Country-wide survey of HIV/AIDS and joint HIV-TB services in Malawi

2. Country-wide survey of HIV/AIDS and joint HIV-TB services in Malawi Rhehab Chimzizi Francis Gausi Andrina Mwansambo Felix Salaniponi Anthony Harries Rex Mpazanje

3. Background • Population • 10.5 million people • HIV/AIDS • 850,000 people living with HIV/AIDS • 70,000 new AIDS cases every year • TB • 27,000 new TB cases every year

4. HIV - TB Epidemic • 77% HIV-prevalence rate in TB patients • Major problems from this joint interaction are: • Difficulties in diagnosis • Increased case fatality • Increased recurrence of TB

5. GOM Responses • National Strategic Plan for HIV/AIDS • GFATM plan for AIDS care and support • TB Control Plan (2002 - 2006) • Joint HIV-TB Plan (2003 - 2005)

6. Deliverable Objectives of joint TB-HIV Plan • Increase VCT services • Provide 1o IPT for HIV-positive people • Give CTX to HIV+ve TB patients • Improve care and support for HIV-disease • Provide 2o IPT to prevent recurrence • Provide HAART to AIDS patients, including those with TB

7. AIM: To conduct a country-wide situational analysis • Specific objectives: • 1. Assess state of HIV/AIDS and joint HIV-TB services delivered on the ground • Inform TWG how best to move forward

8. METHODS • Study conducted from Jan to Mar 2003 • Data collected into a structured proforma • Visits to all (GOM and CHAM) VCT sites • in Malawi • Visits to all TB registration and treatment facilities with an in-depth focus • Discussions with DHMT on findings and how to move forward

9. FINDINGS

10. HIV Testing Sites in 2002 • HIV Testing Sites = 70 • Major MOHP and CHAM hospitals 44 • Smaller mission / rural hospitals 13 • Health centres / clinics 9 • “Stand-alone” sites 4 • Other sites providing counseling only: 22

11. Number of those who were HIV-tested in 2002 • Total no. persons tested 149,540 • Blood donors 57,850 (39%) • Pregnant women (PMTCT) 5,059 (3%) • VCT clients / patients 86,631 (58%) VCT Clients / patients hospitals / health centres/ clinics35,407 “stand-alone” sites51,224

12. Counseling services in the 44 major MOHP and CHAM hospitals • Some form of VCT service44 (100%) • Designated counseling room 22 (50%) • Some form of VCT register 31 (70%) • Full-time counselors 13 (30%) • Quality assurance of counseling 7 (16%)

13. Trained counsellors 456 Part-time 418(67% HCW and 33% lay people) Full-time 38(24% HCW and 76% lay people)

14. Factors associated with an increased number of HIV tests • Presence of a dedicated VCT room • Presence of full-time counselors • Hospitals allowing laboratory staff and counselors to do rapid whole blood testing

15. HIV- testing in the 44 major MOHP and CHAM hospitals Main kits in stock were the whole blood rapid test kits: Determine HIV-1/HIV-2 (Abbott) Uni-Gold HIV-1/HIV-2 (Trinity Biotech)

16. HIV- testing in the 44 major MOHP and CHAM hospitals • Stock-out of HIV test kits (2002) 15 (34%) • Stock-outs at time of visit 0 • Laboratory staff only doing tests 36 (82%) • Correct methodology for VCT 35 (80%) • Reporting results to NAC/HMIS 33 (75%) • External QC 1 (2%)

17. Package of care offered to HIV +ve persons at 44 major MoHP and CHAM hospitals • Screen clients actively for TB 4 (9%) • Screen clients actively for STI 24 (55%) • Access to special HIV clinic 6 (14%) • Isoniazid Preventive Therapy 0 • Acess to HAART 3 (7%) • Access to NVP for PMTCT 7 (16%) • Link with Home Based Care group 36 (82%)

18. Provision of HAART in 2002[d4t /3TC/NVP] • Two central hospitals • fee-paying service • 904 patients • One district hospital (linked with MSF-F) • free service • 316 patients

19. TB case notifications in 2002 • Total notifications 26,532 • Notifications at the 44 major • MOHP / CHAM hospitals 25,899 (98%) • Notifications from private 633 (2%) • hospitals

20. HIV tests and adjunctive treatments for TB patients - 2002 • TB patients known to be tested 2130 (8%) • TB patients HIV positive 1630 (77%) • TB patients known to start CTX 1668 • TB patients offered 2o IPT 0 • TB patients offered HAART 61

21. District AIDS and TB Management Systems • Number of AIDS and TB Coordinators • (Full-time or part time/ category) • AIDS coordinating committees • (Meetings and functions) • Structures for HIV-TB coordination • In-service HIV-TB training

22. Expansion of HIV-TB activities: Assessment for readiness • HIV and AIDS • No. of patients tested • Dedicated VCT room • Regular VCT service • Well kept registers • Supportive DHMT • Tuberculosis • TB office organization • Well kept TB Register • Returned Rx cards • Cure rate of sm+ve PTB

23. 15 (34%) hospitals in eleven districts are ready for expansion of HIV-TB activities in the first year Activities include: VCT and CTX, ARV, nutritional support, IPT

24. CONCLUSION

25. A clear need for scaling up HIV services and HIV-TB activities,both in quantity and quality Particularly in counseling and HIV testing

26. Improving counseling: Main issues to be considered • More full-time counselors (? lay people) • Dedicated VCT rooms in each hospital • Standardized VCT registers • Regular supervision and monitoring of sites

27. Improving HIV testing: Main issues to be considered • Uninterrupted supply of HIV test kits • Visible standardized laboratory guidelines • Counselors to be trained to do WBRT tests • Separate registers for blood donors and patients • Mandated quarterly reporting of results • Regular standardized quality control

28. ACKNOWLEDGEMENT We thank: DFID, NORAD, KNCV, USAID for financial support WHO – STOP TB for technical assistance and financial support Ministry of Health and Population and National AIDS Commission for guidance and support