Summary

USG Malawi put into place a Counseling and Testing Agency staff member beginning in 2000 to provide

technical leadership and program management in CT, as well as in TB/HIV and PMTCT. The CT specialist

works directly with the Government of Malawi (GoM) and implementing partners to provide technical

assistance (TA) on national policy, produce policy documents, guidelines, training packages, and to

manage USG CT programs.

Using FY 2008 funds, the USG country team will continue to maintain a CT Specialist within its

multidisciplinary technical team. As a member of the USG interagency team, the CT specialist will provide

up-to-date technical information relating to CT, monitor CT activities of local partners to ensure adherence

to prescribed standards, and work with the GoM to develop and change policies in CT. Other core

responsibilities of activities of the CT specialist will include collecting and analyzing performance information

to track progress toward planned results, use performance information to inform program decision-making

and resource allocation, and communicate results achieved for all CT partners.

This activity is linked to, and will complement, the NAC-supported full time CT Technical Assistant (TA)

within the MoH (Activity ID#10711). The NAC-supported TA will work within the MoH structure directly

coordinating all CT activities and leading day-to-day implementation of activities at all levels. The USG CT

specialist will work within the USG country team to strategically support Malawi's national CT program and

ensure that activities meet quality standards for the USG emergency Plan (EP) plan for Malawi.

During FY 2007, the CT specialist provided significant technical input for landmark CT activities in Malawi

including the second round of the National CT week campaign, the change in policy to switch from parallel

to serial testing, development of guidelines for HIV testing in Children, the revision of national curricula for

training CT counselors, and the incorporation of CT as part of the standard package of care for TB and STI

patients.

Activity 1: Full-Time CT Specialist within USG Malawi Technical Team

USG will use FY 2008 funding for CT to maintain a full time CT specialist within USG Malawi's interagency

team. In FY 2008, the CT specialist will continue to support policy development including review and

revision of existing national CT documents. Specific tasks in FY 2008 will include guiding the transition

from parallel to serial testing, and further developing provider initiated CT in Malawi. The activities of the CT

specialist are as follows:

i) Technical Assistance (TA)

The CT specialist will provide TA to NAC, the MoH, NGOs, and other collaborating organizations in the

planning and implementation of CT activities in Malawi. S/he will assist the Interagency team in ensuring

that priorities, goals, and objectives consistent with the USG policies, international guidelines, and those of

host country are established and followed. The CT specialist will advice on appropriate quality assurance

procedures, staffing, facilities, patient information, client confidentiality, outreach efforts, reporting, and

record keeping procedures. Other activities will include promoting collaborative efforts with minimal overlap

by collaborating organizations, promoting coordination with lab support staff to ensure quality assurance for

HIV testing as required, serving as the primary contact for all CT collaborators within Malawi to the USG

team assisting in resolving significant issues arising in the implementation and delivery of CT services in

Malawi and advising the USG inter-agency on the key issues related to the planning and implementation of

CT activities.

ii). Program Planning

The CT specialist will plan and monitor activities and budgets with USG CT partners, assist partners with

development and monitoring of work plans, assist in writing the technical aspects of funding mechanisms

(such as cooperative agreements and contracts) and budgets with partners. The CT activities will include

ensuring that partners' quarterly reports are timely and accurate. On a regular and on-going basis, the CT

specialist will assess partners' progress in meeting program targets, goals ,and activities; recommends

corrective action if a partner fails to perform well; promote and monitor the routine offer of HIV Testing and

Counseling from services such as STI treatment, PMTCT, and TB treatment; promote and monitor that CT

providers refer clients and patients to appropriate services; and ensures that partners perform regular

supervision and quality assurance activities for counseling and testing consistent with MoH and USG

guidance.

iii). Monitoring and Evaluation

The CT specialist will collaborate with the USG M and E officers; monitor CT programs and activities carried

out by USG partners in Malawi; and review CT data collected, record keeping procedures, and

methodologies and approaches used in the delivery of CT services. The CT Specialist will analyze data

collected to assess accuracy, trends, and quality of services; develop, monitor, and present special studies/

evaluations to inform site, district and national level; review efforts by collaborators to maintain quality

assurance in the delivery of services; assist in analyzing the effectiveness of activities in terms of their

appropriateness, methodology and coverage; and evaluate activities of collaborators in reaching agreed-

upon goals and objectives and recommend actions to enhance and improve CT services and activities.

Where appropriate, participates in and supports dissemination efforts to inform CT practice and policies.

Summary

The USG team will hire a US board-certified Medical Officer with expertise in AIDS care and infectious

diseases management to provide leadership, expert advice, and direct technical support to the USG team in

all matters relating to ART treatment and clinical care. The incumbent will be the Project Officer that

provides technical oversight to the USG cooperative agreement with the Lighthouse Trust and the National

TB Program.

Background

Malawi is making considerable progress towards achieving its target of enrolling 250,000 individuals into the

ART program by 2010. By June 30, 2007, 114,375 patients had been enrolled into the ART program in both

public and private sector institutions. Management of existing patients at the 146 public and private sector

sites is anticipated to become increasingly complex as the Malawi program transitions from acute to chronic

care. Changing from standard first line drug regimens to alternative first line drugs increasingly will be

challenging. Viral resistance to first line drugs and switching to second line drugs is a cause for concern for

those that have been on treatment for a long time. Even though resistance to ART drugs may not be an

immediate threat, we will continue to conduct active surveillance and support the early warning system for

drug resistance. The issues of TB/HIV co-infection and the management of multi-drug resistance for TB

including X-DR TB is a looming specter in Malawi. This is further compounded by the changing treatment

options for pregnant and breast feeding mothers as well as the proper management of infected infants.

The USG Malawi has supported the Ministry of Health (MoH) with ART service deliver by mostly investing in

the management and coordination of the service and monitoring the service outcome. This has been done

without a resident Medical Officer on the USG team. With the anticipated complexity of the ART service in

Malawi, the USG team thought it prudent to recruit a Medical Officer that would play a leadership role in not

only in advising the USG team on clinical matters relating to AIDS case management but would work

actively with counterparts especially to TA that will be placed in the MOH to support the Government of

Malawi (GoM) efforts at reaching the target of enrolling 250,000 patients on ART by 2010. The incumbent

would provide technical input to any policy changes associated with the management of AIDS cases in the

general adult population, pregnant women, and children

Activity 1: Clinical care

• The incumbent will represent the USG in all matters pertaining to HIV/AIDS treatment and care as well as

provide expert advice and direct technical support to the GoM and private as well as Mission efforts at

expanding ART services from the current 114,375 patients at 146 sites to 250,000 patients at 150 sites by

2010. This is in concert with Malawi's aspiration for Universal Access to ART services by 2010.

• The incumbent will provide expert advice in the development and implementation of a GoM strategy that

would increase the number of children less than 15 years of age accessing ART services from 6% to 15%

by 2010. This will be part of a broader PMTCT program.

• The incumbent will provide advise and actively provide support for the expanded management of

opportunistic infections in AIDS patients, including wide spread use of cotrimoxazole.

• The incumbent will participate in the ART drug resistance monitoring effort in partnership with the

epidemiology and laboratory teams. He/she would be a resource for any change in policy with regard to

drug regimen changes.

Activity 2: Project officer

• The incumbent will be the Project Officer managing the Cooperative Agreement between USG and the

Lighthouse Trust, the single largest provider of treatment and care services in Malawi. The incumbent will

also oversee the new agreement in FY 2008 with NTP

• The incumbent will consider providing direct patient care at the Lighthouse, if so desired, as part of

Continuing Medical Education.

Activity 3: Applied Research

• The incumbent will advise the USG on priorities for public health evaluations and and targeted operations

research. In partnership with others in both the public and NGO sectors, the incumbent conduct applied

scientific research targeted at improving clinical management and care for AIDS cases.

• The incumbent will work with the MoH and other partners to organize research findings dissemination

meetings and workshops.

Summary

The USG Malawi Monitoring and Evaluation (Mand E) Officer provides technical leadership and program

management for M and E and Health Management Information System activities, including strategic

planning, routine monitoring and evaluation, capacity building, and data quality assessments. USG provides

technical assistance to partners in order to assist Malawi in meeting its SI goals of generating empirical

information about HIV and AIDS that informs policy, practice and interventions, building capacity at national,

district and community levels, and pursuing one of the ‘three ones', one harmonized and functional M and E

system for the national response to HIV and AIDS.

The PEPFAR team employs two full-time M and E personnel (CDC M and E Officer and USG SI Liaison

Advisor). The CDC M and E officer functions as an integral member of the GAP office in Malawi, and

initiates, conducts, and coordinates complex HIV/AIDS M and E program activities in collaboration with the

Ministry of Health (MoH), its National AIDS Commission (NAC), nongovernmental, multinationals, and

bilateral organizations. In FY 2007, the M and E Officer advised the USG on matters related to the

measurement of its contribution toward achieving PEPFAR's targets, translated M and E and other Strategic

Information (SI) into improved programming and delivery of services, strengthened systems of

accountability for use of PEPFAR resources, contributed to a single national monitoring and evaluation (M

and E) system in Malawi and strengthened systems and capacity among partners to collect, manage, and

use quality M and E data to inform program and policy in the national response to HIV and AIDS.

Activity 1: Country Operation Plan Development (COP)

In FY 2008, the M and E Officer will ensure systems are in place at USG and USG's implementing partners

to effectively plan and monitor programs for the Emergency Plan (EP) requirements. In close collaboration

with the USG HIV/AIDS Coordination Team (HCT), and in collaboration with the USG/Malawi Strategic

Information Liaison, the M and E Officer manages and coordinates M&E-related processes required for the

development of the annual COP for CDC-funded partners and provides technical guidance on M and E

needs of the EP in Malawi. The M and E Officer will build implementing partner capacity to respond to

planning and reporting requirements, review and assess the targets set by individual partners and ensure

that they are ambitious, yet reasonable. The M and E Officer will track the progress of results achieved by

implementing partners against their targets and track overall progress in achieving the EP goals as outlined

in the Malawi strategy and, when needed, recommending adapting targets to be consistent with

appropriated budgets, country constraints, and new opportunities.

Activity 2: Coordination for Monitoring and Evaluation

In FY 2008, the M and E Officer will continue to provide technical support to the ongoing implementation

and enhancement of the National HIV/AIDS M and E System, including harmonization of national indicators,

data sources, and reporting systems to assess progress and report on HIV/AIDS programs in Malawi. The

M and E Officer will also participate in key technical working groups (the Monitoring and Evaluation and

Information Systems Technical Working Group at NAC and the Monitoring, Evaluation, and Research

Technical Working Group at MoH) to ensure enhanced coordination, harmonization, and strengthening of M

and E Systems. The M and E Officer is expected to establish and maintain close relationships with all

international development partner representatives and GoM officials working in these areas to ensure

consistency and harmony of results reporting and to develop shared languages around issues of attribution.

The M and E Officer is also expected to participate in the collaboration and coordination of activities with

other international partners present in country (e.g., World Health Organizations (WHO), UNAIDS, Global

Fund to Fight AIDS, TB and Malaria (GFATM), and the World Bank).

Activity 3: Strategic Planning

In FY 2008, the M and E Officer will assist with the coordination of strategic planning, monitoring, and

evaluation of programmatic activities of USG, including the development of M and E plans and standardized

program monitoring systems. The M and E Officer will work closely with USG staff across HIV/AIDS

technical areas supported by USG to ensure that data generated by the M and E systems are useful and

used for program planning, policy development, advocacy, and program evaluation.

Activity 4: Technical Leadership and Coordination of EDS

In FY 2007, USG played a critical leadership role on the Electronic Data System Task Force, and provided

technical input on the evaluation of the EDS system. A detailed evaluation protocol has been developed

outlining the methodology and timeline for the pilot of the Electronic Data System (EDS) for ART. The tools

for data collection include a time-flow survey tool, a quality of care observation form, user surveys and

system error log forms. The evaluation protocol and tools have been shared with a broader audience,

including a presentation at the HIV implementers meeting. Additionally, USG facilitated a detailed and

systematic beta testing for the two systems under development.

In FY 2008, the M and E Officer will continue to provide technical leadership and coordination to Electronic

Data System for ART pilot and roll-out, including the coordination of the EDS Task force, the coordination

and implementation of the EDS pilot evaluation, the finalization of data transfer/exchange (HL7, Data

Repository), roll-out planning (site development, evaluating EDS roll-Out), and documentation and

dissemination of Malawi EDS as Best Practice.

Activity 4: Program Monitoring and Reporting

The M and E Officer will continue to be responsible for timely compilation and reporting of indicators for

monitoring the progress of the Emergency Plan for USG-funded partners. This requires the updating and

dissemination of country M and E guidelines, standards, and manuals to partners and ensuring consistency

with the latest Emergency Plan M and E guidelines. In FY 2008, the M and E Officer, in collaboration with

the HCT team, will ensure that the Emergency Plan data and indicators meet benchmark data quality

standards; and will be the point of contact for auditors and program reviewers addressing reporting

standards.

Activity Narrative: The M and E Officer will also provide technical oversight to activities and milestones agreed upon with the

partners and the USG management team. As the primary point of contact, the M and E Officer will meet

with the partners on a regular basis to review progress, and provide technical input to strengthening the

implementation and coordination of partner activities.

Activity 5: Systems Strengthening/Partner Capacity Building

In FY 2008, the M and E Officer will work with USG funded partners, including National AIDS Commission

and Ministry of Health, to strengthen their M and E capacity. The M and E Officer will support partners in

their efforts to better plan and monitor programs using M and E and other strategic information. Assistance

may include training or technical assistance in data collection, data management, analysis, data use and

dissemination. The M and E Officer will provide assistance to USG partners to enhance M and E systems

through the use of innovative technologies. The Officer will support CDC partners to better understand

implications of M and E data and translate M and E findings into meaningful programs and practices.

Activity 6: Data Quality Assessment Tools

In collaboration with the OGAC SI Liaison and USG SI Liaison Advisor, the M and E Officer will work with

local partners to implement data quality assessment activities to assess the data collection, reporting, and

management systems in place to measure indicators of program and project success.

Summary

The USG Malawi Epidemiologist provides technical leadership and program management over all HIV/AIDS

surveillance, public health evaluations and management for a subset of USG partners in Strategic

Information - related activities. This is an integral part of the USG team core competencies provided by

CDC. USG provides technical assistance to partners in order to assist Malawi in meeting its SI goals of

generating empirical information about HIV and AIDS that informs policy, practice and interventions,

building capacity at national, district and community levels, and pursuing one of the ‘three ones', one

harmonized and functional M & E system for the national response to HIV and AIDS.

PEPFAR supports implementation of these activities through partner organizations such as the HIV Drug

Resistance Monitoring Survey (National AIDS Commission (NAC), Ministry of Health (MoH)), Data

Triangulation (NAC), and Operations Research (NAC, Lighthouse).

Background

The PEPFAR team employs one full-time Epidemiologist who works as an integral member of the USG

Malawi. The Epidemiologist initiates, conducts, and coordinates complex HIV/AIDS epidemiologic program

activities in collaboration with the MoH, NAC, nongovernmental, multinationals, and bilateral organizations;

and provides epidemiologic advice and consultation as a national and internationally recognized expert.

In FY 2007, the USG Epidemiologist provided technical support on several major activities, including the

HIV Drug Resistance Threshold Survey (HIVDR) and Early Warning Indicator (EWI) Report, the Behavioral

Surveillance Survey (BSS), the Demographic Health Survey (DHS) Lilongwe re-sample, and National

Triangulation and Impact Assessment Workshops. The Epidemiologist served as a mentor to an

Association of Schools of Public Health (ASPH) Strategic Information Fellow, also supported through

PEPFAR, who assisted with implementation of these activities.

Activity 1: Technical Support for HIV Surveillance

In FY 2008, the USG Epidemiologist will provide direct technical support for a variety of HIV surveillance

and epidemiology activities planned for Malawi, including the HIVDR Surveillance Activities (Prospective

Monitoring Survey, Early Warning Indicator Reports), Data Synthesis and Triangulation, Behavioral Sentinel

Surveillance (Interpretation of FY 2007 results, planning for FY2009 activities), and HIV Prevalence National

Estimates Workshops. The epidemiologist will also continue to work with primary partners on reviewing the

national surveillance plan, identifying gaps that require additional attention.

In addition to supporting these large surveillance activities, the epidemiologist will provide technical support

as needed as a member of the Research Technical Working Group, BSS Technical Working Group, and

HIV DR Task Force.

Activity 2: Assist Develop a National Surveillance Plan

The USG Epidemiologist will continue to work with MoH, NAC and other stakeholders to develop a national

surveillance plan that includes both sero/biological surveillance as well as behavioral surveillance. This

includes the development of an operational plan for the MoH Epidemiology Unit as it takes responsibility for

conducting and or assuring HIV Surveillance

Activity 3: Maintain Collaborative Relations

The USG Epidemiologist will maintain collaborative working relationships and promote mutual sharing of

surveillance data and analysis from HIV/AIDS programs with other USG partners, local NGOs, and donors.

The Epidemiologist will provide technical assistance for planning, analysis and use of existing data as part

of on-going 2nd Generation Surveillance, e.g. Triangulation analysis.

Summary

This activity is linked to the activity narrative in HTXS ID# 15422 describing the USG intergagency team

Medical Officer.

Background

USG Malawi plays a critical role in providing technical assistance to the Ministry of Health (MoH) in planning

and implementing HIV/AIDS programs. Therefore, in FY 2008 CDC will hire a Medical Officer to provide

senior technical leadership and management to the inter-agency USG team and its partners, including the

National AIDS Commission (NAC) and MoH, in the provision of quality HIV/AIDS treatment and care

services.

The Medical Officer will provide expert advice and direct technical support as it relates to training clinical

officers, nurses, and other service providers in the management of AIDS cases; will represent the USG

team on several Technical Working Groups; and will be critical to the overall USG strategy of strengthening

capacity and systems for AIDS patient care provided by the Government of Malawi and other partner

institutions.

Activity 1: Training support to MoH staff

i). The USG Medical Officer will provide USG technical leadership for training clinical officers, nurses, and

other service providers in the management of

AIDS cases.

ii). The USG Medical Officer will mentor key staff of USG partner institutions for leadership roles in clinical

HIV/AIDS service provision.

Activity 2: National Policy Development

i). The USG Medical Officer will participate as a subject-matter expert in the development and

implementation of national policies for the proper

management of TB/HIV co-infection.

ii). The USG Medical Officer will participate as a subject-matter expert in the development and

implementation of policies that greatly increase access to

ART services by eligible pregnant women.

Activity 3: Technical Working Groups

The USG Medical Officer will represent the USG team on several technical working groups including:

i). Care and Treatment

ii). Pediatric Diagnosis and Referral

iii). TB/HIV

iv). Scientific Planning and Information Dissemination

This narrative describes the CDC Malawi M and S needs for both GHAI and Global AIDS Program (GAP)

funds. The CDC Malawi M and S budget, including GHAI and GAP funding, has been vetted through the

interagency decision making process and agreed to as presented in the FY 2008 COP submission.

Malawi is not a PEPFAR focus country but Malawi receives significant resources from the Global Fund for

AIDS, TB and Malaria (GFATM). Because of the very limited human and technical capacity to implement

programs in Malawi, the GFATM depends on the USG to complement their efforts by providing critical

technical staff to assist with program design and implementation. The USG Malawi team's M and S goals

reflect a strategic approach to both addressing the needs of the GFATM programs and that of the programs

directly supported by the USG. The M and S plan for the HHS/CDC office in Malawi, is designed to have

sufficient staff during the FY 2008 period and beyond, to provide appropriate technical and programmatic

oversight and assistance to all implementing partners in Malawi. The CDC M and S budget in FY 2008

COP supports the USG interagency team process of providing technical assistance and monitoring of

PEPFAR activities across a significant array of implementing partners in Malawi. CDC has seven

cooperative agreements supporting a broad range of implementing partner activities including GFATM

activities in nine program areas. Upcoming RFA awards will add two new partners in calendar year 2008.

To achieve the goals of effective technical assistance to the Government of Malawi and its' implementing

partners, the CDC GAP Office in Malawi had planned for fifteen positions in FY 2008. This is an increase of

one technical position (Medical Officer) over the previous year. Two technical positions were originally

planned for in 2008 however limits in our budget did not permit the addition of the second position, a

Laboratory Specialist. If funding is available and the entire PEPFAR USG team is in concurrence we will be

able to fill this position in FY 2009.

The FY 2008 COPHHS/CDC staffing plan includes four USDH that are comprised of the Chief of Party,

Deputy Director, Medical Officer, and Epidemiologist. No new USDH positions are sought in COP 2008.

The current HHS/CDC staffing plan also includes two non PSC contractor positions; a Monitoring and

Evaluation Officer and a Counseling and Testing Specialist (both supported through Comforce) and one

ASPH fellow. We are currently converting both our Comforce non PSC contractors to US PSC positions in

FY 2008. Additionally we have eight FSNs which include a Program Management officer, an Administrative

Officer, two IT support staff, three drivers and one custodian.

M and S costs are inclusive of rent for offices, utilities, office operational costs, M and S specific equipment,

travel for M and S staff, training for M and S staff, residential leases and post allowance for the 2 USDH M

and S positions, and increased communications costs related to enhancement of office communications

and connectivity. This FY 2008 COP submission does not include HQ TA support in keeping with FY 2008

COP guidance that this will be funded through the Headquarters Operational Plan process.

ICASS charges of $366,000 and CSCS charges $178,525 are budgeted separately in their own activities

with the prime partner listed as State as required by FY 2008 COP guidance.