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10 years of scaling up HIV Treatment & Care

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

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10 years of scaling up HIV Treatment & Care

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  1. 10 years of scaling up HIV Treatment & Care 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 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 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

  11. Malawi -patients alive on ART: public and private sector

  12. 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

  13. 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 (Depoprovera + 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

  14. 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

  15. 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

  16. The 4 different patient Master cards

  17. 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

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