OVC activities wraparound education efforts

New/Continuing Activity: Continuing Activity

Continuing Activity: 29422

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

29422 29422.08 U.S. Agency for Academy for 12040 12040.08 OVC/AED $100,000

International Educational

Development Development

Table 3.3.13:

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 14 - HVCT Prevention: Counseling and Testing

Total Planned Funding for Program Budget Code: $1,720,740

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Context

High quality HIV Counseling and Testing (HCT) is one of the most successful interventions in the national response to HIV/AIDS

in Malawi. From just 50 testing sites in 2004, Malawi now has over 750 HCT sites in the public and NGO sectors. There are over

2,000 trained counselors providing services in the country. Early in 2008 the standardized HCT training was compressed from its

original 5 weeks to three weeks without compromising the quality of the training. Malawi's success in HCT service uptake has

been complemented by several major policy changes; the acceptance of provider-initiated testing and counseling (PITC) with an

opt-out clause, the focus on offering testing services to all pregnant women in antenatal clinics as part of an expanded PMTCT

program, the offering of testing to all TB suspects, and the transition from parallel to serial HIV rapid testing.

In addition to the significant policy changes, the increased publicity surrounding national HIV testing week campaign which is

conducted once a year has raised awareness of this service and promoted it's rapid uptake. Counseling and testing week targets

the general population by taking services to the community, with a heavy emphasis on outreach, mobile, and more recently door-

to-door testing. In both previous campaign years, the targeted number of people to be tested was exceeded by at least 35%. The

success of the first two testing week campaigns indicated that Malawians were eager to access HCT services when those

services are made more accessible. A national shift in HCT models is rapidly emerging as HCT is taken closer to potential clients

through outreach and door-to-door programs and well as mobile programs for hard-to-reach communities. In the first quarter of

2008, 21% of all testing reported to the Ministry of Health (MOH) were outreach sites as opposed to static sites. With the

diversified models of HCT practiced in Malawi, including outreach, mobile, and door-to-door testing, larger numbers of people than

ever before are accessing testing and subsequent referrals to care and treatment. Impressively, between July 2007 and June

2008 over 1,000,000 individuals were counseled and tested for HIV.

A major challenge to HCT services particularly in stand-alone non-medical facilities, mobile clinics, and in outreach programs, is

the national policy of anonymous testing. A transition from anonymous to confidential counseling and testing will greatly improve

the linkages between HCT and other HIV/AIDS services in Malawi.

Previous USG Support

PEPFAR funding for HCT services previously focused on five major areas; 1) Central-level coordination, 2) Support to major

implementing partners, 3) Training counselors and service providers 4) Quality assurance of the use of simple HIV rapid tests,

and 5) HIV testing week campaign.

i. Central-level coordination

USG hired and placed a senior-level Technical Assistant (TA) with the Department of HIV/AIDS MOH. The TA works with

technical staff from the USG and host country counterparts, to coordinate all HCT activities in the country. He oversaw the HCT

component of quarterly supervisory visits to all HCT sites. He guided the development of key policies such as the Provider-

initiated testing (PITC) policy which is critical to the implementation of routine HCT in hospital and clinic settings. The TA

coordinated training for HCT providers and oversaw the seamless transition from a 5-week to 3-week training model for HCT

providers. The TA also coordinated the development and dissemination of key guidelines including the guidelines for pediatric

counseling and testing. The TA coordinated the two previous national HIV testing week campaigns.

ii. Major implementing partners

USG directly supported three of the major NGOs which provide HCT service in the country; MACRO, Lighthouse, and BASICS.

MACRO, a local NGO with 6 stand-alone and several outreach and mobile counseling and testing operations tested 124,723

individuals in FY08. Similarly, Lighthouse, another local NGO and one of the largest providers of care and treatment services,

provided HCT services to 34,106 clients in 2008. BASICS is another USG partner which has active HCT services in 8 of the 28

districts of the country and they tested 35,574 individuals in 2008. MSH/SPS provided HCT services to 7,108 and EGPAF

provided HCT services to 39,003 in PMTCT settings. Altogether this accounted for 194,403 people tested; almost 22% of the

total number of people tested in Malawi during FY08.

iii. Training counselors

USG supports the training of HCT counselors through support to two partners, MACRO and Lighthouse. At MACRO, USG

supports salaries of all trainers and the physical infrastructure of the training facility. At Lighthouse USG supports a TA to oversee

training efforts. The efforts of the training unit extend beyond the training course provided at Lighthouse; they provide ongoing

mentoring support to graduates from their training program. Between the USG partners, 677 counselors were trained and

mentored in 2008.

iv. Training and quality assurance of HIV rapid tests

With direct funding support to the National Reference Laboratory (NRL), and USG technical assistance, Malawi successfully

transitioned from a parallel to a serial HIV testing algorithm. USG assisted the NRL in the creation of job aides and provided

training assistance to service providers throughout the country. USG also supported the establishment of a national Quality

Assurance program for HIV rapid tests to ensure that reliable test results are generated at all the testing sites in the country.

v. HIV testing week campaign

For the past two years USG supported the successful HIV testing week campaigns. In 2006, over 89,000 individuals were

counseled and tested for a pre-launch target of 50,000. In the following year, 186,000 individuals were tested of a targeted

130,000. For 2008 the target has been set at 250,000, and the campaign is in effect from November 10-16. USG support for the

2008 campaign involved coordination at the central and district levels, procurement of commodities, assistance with training,

implementation by USG supported partners, quality assurance of the tests and testing process, design of data collection forms,

and analysis of the data from the campaigns.

FY09 USG Support

In FY09, USG through PEPFAR will support Malawi's goals of increasing access to, and improving the quality of, HCT services.

USG will also work with partners to improve linkages between HCT and other treatment and care services. This will be done

through 1) continued provision of national level technical assistance, 2) advocacy for aggressively implementing the PITC policy,

3) Improving access to HCT through training and deployment of additional counselors to districts, 4) policy changes which would

permit confidential instead of anonymous HIV testing at client-initiated testing and counseling sites, and 5) continued support for

HCT in the Malawi Defense Force (MDF) facilities.

i. Supporting technical leadership of HCT at national level

The MOH through the Department of HIV/AIDS coordinates HCT activities at the national level. This has been done through

effective planning, setting national priorities and standards, developing and overseeing the implementation of national guidelines,

and providing quarterly supervisory visits to implementing partners across the nation. Besides providing additional human capacity

at the MOH, USG-supported TA has had a significant impact on the quality of HCT services nationally. In FY09, USG funds will

be used to continue supporting HCT at national level through the ongoing support of the HCT TA. Additional direct support will be

provided through technical assistance from the USG Agencies and other key PEPFAR funded implementing partners.

ii. Advocacy for improving Provider-initiated Testing and Counseling

PITC was officially endorsed by the MOH in 2007 Implementation of the program has been unacceptably slow. USG will work

directly with MOH and indirectly through partner institutions to both advocate for and implement a much more aggressive PITC

program.

A phased-in approach to PITC is planned with primary funding secured from the GFATM and available from September 2008.

Implementation of PITC will be done in part through the USG partner BASICS. BASICS has a low-cost, high impact program

which provides a total of 16 counselors to 8 district hospitals, and contributed over 35,000 tests in the 2008 calendar year. These

counselors will play a critical role in implementing PITC in the facilities they are assigned to.

Early in 2009, USG will provide additional technical assistance for the implementation of PITC in Malawi. The HCT TA, national

HCT coordinators, and in-country USG staff will engage the District Health Officers (DHO's) and work with them to develop and

implement district-wide PITC plans. PITC will first be implemented in those health care facilities providing services to populations

with high prevalence of HIV as well as TB and in STI clinics. In some of these facilities, PITC is already implemented at ANC sites

for mothers. With PEPFAR funding these services will be strengthened by the deployment of additional HCT staff. Also, with the

expansion of the USG-supported DNA-PCR based Early Infant Diagnosis (EID) program, HIV-exposed infants from 6 weeks of

age will benefit from PITC. PEPFAR funds will be used to increase access to these services through increasing the number of

sites offering PCR testing as well as strengthening referral networks. Full implementation of PITC into general clinics and wards

will follow.

iii. Supporting improved access and quality of HCT services at district level

The MOH relies on three major PEPFAR funded partners; Lighthouse, MACRO, and BASICS to train HCT counselors. These

partners have the mandate to train HCT counselors for all three regions of the country. Lighthouse and MACRO have both

employed a model which allows for mentoring after the completion of training, ensuring that quality HCT services are provided

after the counselors' deployment. With the recent Government of Malawi policy on decentralization of training to districts there is

concern that the quality of training is being compromised as districts implement the national HCT training curriculum with limited

monitoring of the training process and of trained counselors. The three USG partners are in an excellent position to support the

decentralization process through becoming a training resource to individual districts. In recognition of the changing needs of the

MOH, FY09 activities will include adjusting the USG partners training model to complement the new national decentralized

approach to training. This will likely include more extensive mentoring of both the district-level trainers and the HCT providers

after their training and deployment to the districts.

MACRO reported that by the middle of 2008 approximately 80% of all HIV tests conducted were at outreach and mobile sites,

showing that a high demand for HCT access in remote and rural areas exists. Outreach sites as defined by MOH are sites which

are visited periodically and do not retain their own register, and mobile sites are those which are temporary. In FY09, MACRO will

be funded to increase access to testing services through expanding their outreach and mobile HCT programs. Efforts will be made

to seek concurrence from the MOH allowing MACRO to provide confidential HCT to show proof-of-concept that clients can be

definitively linked to other HIV/AIDS services.

In FY09 USG will support BASICS in evaluating a project which looks at utilizing lay counselors who are hired by NGOs and

seconded to MOH facilities to perform HCT instead of medical staff. If this project is successful, these lay counselors may help

address the human resource shortages by freeing medical staff to utilize their higher-level technical skills in the areas they trained

in.

In FY09 USG will also promote the deployment of HCT counselors to district health facilities from funded partners. These

counselors will increase access and quality of HCT services, and enable MOH's implementation of PITC. These counselors will

play a critical role in both providing HCT services and ensuring that the linkages between HIV testing and antiretroviral clinic

services are strengthened.

iv. Policy changes form anonymous to confidential HCT

A major barrier to linking HCT with other HIV/AIDS services is the national policy which supports anonymous testing instead of

confidential testing. Without names or identifiers on records it is not possible to track clients who are referred from HCT providers

to ART or other programs. This is a missed opportunity for providing continuum of care from diagnosis to treatment.

In FY09, USG will provide funds and technical assistance to Lighthouse and MACRO and help them demonstrate to the MOH the

value of confidential HCT when it is linked to other HIV-related services through an electronic data system. Both institutions

currently use an electronic data system to capture routine client data. It is hoped that the routine data from this system will provide

evidence to promote a change in national policy from anonymous to confidential counseling and testing.

v. HCT in the Armed Forces

The Malawi Defense Force (MDF) has eight HCT centers covering ten barracks, garrisons, and other facilities. Six of the HCT

centers were constructed with USG funds. The HCT centers are open to all military, their family members, and the surrounding

community. Over 60% of those tested are civilians. In FY09 no increase in current activities is anticipated.

Compact Funding Program Plans

GOM and PEPFAR have discussed a framework under which a new partnership agreement will be developed using FY08 and

FY09 Compact funds. In September 2008, a Concept note was submitted to OGAC, and the country team was given approval to

begin developing a partnership compact with the GOM. Counseling and testing is a priority area under consideration.

In collaboration with the GOM, USG would prioritize the following: 1) achieving increased access to HCT through expansion of

mobile HCT services; 2) supporting nationwide scale-up of provider-initiated testing for all individuals accessing treatment at

health care facilities in Malawi with particular focus on individuals accessing TB and STI services through the provision of

additional lay counselors; 3) improving the training curriculum for HCT providers to include specialty areas such as pediatrics; 4)

expanding the role of USG-funded partners in providing mentoring and quality assurance of HCT services nationally; and 5)

increasing the availability of EDS in health facilities to promote the linking of HCT, pre-ART, and ART services.

Table 3.3.14: