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Dr Sam PhiriExecutive Director, Lighthouse Trust

Universal Access to HIV services – Malawian perspective

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*

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

Malawi National HIV and AIDS Response

• Prevention and behaviour changePrevention and behaviour change

• Treatment, care and supportTreatment, care and support

• Impact mitigationImpact mitigation

• Mainstreaming and decentralisationMainstreaming and decentralisation

• Research, monitoring and evaluationResearch, monitoring and evaluation

• Resource mobilisation and utilisationResource mobilisation and utilisation– Main funding from Global FundMain funding from Global Fund

• Policy and PartnershipsPolicy and Partnerships

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

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

The Goal for 2006-2010

Year New patients on ART each year

Cumulative patients ever started on ART

2005 20,000 37,840

2006 35,000 70,000

2007 40,000 110,000

2008 45,000 155,000

2009 45,000 200,000

2010 45,000 245,000

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

National outcomes (cumulative analysis) December 2010

Number %

Enrolled to ART 345, 598

Alive on ART 250, 987 73

Dead 40, 211 12

Lost to Follow Up 53, 281 15

Stopped ART 1, 350 <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

Cost implications for the new WHO recommendations

Costs per Annum for Different Scenarios

-

20

40

60

80

100

120

140

160

180

2009 2010 2011 2012 2013 2014

US

$ (

mil

lio

n) GOM contribution to health

current scale up

early start

early start (AZT+3TC+NVP)

early start (TDF+XTC+EFV)

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.

Infection

with HIV

Infection

with

TB

Sub-Saharan Africa

TB/HIV Co-infection

TB / HIV interaction in Malawi

0

5,000

10,000

15,000

20,000

25,000

30,000

1985 1990 1995 2000 2005

0

0.05

0.1

0.15

0.2Notif ied TB cases

Adult HIV-seroprevalence

TB cases per annum Adult HIV prevalence

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

HIV positive no ART

HIV negative

HIV positive on ART

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

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

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

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

Purpose-built model of ART/TB Care

Outdoor waiting areas External sputum

submission Separate TB & ART

wings

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

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

TB cases in Lighthouse clinics

N %

ART patients 13,009

TB screened 12,800 98

TB confirmed 833 7

On TB treatment 795 95

Incidence of TB is ~7% per year among those on ART

Between June 2009 and September 2010:

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

Challenges…

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

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

Acknowledgement