Summary

NAC will use FY 2008 Emergency Plan (EP) funds to support monitoring and evaluation (M&E) of ongoing

PMTCT trainings and to support phased introduction of more efficacious combination ARV prophylaxis at a

number of selected health facilities.

Background

The national PMTCT program for Malawi was launched in 2003 but implementation of core activities

remained slow until the end of FY 2006 when the need for accelerating performance was acknowledged

during the National program review. In March of 2007, the National AIDS Commission (NAC)together with

the Ministry of Health (MoH) and other in-country PMTCT partners launched an initiative for accelerating

PMTCT program performance within 18 months. This was a direct result of the high level Global Fund

meeting in February of 2007 convened by the USG PEPFAR team to address bottlenecks in disbursements

from the Global Fund Secretariat and poor grant performance. Using FY 2006 funds, NAC supported the

development of a national PMTCT training package and spearheaded national consultations that led to

approval of a new, more efficacious ART prophylactic regimen for Malawi. These activities were part of a

broader national PMTCT scale up plan that received of the majority of its funding from the Global Fund and

from UNICEF.

With FY 2008 EP funding NAC will support the planned evaluation of National PMTCT training activities and

phased introduction of more efficacious combination ARV prophylaxis for PMTCT that will be carried out as

part of a comprehensive national initiative whose ambitious targets are to be achieved by August 2008. The

National goal is to include the provision of CT as a standard package of ANC services at all 540 ANC and

maternity units in the country, the provision of ARV prophylaxis to 90% of all HIV positive mothers and

exposed infants, and the screening of all HIV-positive mothers for ART eligibility and determination and

recording HIV status of mothers at all delivery units.

The main areas of emphasis for these planned activities are training, logistics for PMTCT communities

including HIV test kits and ARVs, human resources, and infrastructure. Planned activities will include

reviewing policies and strengthening M&E of the PMTCT program. They are therefore linked to OHPS,

HVSI, HVCT and HTXD.

Activity 1: Enhanced Monitoring and Evaluation of National PMTCT Training

The first activity will be to develop materials to assist MoH supervisors in assessing the knowledge and

skills of Health Care Workers (HCWs) trained using the revised national PMTCT curriculum. A standard

support manual on expected knowledge and skills outputs of trained HCWs will be developed for use by

supervisors at national, district and facility level. A system of quality assurance of PMTCT trainings will be

developed and implemented. The final output will be a standard package to monitor and evaluate PMTCT

training at all levels. This package will be integrated into the National PMTCT monitoring system.

Activity 2: Phased Introduction of a more Efficacious Combination ARV prophylaxis for PMTCT

Since the inception of the national PMTCT program in 2003, Malawi has used single dose Nevirapine for

the mother during labour and single dose Nevirapine for the infant within 72 hours of delivery as standard

prophylactic ARV regimen. Other more effective regimens given daily during pregnancy and in combination

are now available.

Malawi has endorsed the introduction of the WHO-recommended more efficacious regimen and gradual

phase out of single dose NVP. The new combination regimen will consist of AZT for mother from 28 weeks

followed by AZT/3TC and NVP in labour then AZT/3TC for 7 days after delivery. Exposed babies will

receive single dose nevirapine followed by AZT twice a day for one week. Combination-ARV prophylaxis

will only be introduced in health facilities with well functioning PMTCT services based on predetermined

minimum criteria including laboratory capacity to monitor Haemoglobin levels, supply management system

to ensure uninterrupted continuous availability of all required antiretroviral drugs, and trained personnel.

Each target health facility will be assessed using a standard tool before being certified for introduction of the

combination ART prophylaxis. A two-day training will be done for qualified PMTCT providers in sites that

meet all other criteria but have no providers trained in combination ARV regimens for PMTCT.

Summary

The National AIDS Commission (NAC) of Malawi is responsible for coordinating all HIV and AIDS

responses in the country and works closely with the HIV/AIDS Unit in the Ministry of Health (MoH) in

developing policies and promoting compliance with operating guidelines for all HIV prevention and care

activities. NAC does not directly implement CT program activities but uses funds from multiple sources to

support CT efforts of the MoH and other service delivery organizations. NAC's current program of work

(Integrated Annual Work Plan (IAWP) emphasizes rolling out of CT including supporting a full-time technical

assistant to provide technical and programmatic leadership for the national CT program to which the USG

has responded. With FY 2008 EP funding, the USG will continue to support CT technical assistance (TA) to

the MoH and support National HIV testing week initiative and other innovative strategies aimed at

increasing access to CT by underserved communities.

Background

Through FY 2006 EP funds, the USG placed a full-time technical assistant in the MoH to provide leadership

in National scale up of CT and mentor key MoH staff to assume this leadership role eventually. This TA has

played a key role in increasing CT sites from 236 to 351 while maintaining quality of services through an

intense program of mentoring and supervision of providers. In addition, this TA spearheaded two successful

National HIV Testing week campaigns in July 2006 and July 2007. Malawi has now incorporated this

campaign in the national program as an annual event.

Apart from central level training of trainers and supervisors in CT, all activities planned for FY 2008 funding

are at a national level, and contribute to creating an environment that supports rapid expansion of CT, and

are only associated with indirect targets.

Activity 1: Support for Full-time CT Technical Assistant at the MoH

This is an ongoing activity. The USG will continue to support the salary for a full-time CT Technical

Assistant at the HIV/AIDS Unit of the MoH. The Technical Assistant will work within the Government of

Malawi (GoM) structure providing both technical and programmatic guidance for CT scale up while building

local capacity for coordination of CT activities at National level.

Key responsibilities of the Technical Assistant will include:

• Provision of technical guidance to MoH on CT policy guidelines, CT sites development, and CT training

• Support to MoH in planning, co-ordination and implementation of CT in a variety of settings, including

health care facilities, NGOs, CBOs and private

sector

• Development of national system for CT standardized generic training, Training of Trainers (TOT), and

training of CT Supervisors

• Provision of technical guidance in setting quality standards for CT.

• Assistance to MoH in developing and implementing a national system for CT supervision, M&E, and

reporting

• Conceptualizing and implementing innovative interventions for increasing uptake of CT by underserved

communities

Activity 2: Support for Malawi's National HIV Testing Week Initiative

Following successful implementation of the first National HIV testing and counseling week in 2006, Malawi

has incorporated this activity in its program of work as an annual event. Consequently a second round of

this campaign was conducted in July 2007 and will be followed by similar campaigns every year. Lessons

from first round of the campaign were applied to improve planning and implementation of the second round

resulting in higher achievement. This success has attracted international attention leading to multiple

requests for partnerships from countries seeking to learn from Malawi's experiences. Documentation and

dissemination of permanent records of this important national exercise will be a priority for Malawi in FY

2008 and beyond. Good documentation will create a framework for continuous improvement and learning

over time.

With FY 2008 funding, NAC will improve documentation of this exercise and develop Malawi-specific

guidelines for implementation of future HTC week campaigns. Through this investment, it is envisaged that

Malawi will produce timely technical reports for each campaign and periodically publish its experiences as

case studies to guide other countries.

The HIV Testing and Counseling event is a high profile national campaign involving accelerated community

education on benefits of CT coupled with creation of opportunities for all Malawians to access HIV testing

and counseling. The bulk of services during the weeklong campaign are provided in temporary sites as

outreach to underserved communities. Resources for the exercise including HIV test Kits are provided

largely through Global fund monies programmed for CT. The campaigns increase visibility of CT services

and give every segment of the population an opportunity to be tested for HIV where they live.

EP funding will support the development of standard planning tools, quality assurance system, and data

management guidelines for CT week campaigns. This activity will also include coordination of external

technical assistance in logistics, social mobilization and other priority components of the national campaign.

Through these efforts, national coordination of CT activities will be strengthened and country specific

guidelines for planning and implementation of National CT week campaigns will be developed. A framework

for continuous improvement will be created based on documentation of lessons from each CT week

campaign. These efforts will also inform planning of the International HIV testing day(s) initiatives at regional

and global levels.

Summary

NAC will assist with implementing the Behavioral Surveillance Survey (BSS); facilitating the triangulation

workshops; developing an HIV Research Database; conducting situational analysis of non-biomedical HIV

interventions; and supporting the HIVDR Surveillance Task Force. Targeted Operations Research: It is

anticipated that the rapid assessment will raise some questions with regard to gaps in the current

knowledge and practice of male circumcision in Malawi. The USG funds will be used in conjunction with

others to support time-limited operations research that will help answer some of those questions.

Background

NAC is responsible for coordinating all HIV and AIDS responses in the country and works closely with the

HIV/AIDS Unit in the Ministry of Health (MoH) to develop policies and promote compliance with operating

guidelines for all HIV prevention and care activities, including the National M and E plan. NAC uses funds

from multiple sources, primarily the Global Fund, to support SI efforts of the MoH, Ministry of Women and

Child Development (MOWCD) and various line ministries. PEPFAR funding is used strategically to address

gaps in programming that impede the flow of all strategic information (SI) required to effectively combat the

HIV/AIDS epidemic.

NAC will continue to coordinate and implement SI activities to expand and improve the quality and utilization

of SI. NAC will collaborate with USG and key stakeholders including UNAIDS, World Bank, DFID, Norway,

and MoH to strengthen the National HIV and AIDS M&E System and its implementation at national and

district levels.

Activity 1. BSS and Analysis of Findings

The first completed and disseminated BSS report occurred in Malawi in 2004. During FY 2007, the BSS

task force finalized protocol development and survey planning. Data collection was completed in May 2007.

Approximately 5680 individuals were surveyed, of which 4663 were also tested for HIV. The National

Statistics Office (NSO), the implementing partner for BSS, is leading preliminary analysis of this data with

report writing commencing in August 2007. With FY 2008 funds NAC will continue to support quarterly BSS

meetings in order to plan analysis and dissemination of this survey and to begin preparations for the 2009

BSS.

Activity 2. Triangulation Workshops

Malawi has a wealth of data available from routine program monitoring and various research studies. This,

coupled with a culture of data and information sharing, provides the perfect platform for investigating

questions using a data triangulation process. The steps of triangulating data include identifying and

prioritizing questions; identifying and collecting relevant data (both original and non-original); synthesizing

data and developing hypotheses and recommendations; and disseminating results and recommendations.

In FY 2007, the triangulation questions, building on questions from the FY 2006 Triangulation, were, "What

is the coverage and trend in prevention programs and behavior change, possible links in general and target

populations?" and "What is the impact of HIV/AIDS facility based response on morbidity and mortality?"

Key data sources used to answer these questions include ANC Sentinel Surveillance, program data (HTC,

ART, PMTCT, and Blood Transfusion), HMIS national data, hospital specific information systems, DHS

(1996, 2000, 2004), BSS (2004 and 2006 preliminary results), Teachers, private sector employer data, etc.

A report of the triangulation research findings were published and disseminated in August of 2007.

With FY 2008 funding, NAC will sponsor a one day meeting to re-evaluate and prioritize key questions for

the triangulation process. This meeting will include the Impact Assessment taskforce as well as

representatives from development partners, non-governmental organizations, public sector and research

institutions. NAC anticipates 25 individuals will participate in this workshop. Once the key questions have

been identified, NAC will hire two fulltime consultants for 30 days to facilitate data collection. NAC will also

cover expenses for ten days of travel for five task force members who will supervise and assist with the data

collection. The primary purpose of this activity is to update existing data, identify new data sources, and to

conduct new research and/or program monitoring that respond directly to the questions identified for the

triangulation.

After the data collection, NAC will invite 50 people from various research institutions, public and private

sectors, non-governmental organizations, and development partners to synthesize the data, generate

hypotheses supported by the data, and make appropriate programmatic recommendations.

Activity 3. Development of HIV Research Database

As the national HIV/AIDS activity coordinating body, it is essential for NAC to track all HIV related research

conducted in Malawi. A national research database will assist NAC on many activities, including identifying

appropriate research proposals that help address areas of the national response neglected in terms of

research; ensuring a complement in biomedical and non-biomedical research; identifying resources to

include in data triangulation and impact assessments; tracking research activities for annual M&E reports

and reporting regionally to SADC on research activities.

NAC will engage four major research review boards to assist with the on-going data collection: College of

Medicine Review Committee (CoMRaC), National Health Sciences Research Committee (NHSRC), Centre

for Social Research (CfSR), and the Malawi National Research Council. The aim is to create a national

database that will assist these institutions in their functions as ethical clearing boards. NAC will harvest this

data on a quarterly basis to update the national research database.

Activity 4. Conduct Situational Analysis of Non-Biomedical HIV interventions

HIV and AIDS programs are often complex and changing. Understanding the situation is an important

component in designing effective intervention programs. Therefore, in FY 2008, a situational analysis of non

-biomedical HIV interventions will be conducted, in conjunction with other USG partners, to help identify

Activity Narrative: target populations and understand program coverage as they relate to prevention programs (i.e., mass

media campaigns, life skills, impact mitigation programs (IGAs), community based programs, support

groups and OVC programs).

Pact's survey assessment conducted with FY 2007 USG funding will be used to help identify groups

providing prevention services. Data will be collected in a stratified way to improve regional understanding: 2

per zone (2 North, 4 Central, and 4 South). One consultant will be dedicated to this project for 10 weeks (1

week planning, 5 weeks collecting data, 4 weeks writing report).

One outcome of the non-biomedical situational analysis will be to identify a sub-sample of organizations

(including CBOs, NGOs and schools) and focus in-depth on the quality of services provided. Key

intervention areas may include ABCs and/or effectiveness of media campaigns. Qualitative research

methods may be used to glean critical information regarding strengths and weaknesses of prevention

programs.

Activity 5. Support HIVDR Surveillance Task Force

As of June 2007, the Malawi Ministry of Health has initiated over 100,000 people on ART. Because the

national ARV program centers around one standardized first-line therapy, and very limited use of one

standard second line treatment, it is critical to monitor the emergence of HIV drug resistance (HIVDR) so

that the MoH can respond accordingly. Malawi has adopted a three prong approach to monitoring HIVDR:

Threshold Survey to look at transmission of drug resistance, Monitoring Survey to understand the

development of drug resistance under treatment pressure, and Early Warning Indicator reporting to assess

programmatic factors that contribute to the development of drug resistance.

In FY 2008, NAC will support quarterly HIVDR Task Force Meetings. The purpose of the Task Force is to

ensure that these activities are being conducted on an annual/biannual basis and that the results are

interpreted, disseminated, and when appropriate, that the MoH is responding by making necessary changes

to the national program. The HIVDR task force includes 15 members from different divisions of the Ministry

of Health, development partners, and representatives of the survey sites.