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Universal Access to HIV services – Malawian perspective

Universal Access to HIV services – Malawian perspective. Dr Sam Phiri Executive Director, Lighthouse Trust. Presentation outline. *. Malawi HIV response: case study towards universal access TB and HIV partnership – national level example

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Universal Access to HIV services – Malawian perspective

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  1. Universal Access to HIV services – Malawian perspective Dr Sam Phiri Executive Director, Lighthouse Trust

  2. Presentation outline * Malawi HIV response: case study towards universal access TB and HIV partnership – national level example TB and HIV partnership – clinic level example –Lighthouse Trust initiative Challenges

  3. HIV and AIDS Situation In Malawi Current statistics: Population – 13 Million 12% HIV prevalence among 15-49 years 900, 000 pe living with HIV/AIDS Impact of AIDS: About 70,000 adult and child deaths annually 700,000 orphans directly related to AIDS ART program progress 1.7 million people tested in 2010 ~406 sites providing ART 345, 598 patients ever started ART (63 % coverage) 250, 987 alive and on ART as of Dec, 2010

  4. 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 • Policy and Partnerships

  5. Guiding principles of the Extended National Action Framework • High-level government commitment, national leadership and ownership • Three Ones (coordinating, framework and M&E plan) • Multi-sectoral and multi-stakeholder partnerships • Greater involvement of people living with AIDS (GIPA) • Human Right • Gender • Evidence-based interventions • Public health approach • Community empowerment approach: • Good governance, transparency and accountability

  6. ART Scale Up Plans (2004-2005) and (2006-2010): main elements for the public sector • 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

  7. The Goal for 2006-2010

  8. Progress in cumulative patients alive on ART in public and private sector

  9. National outcomes (cumulative analysis) December 2010

  10. 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

  11. Cost implications for the new WHO recommendations

  12. Common ground: WHO-recommended collaborative TB/HIV activities A. Establish a mechanism for collaboration • TB/HIV coordinating bodies • HIV surveillance among TB patients • TB/HIV co-planning • TB/HIV monitoring and evaluation B. Decrease the burden of TB in PLWHA • Intensified TB case finding • Isoniazid preventive therapy • TB infection control C. Decrease the burden of HIV in TB patients • HIV testing and counselling • HIV preventive methods • Cotrimoxazole preventive therapy • HIV/AIDS care and support • Antiretroviral therapy to TB patients.

  13. TB/HIV Co-infection Sub-Saharan Africa Infection withTB Infectionwith HIV

  14. TB / HIV interaction in Malawi

  15. TB/HIV co-infection in Malawi 60% of TB/HIV co-infected patients did not get on ART 27,000 TB patients per year but case detection <50% (51,000 estim. cases) 66% TB patients HIV + 16% TB case-fatality

  16. National Level Collaboration: Malawi • National TB control programme (NTP) and the National AIDS Commission (NAC) collaborate closely at national policy level • NTP and NAC funded separately with their own directorates • ART M&E strategy based on previous TB M&E supervision and tools • TB program weakened by focus on HIV care • Closer service integration could benefit both

  17. Clinic level integration & coordination: Lighthouse and Martin Preuss Clinics • WHO Centre of Excellence • 2 clinics: • HTC– 4, 000 clients/month • ART service provision • > 10,000 patient visits/month • > 15,000 patients ART • Integrated TB, FP, STI, and PMTCT • Home- and community-based care • Capacity building • National trainers in HTC, ART, palliative care • Supports MOH in supervision, mentoring and coaching

  18. Partnership Principles for TB/HIV at MPC • Partnership with MoH • Policy support from National TB Program • Policy Support from Department of HIV and AIDS • Supplies and support from District Health Office • Partnership with other institutions • Baobab Health Trust • Electronic Data System • Staff training & education • Ownership and buy-in • Space for service provision • Lighthouse and District Health Office

  19. Martin Preuss Centre • Malawi’s first integrated TB/HIV clinic: opened 2006 • Located near central bus station and large maternity hospital in Lilongwe, Malawi’s capital • Purpose built to reduce infection transmission

  20. Purpose-built model of ART/TB Care • Outdoor waiting areas • External sputum submission • Separate TB & ART wings

  21. MPC: TB and HIV service integration • Largest TB registry: • 4000 sputum submissions (TB suspects) • 3,200 TB patients per year • ~ Of TB patients, 30% complete treatment at MPC • 95% ascertainment of HIV status among TB patients • ~ 60% are TB/HIV co-infected • Services provided by TB officers and MPC clinical officers • Routine HTC for TB suspects and TB patients • Use of standardized TB monitoring tools • Information includes ART & CPT data

  22. MPC: Integration at the data level • TB and ART registration data in electronic data system • TB sputum, treatment, and outcomes data in paper registers • All ART data in electronic system [Access database] • Manual back data entry to get TB data into matched database for analysis

  23. TB cases in Lighthouse clinics Between June 2009 and September 2010:

  24. Lessons learned • Monitoring and evaluation of TB/HIV requires effort • Training and consistent supervision • Quality M&E tools for spectrum of services • Electronic systems improve clinical management of TB suspects and TB patients • Training TB clinicians in ART increases ART uptake • With ascertainment of HIV status, ART entry can be sped • Additional training is needed to improve flow and efficiency

  25. Challenges…

  26. Challenges for HIV program in Malawi • Inadequate Human Resource • 1 doctor / 41,045 pop MOH and CHAM) • 1 nurse/ 2,643 pop ( MOH and CHAM) • Against target of 1/31, 000 and 1/1, 700 respectively • Inadequate infrastructure • Weak supply chain management system • Lack of consistent availability of health products • Uncertainty with funding • Global Fund Round 10 proposal not successful • Implication of the implementation of the new WHO recommendation

  27. Challenges for TB/HIV operations • Management issues: • Process of merging data between paper and electronic records • Efficient patient flow for TB/HIV co-infected patients • Patient-based barriers: • High pill burden and side-effects deter patients from seeking dual care • Complexity of information especially HIV+ individuals • Case detection of M/XDR cases: • Delay in getting culture results • Lab infrastructure is poor • Home Based Isolation difficult to monitor

  28. Acknowledgement

  29. ZIKOMO Thank you

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