10 years of scaling up HIV Treatment & Care
Translating the Vision Towards Universal Access
Dr Zengani Chirwa
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
Resource Limited CountryLimited Human resource capacity (clinicians,
Technicians, nurses etc)Weak Procurement Supply Management
systemsLimited lab capacity (e.g. CD4 cell count)Limited financial resources, single Donor i.e.
Global Fund
Human Resource ShortagesMalawi Zambia South Africa
Nurses per 100,000
25 113 388
MDs per 100 000
1 7 69
PLWHA per MD
7435 1216 171
PLWHA per nurse
286 75 30
Source: UNAIDS & WHO, 2004, thanks to Wim van Damme
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
Strategy Cont’dStandard 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
Strategy Cont’dHaving 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
Country-wide expansion:key elements in public sector
ART is free for all patients in public sectorFacilities only start first line ART if assessed
as being ready to deliver ARTFacilities move to alternative first line
regimens when they show capacity to delivery 1st line
Quarterly supervision is conducted to all sitesSites classified by patient burden: low (25),
medium (50), high (150) or super high (150+)
Addressing HCW ShortagesSevere shortage of health workers in MalawiStrategies: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
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 1st line (triomune), 8%
on alternative 1st line, 1% on second line• Alive 73%,Defaulted 15%, died 12%, stopped
<1%• PMTCT offered in 650 sites providing MCH
services
Malawi -patients alive on ART: public and private sector
Year Target Achievement
December 2006 60,000 59,980 [ - ]
December 2007 90,000 100,649 [ + ]
December 2008 130,000 147,479 [ + ]
December 2009 180,000 198,846 [ + ]
December 2010 230,000 250,987 [ + ]
New Malawi integrated ART/PMTCT guidelines July 2011Objectives for the integration: To increase access to triple ART for HIV infected
pregnant and lactating womenTo reduce morbidity and mortality among HIV
infected women and their childrenTo reduce transmission of HIV from mother to
child and between discordant couplesTo improve adherence to ART in PMTCTTo provide FP services within ART/PMTCT
services
InterventionsIntegrate 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
ImplementationIntegrated ART/PMTCT Guidelines and
curriculum developedTraining of 120 TOT’s conductedTraining of 3,900 current health care providers is
underway currentlyImplementation date July 2011
Monitoring & EvaluationJoint 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
The 4 different patient Master cards
I Thank you. Presented by Dr Zengani Chirwa Technical Advisor, Care & Treatment, HIV &
AIDS Department, Ministry of health, MalawiAcknowledgements:Ministry of Health, Dept of HIV & AIDS – MalawiI-TECH – MalawiMatrix LaboratoriesIAS committee