Summary

With EP funding, The EGPAF program will provide comprehensive PMTCT services and referrals, linking

HIV-positive mothers, exposed infants, and children to HIV care and treatment services and training of

PMTCT service providers. Services provided in these clinics include: HIV/PMTCT education to

communities; routine counseling and testing (CT) for all pregnant women; CD4 testing for all HIV-positive

women; infant feeding counseling; provision of comprehensive antenatal, obstetrical, and post-natal care;

provision of antiretroviral prophylaxis to mother and infant pairs; cotrimoxazole prophylaxis for all exposed

children and their mothers; and the provision of social support for HIV-infected and lactating mothers

through clinic-based support groups.

Background

In 2001, EGPAF began supporting PMTCT in Malawi with private funds and in 2002 partnered with the

Lilongwe Medical Relief Fund Trust/University of North Carolina-Chapel Hill to launch the implementation of

PMTCT services.

In FY 2008, EGPAF will manage a cohesive unified program with private and USAID funding contributing to

the common goal of scaling up PMTCT services in Malawi using FY 2007 Emergency Plan (EP) funding.

HIV-positive mothers receive their NVP dose at the initial ANC visit, which has helped to increase the

uptake of maternal ARVs; introducing CD4 testing at the initial visit for all HIV-positive mothers has

increased the number of pregnant women accessing HAART. The PMTCT program works to strengthen the

continuum of care for HIV-positive women and their families by accommodating their medical needs within

the ARV care clinic, thereby adapting a family-focused care model.

EGPAF's expertise allows for maximum impact at both the policy and program levels. The immediate

objectives are to increase access to services that will prevent the transmission of HIV from mother to child.

The long-term goal is to strengthen the capacity of in-country health care facilities and the counterpart

national systems so that they can assume increasing levels of responsibility to provide comprehensive

PMTCT services. The Foundation works to integrate PMTCT into existing programs through antenatal care,

labor, and delivery and postnatal services for mother and infant. EGPAF provides TA, training, support for

related equipment, commodities, facilitative supervision, and M and E. EGPAF actively engages in national

policy task forces and working groups to bring the latest scientific evidence and the best program

approaches into discussion. Service integration will continue to be a priority, as will greater emphasis on

providing access to complementary prevention, care, and treatment services and facilitating longitudinal

follow-up of HIV-exposed infants.

Through EGPAF's partnership with UNC, 100% of ANC clients are counseled, 99% are tested and get their

results and 99% of HIV-positive mothers receive ARV prophylaxis to provide comprehensive PMTCT

services within government antenatal and postnatal care clinics. All antenatal women who test HIV-positive

receive CD4 tests and those with CD4 counts less than 250 are referred for care and treatment. CD4 testing

has helped to increase the identification of more HIV -positive women eligible for HAART by 25%.

EGPAF leverages a considerable amount of private funds to support the Ministry of Health (MoH) in its

PMTCT scale up. FY 2008 USG funds will augment this by building on a base of technical expertise already

existing to expand PMTCT even further. EGPAF will coordinate PMTCT program scale up with the MoH's

nationwide scale up of PMTCT services and work to strengthen the MoH's capacity to provide PMTCT

services. FY 2008 funding will be used to provide TA within or outside Lilongwe, strengthen social support

for HIV-infected mothers through community- and clinic-based support groups, and allow the program to

participate actively in the formulation and updating of PMTCT guidelines, national guidelines, and

curriculum development.

Activity 1: Strengthen PMTCT Services

In FY 2008, EGPAF will provide TA to their sub-grantees, UNC, and another partner (to be determined), to

strengthen ANC services at a minimum of six new sites (in high HIV prevalence areas) to integrate

comprehensive, high quality PMTCT services. EGPAF will coordinate with the MoH as they roll out PMTCT

services nationwide to reach underserved areas. Activities include support for provider-initiated and client-

initiated group pre-test counseling and testing using rapid test kits that enable clients to receive the results

on the same day. Post-test counseling will include maternal nutrition, infant feeding options, the importance

of postnatal care and family planning after delivery for both HIV-negative and positive women. For HIV-

positive pregnant women post-test counseling will include offering take-home NVP at the time of diagnosis.

The program encourages HIV-positive women to bring spouses/partners to be counseled and tested at

PMTCT sites to enhance support for wives/partners irrespective of the men's HIV status, reduce stigma,

and accord individuals/couples the opportunity to make informed decisions on accessing care and treatment

services. An emphasis is placed on male participation at the first ANC visit so that both partners can be

counseled and receive their results as a couple. This eases the pressure of partner HIV status disclosure

and thereby reduces the chance for gender based violence against women. Providers will continue to

counsel family planning clients, men, children, and other family members within PMTCT services as EGPAF

will be supporting the implementation of a family-centered care model using women as entry points to

families.

EGPAF will strengthen PMTCT services in maternity wards where women in the first stage of labor with

unknown HIV status will be given the opportunity to be counseled and tested for HIV. The women will be

given the results and ARV prophylaxis if they are positive, and exposed infants will receive ARV prophylaxis

as well. Pregnant women with unknown HIV status in the second stage of labor will be offered counseling

and testing after delivery and infants will receive appropriate ARV prophylaxis. Maternity staff will be

supported to modify obstetric practices during labor and delivery to reduce the chance of HIV transmission.

EGPAF will continue to mentor health workers and traditional birth attendants to encourage women with

known and unknown HIV status who deliver at home to return to the facilities with their newborn infants

within 48 hours (72 hours is recommended but this timeframe can make babies miss the opportunity for

NVP depending on the time the infant was born) for the infant to receive ARV prophylaxis including

Activity Narrative: counseling and testing of mothers with unknown HIV status. EGPAF will strengthen efforts to follow-up

women and infants in MCH after delivery to strengthen the continuum of care for HIV-positive mothers and

exposed infants and will continue to support acceptable management of medical waste practices at all the

sites.

EGPAF will promote innovative approaches to support the follow-up of mother-infant pairs and linkages to

care and treatment. EGPAF will explore strategies to fast track pregnant women to treatment services

including the identification of a reference laboratory for each PMTCT site, provide CD4 count to all HIV-

positive pregnant women (this is new policy from the MoH), provide training for MCH providers in HIV care,

and provide routine CD4 analysis of HIV-positive mothers to increase efficiency of linkages to care (See Lab

summary and narrative on CD4 machines).

EGPAF will coordinate with the MoH's national PMTCT scale-up plan and with other partners providing

PMTCT services to ensure that services are complementary and work to avoid district and services

duplication. In coordination with the MoH, EGPAF will focus on sustainability by strengthening health care

worker skills through training and preceptorship activities in PMTCT services, and strengthening M&E skills

to enhance collection of quality data at the sites. EGPAF will support the sites to ensure that they provide

take home NVP tablets at the time of diagnosis.

EGPAF will support strengthening of a PMTCT M&E system with an emphasis on improving the quality of

data collection, data analysis and reporting.