV clinic: opened 2006 Located near central bus station and large maternity hospital in Lilongwe, Malawi’s capital Purpose built to reduce infection transmission

21. Purpose-built model of ART/TB Care  Outdoor waiting areas  External sputum submission  Separate TB & ART wings

22. MPC: TB and HIV service integration Largest TB registry: –4000 sputum submissions (TB suspects) –3,200 TB patients per year –~ Of TB patients, 30% complete treatment at MPC –95% ascertainment of HIV status among TB patients –~ 60% are TB/HIV co-infected Services provided by TB officers and MPC clinical officers Routine HTC for TB suspects and TB patients Use of standardized TB monitoring tools –Information includes ART & CPT data

23. MPC: Integration at the data level TB and ART registration data in electronic data system TB sputum, treatment, and outcomes data in paper registers All ART data in electronic system [Access database] Manual back data entry to get TB data into matched database for analysis

24. TB cases in Lighthouse clinics N% ART patients 13,009 TB screened 12,80098 TB confirmed8337 On TB treatment79595 Incidence of TB is ~7% per year among those on ART Between June 2009 and September 2010:

25. Lessons learned Monitoring and evaluation of TB/HIV requires effort –Training and consistent supervision –Quality M&E tools for spectrum of services –Electronic systems improve clinical management of TB suspects and TB patients Training TB clinicians in ART increases ART uptake –With ascertainment of HIV status, ART entry can be sped –Additional training is needed to improve flow and efficiency

26. Challenges …

27. Challenges for HIV program in Malawi Inadequate Human Resource –1 doctor / 41,045 pop MOH and CHAM) –1 nurse/ 2,643 pop ( MOH and CHAM) –Against target of 1/31, 000 and 1/1, 700 respectively Inadequate infrastructure Weak supply chain management system –Lack of consistent availability of health products Uncertainty with funding –Global Fund Round 10 proposal not successful Implication of the implementation of the new WHO recommendation

28. Challenges for TB/HIV operations Management issues: –Process of merging data between paper and electronic records –Efficient patient flow for TB/HIV co-infected patients Patient-based barriers: –High pill burden and side-effects deter patients from seeking dual care –Complexity of information especially HIV+ individuals Case detection of M/XDR cases: –Delay in getting culture results –Lab infrastructure is poor –Home Based Isolation difficult to monitor

29. Acknowledgement