dr sam phiri: hiv and aids situation in malawi

HIV and AIDS Situation in Malawi: Towards Universal

Access

Dr Sam Phiri

Executive Director

Lighthouse Trust

Global Community Links

Presentation outline

•HIV situation and national

response

•ART program

•The Lighthouse Initiative

•Challenges

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HIV and AIDS Situation In Malawi •Current statistics:

– Population – 13 Million – 12% HIV prevalence among 15-49 years – 1.6% HIV Incidence – 900, 000 people living with HIV/AIDS

•Impact of AIDS: – About 70,000 adult and child deaths annually – 700,000 orphans directly related to AIDS

•HIV Prevalence in most at risk populations – FSW – 70.7% (2006) – MSM – 21.4% (2009)

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HIV Prevalence by Age

• Content

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17.10% 15.30%

19.00%

11.30%

13.80%12.30%

8.00%

0.00%2.00%

4.00%6.00%8.00%

10.00%

12.00%14.00%16.00%

18.00%20.00%

Less than 15

15 - 19

15 - 24

20 - 24

25 - 29

30 - 34

35 - 39

40 - 44

45+

HIV Prevalence by Education

• Content

Global Community Links

14.9%16.6%

15.5%

13.9% 14.2%

17.5%

0.0%2.0%4.0%6.0%8.0%

10.0%12.0%14.0%16.0%18.0%20.0%

Non

e

Std

1 -

5

Std

6 -

8

Form

1 -

2

Form

3 -

4

Pos

t sec

onda

ry

HIV Prevalence by Marital Status

• Content

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17.30%

13.30%14.80%

32.60%

42.90%

22.60%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

Single Cohabiting Married Divorced Widowed Separated

National HIV Prevalence by

Year

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18.5

16.9 17

1513.5

0

5

10

15

20

1998 2001 2003 2005 2007

% P

revale

nce

Malawi Median

HIV Prevalence by Locality

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11.2 10.7

14.513 12.3

20.9 21.1 20.8

17

15

25.3

22.521.7

20.4

17.6

0

5

10

15

20

25

30

1998 2001 2003 2005 2007

% p

revale

nce

Rural

Semi-Urban

Urban

Prevalence trends in 15-19 and 15-24 age groups

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14.315.2

10.39.5

19.118.3

14.3

12.3

0

5

10

15

20

25

1998 2003 2005 2007

% P

reva

lence

15 - 19

15 - 24

Malawi National HIV and

AIDS Response

• Prevention and behaviour change

•Treatment, care and support

•Impact mitigation

•Mainstreaming and decentralisation

•Research, monitoring and evaluation

•Resource mobilisation and utilisation

– Main funding from Global Fund and other partners

•Policy and Partnerships

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ART Scale Up Plans (2004-2005) and (2006-2010) • 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

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Progress in cumulative

patients alive on ART in public and

private sector

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National outcomes (cumulative analysis) March 2011

•

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Number %

Enrolled to ART 365, 191

Alive on ART 264, 512 72

Dead 42, 549 12

Lost to Follow Up 66, 662 16

Stopped ART 1, 761 <1

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

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Challenges - Opportunities

•Slow behaviour change response

•Inadequate professional human resource

•Residual social and cultural practices

•Maintaining sustainable financial support

•Balancing HIV agenda with general health agenda

•Early mortality among patients initiated on ART

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Public Trust Initiative to complement Government

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Lighthouse Strategic Approach

Client-centered care based on 3-prong technical

approach:

•To expand high-quality, integrated HIV and AIDS

prevention, treatment, care and support services

•To promote innovative approaches for HIV

prevention, treatment, care and support through

program development, piloting, evaluation and

dissemination;

•To build and strengthen capacity for HIV and AIDS

treatment, care and support in Malawi.

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The Lighthouse Trust •Centre of Excellence for integrated continuum of HIV prevention, treatment, care and support •2 clinics: MPC and Lighthouse

1. HIV Testing and counselling including 31 HC in Lilongwe 2. ART service provision

• 10,000 patient visits/month • > 15,000 patients alive on ART • Integrated with TB, FP, STI, and PMTCT

3. Home- and community-based care 4. Capacity building

• National trainers in HTC, ART, palliative care • Supports MOH in Supervision, mentoring and coaching

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HIV Testing and Counseling

(HTC)

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HTC Services

Lighthouse urban HTC sites : – Lighthouse and Martin Preuss Centre clinics – Kamuzu Central Hospital medical wards, paediatric

wards, antenatal – STI clinic – Maula prison – Chinsapo

Rural health center outreach 31 rural Lilongwe HTC sites supported for HTC to ANC

mothers Increasing links to prevention of mother to child

transmission services

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HIV Testing and Counseling

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Total HTC client visits

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HTC Cummulative Encounters

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Jan-0

1

Jul-01

Jan-0

2

Jul-02

Jan-0

3

Jul-03

Jan-0

4

Jul-04

Jan-0

5

Jul-05

Jan-0

6

Jul-06

Jan-0

7

Jul-07

Jan-0

8

Jul-08

Jan-0

9

Jul-09

Jan-1

0

Jul-10

Jan-1

1

Jul-11

Cli

en

ts T

este

d

Clients Testing Positive Clients Testing Negative

The Lighthouse Clinic

A Specialist Clinic for

HIV and AIDS

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Clinic Registration

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Clinical Care •Free, public HIV/AIDS clinic

– 15,000 on ART by December 2010

– 56% female

– 91% on first line medications

– 9% children under 15 years

•Routine follow-up visits include:

– Regular appointments at intervals of 1, 2, or 3 months

– Diagnosis and treatment of opportunistic infections

– Initiation and maintenance of prophylactic therapy

– Referral to other services especially at KCH

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Clinical case review

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Lighthouse Trust cumulative outcomes: Q4, 2010

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Number % of ever enrolled

Ever enrolled in ART 24,590

Alive on ART 14,293 59%

Dead 1,771 7%

Defaulted 3,310 13%

Stopped ART 440 2%

Transferred-out 4,766 19%

Total Clinic Reviews

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0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

Apr-

01

Nov-0

1

Jun-0

2

Jan-0

3

Aug-0

3

Mar-

04

Oct-

04

May-0

5

Dec-0

5

Jul-06

Feb-0

7

Sep-0

7

Apr-

08

Nov-0

8

Jun-0

9

Jan-1

0

Aug-1

0

Mar-

11

Clin

ic C

lien

t V

isits

New Patients

Follow-ups

Lighthouse Centre

Opens

Free

ARVs

Limits

Imposed

MPC Opened

Electronic Data Management •Lighthouse and MPC implemented a real-time electronic data system (EDS) in 2005 •Collection of patient level information on all ART patients

– Registration, vitals, nurse visits, clinical care, and dispensing records

•Uses touch screen technology •Label scanners and printers facilitate easier monitoring and supervision for blood samples and drug dispensing. •Near completeness of patient level data from 2006 onward. •All patient EDS data is accessed through an Access database for effective monitoring and evaluation

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The Lighthouse Community Home Based Care

Quality Care at Home

for the Chronically Sick

in Lilongwe City

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Home based care (HBC) program

•Leader in promotion of Palliative Care

– End of life care for terminal and dying patients

•Works through existing community groups to encourage ownership and sustainability

•Patients identified through:

– Lighthouse or MPC referral

– Community volunteers

– Local hospitals

•Dedicated, well-trained community nurses provide quality care

– 150 patients, on average, per month

– Patients receive 2 nurse visits/week for medication and follow-up

– Patients receive visits from community volunteers for psycho-social support

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Community Home Based Care

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Total Ndife Amodzi client uptake

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Ndife Amodzi

0

1000

2000

3000

4000

5000

6000

7000N

ov-0

5

Feb-0

6

May-0

6

Aug-0

6

Nov-0

6

Feb-0

7

May-0

7

Aug-0

7

Nov-0

7

Feb-0

8

May-0

8

Aug-0

8

Nov-0

8

Feb-0

9

May-0

9

Aug-0

9

Nov-0

9

Feb-1

0

May-1

0

Aug-1

0

Nov-1

0

Feb-1

1

May-1

1

Clie

nts

Re

gis

tere

d

HBC CV LH LHMPC (Bottom) HC Other

Capacity Building Role

•MoH certified Training Courses:

– ART, HTC, and palliative care

– Over 1,000 clinicians and nurses trained in ART provision

•Provides clinical attachment for ART & HTC

•National supervision teams for HTC and ART

•Mentoring for new ART/HTC sites

•Leader in national policy development and piloting

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Challenges…

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Space challenges in clinic reception

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Lighthouse challenges •Balancing service quality with overwhelming demand

•Balancing service delivery with capacity building

•Balancing service delivery with operational research

•Maintaining high community volunteer retention

•Financial support for human resource

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A cross section of the Lighthouse Team

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•

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