Related to activity #1738, this is the PHE on MDR-TB surveillance. Funding level will follow.

Activity 6: MDR Survey Sub-Contract

Using FY 2007 funds, TBCAP will sub-contract the sample collection, data entry, and analysis aspects of

the MDR survey to a dedicated Malawian research team. This team will work with the NTP for at least three

months. TBCAP through Reach, NTP, and LSTM will engage the following research personnel: five

dedicated logistics and sample collection officers, one data manager, and two data entry clerks.

Administrative, transport, and logistic support will also be provided.

Summary

Previously the USG has provided technical assistance (TA) and support for TB/HIV through the MSH-TB

Control Assistance Program (TBCAP) with child health funding. The activities are focused on ensuring

quality of TB and HIV diagnosis and treatment at the Central TB Reference Laboratory (CRL) and local

laboratory sites in Zomba and Mangochi districts. The overall objective of the project is to strengthen

management and technical systems for the delivery of TB/HIV services in Malawi. This wrap around activity

is part of a larger USAID-funded TB program. In recognition of the needs of the National TB Program (NTP)

in Malawi, USG will also provide direct support to the NTP in FY 2008 (see narrative HVTB ID# 15410).

Background

The National TB Program (NTP) in Malawi has attempted, and failed, to conduct an MDR-survey since

2001. The central obstacle to successful completion of this survey is the non-functional Central TB

Reference Laboratory (CRL), particularly the lack of competent leaders and managers within the laboratory.

Additional difficulties in the health system around sample collection and case detection though important,

are non functional in some local labs.

USG Emergency Plan (EP) funds and other wrap around funding will be used to rebuild and strengthen the

capacity of CRL and selected local labs to implement the MDR-TB survey. The proposed key activities to

be funded with EP funds by TBCAP will include the complete refurbishment of CRL and selected local labs

in Zomba and Mangochi districts, improving the management and technical capacity of CRL staff through

international TA and sub-contracting of sample collection, data entry, and analysis aspects of the MDR

survey by a dedicated Malawian research team to work with the NTP. In addition, a basic "TB/HIV

package" will be implemented in selected health facilities that will help build capacity for joint TB/HIV

planning, monitoring and evaluation (M and E), and surveillance of HIV prevalence in TB patients in Zomba

and Mangochi districts. Malawi recently applied for a $35million TB Grant through the Global Fund Round 7

call for proposals. Should additional resources become available, this effort by TBCAP could be expanded

into more districts beyond Zomba and Mangochi.

Key previous achievements using USG support have included

• Drafting the Terms of Reference (TOR's) defining the working relationship between TBCAP and the

National TB Program (NTP)

• Drafting the TOR's defining the working relationship between TBCAP, REACH Trust, and the Liverpool

School of Tropical Medicine (LSTM)

• Conducting the baseline survey in Zomba and Mangochi from the 22nd to 27th May 2007

• Conducting orientation meetings of 400 Health Center health workers on the role and function of TBCAP

TBCAP started activities in April 2007. During the three months start-up period, the project team focused on

organizing the administrative and logistics support as well as providing orientation to the MoH district teams.

Now they are shifting focus to technical activities.

Activity 1: Build Capacity for TB/HIV Control

The following activities will be implemented with FY 2007 EP funds:

i) TBCAP will organize collaborative national meetings between NTP and the HIV/AIDS unit; the Zonal

Health Management Team (ZHMT) in selected zones, districts, health centers, and communities in an effort

to implement the model of care for TB and HIV.

ii) TBCAP will identify/set up/support district and community level committees with broad representation, to

guide and monitor TB/HIV activities.

iii) TBCAP will assist the NTP and the MoH's ART program to organize stakeholders to fine tune,

implement, and scale up the model for the "continuum of integrated TB/HIV care" in a step-wise approach in

selected districts in the South East Zone.

iv) Using current norms and guidelines of the TB and ART programs, TBCAP will adapt the roles and

responsibilities for integrated TB/HIV services at each level and document in the form of SOPs.

v) TBCAP will develop/adapt training and reference materials for community health workers, home-based

care workers, and HSA's.

vi). TBCAP will mobilize the communities to become engaged in TB and HIV integrated care.

Activity 2: Consolidate Model of Integrated TB/HIV Care from Zones to Home Model.

TBCAP will support the implementation and scaling-up of community sputum collection sites and use EP

funds to assist the District Health Officer (DHO) implement and monitor the integrated model of care at the

district level.

To improve case detection on TB/HIV cases and quality of care the project will design and implement a

"TB/HIV kit" in line with the Essential Health Package (EHP) on selected health facilities in Zomba and

Mangochi districts. The EHP is the minimal set of services offered to every Malawian through the Sector

Wide Approach (SWAp) plan. USG EP funding will support minor refurbishment of treatment areas for TB

and TB/HIV patients in selected health facilities in both districts.

Activity 3: Complete Refurbishment of CRL and Local Labs in Zomba and Mangochi Districts.

With previous USG support, TBCAP initiated refurbishment of CRL. With FY 2008 EP funds, TBCAP will

complete the refurbishment of the CRL, ensuring that basic working and biosafety conditions are in place.

Once the refurbishment is completed, the MDR survey will be conducted finally.

Activity Narrative: Activity 4: Provide Technical Assistance to the CRL

Technical assistance to the CRL is an identified need. With FY 2008 EP funds, TBCAP will hire an external

consultant detailed to the CRL through REACH Trust, NTP, and the LSTM tasked with training the CRL

team, including the transfer of knowledge and skills to assist effectively the implementation of MDR survey

activities. The Consultant will be in hired for 6 months.

Activity 5: Improve Management and Technical Capacity of CRL staff.

Using FY 2008 EP funds, TBCAP will review the position descriptions of the 2 laboratory technicians

currently employed by the CRL to ensure the staff are capable of doing the necessary laboratory work in

microbiology, run quality assurance, and link the latter with the external quality control measures provided

by the supra-regional laboratory in South Africa for the MDR survey. The lab technicians will be provided

with the necessary training to ensure they are technically capable of providing reliable data for the survey.

This is a new activity.

Activity 6: MDR Survey Sub-Contract

Using FY 2007 funds, TBCAP will sub-contract the sample collection, data entry, and analysis aspects of

the MDR survey to a dedicated Malawian research team. This team will work with the NTP for at least three

months. TBCAP through Reach, NTP, and LSTM will engage the following research personnel: five

dedicated logistics and sample collection officers, one data manager, and two data entry clerks.

Administrative, transport, and logistic support will also be provided.