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