1. Translating the Vision Towards Universal Access Dr Zengani Chirwa

2. Background Resource limited country, HIV prevalence – 12% Estimated 1 million people living with HIV National AIDS Commission established to coordinate the National response in Malawi The Ministry of Health to provide leadership and is the main implementer Rapid scale up started 2004 (with about 4,000 patients) according to scale up plan 2004-2006 ART sites had to be accredited using set criteria

3. Resource Limited Country Limited Human resource capacity (clinicians, Technicians, nurses etc) Weak Procurement Supply Management systems Limited lab capacity (e.g. CD4 cell count) Limited financial resources, single Donor i.e. Global Fund

4. Human Resource Shortages MalawiZambiaSouth Africa Nurses per 100,000 25113388 MDs per 100 0001769 PLWHA per MD74351216171 PLWHA per nurse 2867530 Source: UNAIDS & WHO, 2004, thanks to Wim van Damme

5. Strategy Technical working groups for ART & PMTCT established to formulate Guidelines and curricula for trainings Guidelines and training curricula developed which centered on simplicity and a public health approach Providers trained and certified as ART providers upon passing exam Providers underwent clinical attachment for 2 weeks after the training

6. Strategy Cont’d Standard first line regimen for all,(triomune) Alternative first line for side effects i.e. AZT,EFV based regimens Selected regimen that has: - minimum pill burden (FDC), - easy to prescribe (therefore easy to train) - easy to take (no restrictions with food) - Does not require Lab monitoring (baseline/CD4) Referral system was set up for second line regimens

7. Strategy Cont’d Having a standardized regimen simplified training, forecasting, quantification, procurement and distribution as well as the M & E system Task shifting: utilizing less skilled cadres to prescribe ARV’s and hence enabling decentralization and rapid scale up

8. Country-wide expansion: key elements in public sector ART is free for all patients in public sector Facilities only start first line ART if assessed as being ready to deliver ART Facilities move to alternative first line regimens when they show capacity to delivery 1st line Quarterly supervision is conducted to all sites Sites classified by patient burden: low (25), medium (50), high (150) or super high (150+)

9. Addressing HCW Shortages Severe shortage of health workers in Malawi Strategies: Follow-up every 2 – 3 months (instead of monthly) Staff with less training to run ART clinics (task shifting - Nurses to initiate ART & follow up, HSA’s provide HTC)) Initiation of ART and follow up of patients decentralized to health centres

10. Achievements by December 2010 Currently ART offered in 395 static and mobile/outreach ART sites Over 345,000 patients ever initiated on ART Out of which 250,000 are alive on ART (63% coverage) 91% of patients still on 1 st line (triomune), 8% on alternative 1 st line, 1% on second line Alive 73%,Defaulted 15%, died 12%, stopped <1% PMTCT offered in 650 sites providing MCH services

12. Malawi -patients alive on ART: public and private sector YearTargetAchievement December 200660,00059,980 [ - ] December 200790,000100,649 [ + ] December 2008130,000147,479 [ + ] December 2009180,000198,846 [ + ] December 2010230,000250,987 [ + ]

13. New Malawi integrated ART/PMTCT guidelines July 2011 Objectives for the integration: To increase access to triple ART for HIV infected pregnant and lactating women To reduce morbidity and mortality among HIV infected women and their children To reduce transmission of HIV from mother to child and between discordant couples To improve adherence to ART in PMTCT To provide FP services within ART/PMTCT services

14. Interventions Integrate ART services into the MCH services using option B+ (ART for life for confirmed HIV infected pregnant & lactating women using TDF/3TC/EFV regardless of CD4/WHO staging) Integrate Family planning into ART/MCH services (prong 2 of PMTCT strategy) with emphasis on dual protection (Depo provera + Condoms) Integration of ART and PMTCT services will simplify and streamline the PSM system in terms of forecasting, Quantification, procurement, distribution, supervision and M& E

15. Implementation Integrated ART/PMTCT Guidelines and curriculum developed Training of 120 TOT’s conducted Training of 3,900 current health care providers is underway currently Implementation date July 2011

16. Monitoring & Evaluation Joint quarterly ART/PMTCT supervision to all 650 sites for data verification & collection as well as cohort analysis Four patient master cards; Exposed infant card, Pre- ART card for children & adults, Adult ARV card & pediatric ARV card

17. The 4 different patient Master cards

18. I Thank you. Presented by Dr Zengani Chirwa Technical Advisor, Care & Treatment, HIV & AIDS Department, Ministry of health, Malawi Acknowledgements: Ministry of Health, Dept of HIV & AIDS – Malawi I-TECH – Malawi Matrix Laboratories IAS committee