New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.05:

Summary

JHPIEGO will assist the Ministry of Health (MoH) to complete the roll out of the performance and quality

improvement initiative in infection prevention to all districts in an effort to reduce HIV and possible Hepatitis

B transmission among health providers in health facilities. This will be achieved through facilitating

sensitization meetings, training quality improvement and assurance support teams in infection prevention

(IP), conducting baseline assessments at the facilities, conducting monitoring and supervision at facilities,

addressing identified IP gaps with available resources, and working with District Health Management Teams

(DHMT's) to ensure they budget sufficient funds to guarantee the availability of adequate and consistent

supply of IP commodities. Target population for the program is the general population. These activities wrap

around performance and quality improvement work to be undertaken by JHPIEGO with family planning and

maternal and child health funding.

Background

Since 2002, JHPIEGO Malawi has worked with MoH Nursing Division and the National Quality Assurance

Steering Committee (NQASC) to improve IP practices in hospitals throughout Malawi. As the JHPIEGO

bilateral agreement comes to an end in September 2007, the follow-on activities in this area will be

undertaken through a central agreement with JHPIEGO. Among the critical activities to be completed is the

roll out of the national IP guidelines and standards to all health facilities.

To date, the PQI/IP process has been introduced in 35 hospitals. Improvements have been documented in

all hospitals and nine have achieved recognition by MoH. JHPIEGO will continue to roll out this initiative to

other facilities and support the existing facilities to achieve recognition status.

Activity 1: Development of National Guidelines

JHPIEGO will build on the assistance provided through the previous JHPIEGO bilateral project to help the

MoH in developing national guidelines and standards for IP. The infection prevention standards cover 14

departments of the hospital that includes the operating theater, labor/maternity wards, medical wards,

surgical wards, casualty department, laboratory, dental, and family planning clinics; and these are being

implemented in 35 health facilities covering all central and district hospitals. Two thousand and twelve

health workers in Malawi have been trained in injection safety with technical support from JHPIEGO and

other USG partners MSH and Save the Children. With FY 2008 funding, JHPIEGO will provide support in

increasing the capacity of health care institution workers to prevent occupational exposure to HIV, Hepatitis

B and other infections including hospital-based nosocomial infections. The first activity is to provide

supportive supervision to the existing 35 hospitals throughout Malawi that have already been introduced to

the national IP standards so that a maximum number of sites receive certification as meeting MoH infection

prevention standards and guidelines. These activities will be coordinated with activities carried out by USG

partner Pact Malawi (ID#17396)

Activity 2: Technical Assistance

JHPIEGO will expand the provision of technical assistance to the MoH to adapt the standards to be

applicable at the Health Center levels so that correct IP practices can be extended. As part of this process,

JHPIEGO will also assist the Reproductive Health Unit (RHU) and the Nursing Directorate to create a

method of recognition and certification for Health Centers which achieve IP standards.

Activity 3: IP Standards

JHPIEGO will work with stakeholders at the district level to roll out IP standards to the Health Center level.

JHPIEGO will demonstrate this process in 15 Health Centers and encourage MoH, DHMTs, and other

partners to take up this initiative.

Activity 4: Training in Injection Safety

JHPIEGO will train 180 health care workers in safe injection practices and universal precautions as well as

introduce health care workers to procedures for using post exposure prophylaxis (PEP). Four training

sessions will be held at these 15 sites, and three members at each facility will be trained. JHPIEGO will

continue to work with the existing 35 hospitals to address multiple underlying factors affecting facilities'

ability to meet their IP goals. Pact Malawi will extend this training and disseminate PEP information to

greater numbers of health care workers (see Pact Injection safety narrative).

This funding will go specifically to support hospital staff training in providing injection safety and hospital

supervisory staff training in ensuring a minimum quality standard for services.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17131

Continued Associated Activity Information

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

System ID System ID

17131 5924.08 U.S. Agency for JHPIEGO 7665 5630.08 JHPIEGO CSH $100,000

International

Development

11127 5924.07 U.S. Agency for JHPIEGO 5630 5630.07 JHPIEGO CSH $0

International

Development

5924 5924.06 U.S. Agency for JHPIEGO 3884 3884.06 $163,958

International

Development

Program Budget Code: 06 - IDUP Biomedical Prevention: Injecting and non-Injecting Drug Use

Total Planned Funding for Program Budget Code: $0

Program Budget Code: 07 - CIRC Biomedical Prevention: Male Circumcision

Total Planned Funding for Program Budget Code: $0

Program Budget Code: 08 - HBHC Care: Adult Care and Support

Total Planned Funding for Program Budget Code: $3,174,764

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Overview

Malawi is making progress towards achieving its target of enrolling 250,000 individuals on antiretroviral therapy (ART) by 2010. By

June 2008 there were 207 public and private health facilities delivering ART in all districts, with 184,405 patients ever started on

ART and 121,707 patients alive on ART, the vast majority of whom were initiated based on clinical staging.

With little to no pre-ART care available in country, there is a need to both expand care and treatment services to include pre-ART

care, as well as focus on quality of care and treatment for those already initiated on ART. Linking HIV counseling and testing

(HCT) services to HIV care services is important to reduce the number of HIV-infected individuals lost to follow-up once tested.

Malawi almost exclusively initiates people on ART based on clinical staging. The use of immunological staging and availability of

laboratory services can help move more people in need of treatment on to ART, and improve the quality of care and treatment.

Management of existing patients is anticipated to become increasingly complex as the Malawi program transitions from acute to

chronic care. Care and treatment challenges which USG will address in FY09 and beyond include a severe lack of human

resources at all levels and an M&E system which needs strengthening.

Increased focus on care and support services nationally is required in communities, as community care and support has not

developed as quickly or as systematically as ART services. The limited national, GFATM and PEPFAR resources which exist for

care and support are directed primarily at supporting community home-based care programs (CHBC) for chronically ill bedridden

patients (not limited to PLWHA) through CBOs and NGOs, even though approximately 90% of ART patients are ambulant. Other

challenges include limited national coordination of care and support; poor procurement and supply chain management of

cotrimoxazole, other OI drugs, and supplies for home-based kits; and a limited focus on prevention (including prevention with

positives). Malawi currently provides HTC for more than 1 million people a year. However, many individuals who have tested HIV-

positive and were not eligible for ART, have been lost to follow-up, and have therefore not benefited from cotrimoxazole

prophylaxis (CPT) and other care interventions that reduce disease progression and prevent opportunistic diseases.

Previous USG Support

Recognizing GFATM support, and in a strategic effort to fill critical gaps, USG funding for facility-based adult care and treatment

has been in human capacity development, training, laboratory services, M&E and program evaluation, while support for

community-based services has focused primarily on CHBC programs through international "umbrella" organizations such as Pact

Malawi, to provide technical and program management support to indigenous CBOs and NGOs. In FY08, Pact Malawi supported

10 partners including the Palliative Care Ass. of Malawi (PACAM) in partnership with Africa Palliative Care Ass. (APCA), National

Association of Persons Living with HIV/AIDS in Malawi (NAPHAM), Lighthouse Trust, and some CHAM health facilities. This

support was to provide clinical, prevention, social, psychological, and spiritual services for people living and affected by HIV and

AIDS in facility, community and home-based care settings. PACAM/APCA provided technical support to the Government of

Malawi (GOM) to scale up palliative care services in Malawi, develop palliative care guidelines and training manuals, train HBC

master trainers, advocate for increased access to opioids; and improve capacity of health workers to assess and manage pain.

Additionally, USG has supported long-term HIV/AIDS Technical Assistant (TA) in MOH, and Lighthouse, a Malawian NGO which

serves as a center of excellence for HIV/AIDS care and treatment, including CHBC.

FY09 USG Support

i. Human Capacity Building

USG will continue support to the national care and treatment effort by funding a medical officer and a laboratory officer as part of

the USG team. These personnel will provide technical oversight for the expansion and improved quality of care and treatment

services. Through ITECH, USG will fund a new clinical support team to assist MOH's Department of HIV/AIDS with the expansion

of HIV/AIDS treatment services throughout Malawi. The team will be comprised of a Senior TA and two Malawian Staff Fellows as

counterparts. The Staff Fellowship program is intended to attract Malawians into a mentorship program to help address MOH

concerns on human capacity development and sustainability of the HIV/AIDS treatment program. USG will continue to support

Lighthouse through funding senior staff, building organizational capacity, and supporting cross-cutting activities such as task

shifting. PACAM/APCA will train palliative care service providers, and sensitize medical training institutions to include palliative

care in pre-service training for health professionals. Pact/Malawi partners will also train home-based care providers.

ii. Laboratory Capacity Building

In partnership with Howard, USG will continue supporting the expansion and sustainability of MOH in laboratory capacity building,

human capacity building and training, uninterrupted flow of laboratory supplies and reagents, quality assurance/quality control

systems, and service contracts for essential laboratory equipment. Laboratory training will include CD4 and CD4% enumeration,

chemistries, hematology, and diagnosis of common infections including opportunistic infections. The training will aim at building

the capacity of lab staff to provide support for HIV services while maintaining quality standards.

iii. Early Referral and Retention in Care and Support

FY09 funding activities will strengthen referral, feedback and patient tracking systems which will facilitate access to a continuum of

HIV/AIDS prevention, care and treatment services, and reduce loss to follow-up. Proposed activities include mapping existing

services: HCT, PMTCT, ART, food and nutrition, livelihoods, malaria, TB, FP services; developing referral directories, simple

referral, feedback and patient tracking tools to improve clinical care and tracking of HIV-infected persons; and providing

psychosocial and adherence support to pre-ART and ART patients. USG will work with MOH, Lighthouse, Pact, and other

stakeholders to adapt successful referral and patient tracking models in Malawi for phased national scale up, and address

program barriers to retention in care such as transport. PLWHA support groups will play a key role in community patient tracking

efforts, and with support from health care workers they will continue to lead interactive individual and group sessions with PLWHA

on positive prevention, disclosure, nutrition, alcohol, safer sex, FP, and positive living.

iv. Cotrimoxazole Prophylaxis and HBC kits

According to the national policy on the use of CPT, the main indications for CPT for any adult living with HIV include symptomatic

HIV disease [Stages 2, 3 and 4] or a CD4 count of 500/mm3 or less, regardless of symptoms. Thus, all patients eligible for ART

are also eligible for CPT. However regular access to CPT remains a serious challenge, as does stocking and replenishing of HBC

kits. USG support will focus on supply chain management through PEPFAR-funded Deliver and Strengthening Pharmaceutical

Services projects to increase access and coverage of CPT and other commodities, and working with MOH to advocate for

increased awareness of CPT in routine HIV care. USG will also explore revising home-based care kits to a manageable number of

critical commodities.

v. Expanded Community Support for HIV Services

USG will partner closely with the National AIDS Commission and MOH to pilot an "expanded community support model" which

complements facility-based HIV services, as well as gender-sensitive community home-based care for bedridden chronically ill

patients with increased adherence and gender sensitive psychosocial support for ambulant ART and pre-ART patients in a few

districts. The key components (5Rs) of the model are to improve Readiness of patients for early and timely initiation to treatment

(ART and cotrimoxazole), support ART and pre-ART patients in adherence and Retention; improve Responsibility of patients

through prevention with positives and positive living; early Referral for ART patients with drug related problems; and Reporting

through simple tools. PEPFAR will support "centers of excellence" such as Lighthouse to mentor other facilities and community

partners and pilot the model in PEPFAR supported programs.

v. Palliative Care

Access to analgesics, especially opioids is a major challenge because of restrictions on opioid prescription by nurses, poor clinical

training in opioid pain management and lack of pain management guidelines. USG will support PACAM/APCA advocacy efforts to

improve access to morphine, and revise current opioid prescription practice to allow nurses prescribe morphine. USG in

collaboration with MOH and PACAM/APCA will also develop opioid guidelines, national M&E guidelines for care and support, and

integrate palliative care into HBC programs.

vi. Basic Care Package

USG will work with MOH to explore developing and standardizing an essential care package for facility and community-based

care. The package is likely to include CD4 counts, cotrimoxazole, TB screening and management, insecticide-treated bed nets

(ITNs), livelihoods, food and nutrition assessment, positive prevention (HCT for family members and other contacts, status

disclosure, FP), pain and symptom management, safe drinking water, personal hygiene and succession planning for children and

families. PEPFAR and PMI will strengthen linkages to the proposed GOM universal access for ITNs that will allow non-pregnant

PLWHA to receive ITNs.

vii. Food and Nutrition

FY09 focus is to strengthen nutrition in care and support interventions through technical assistance from the PEPFAR Nutritionist.

PEPFAR-funded partners will conduct nutrition assessments for PLWHA through facilities and HBC programs to identify and refer

malnourished patients to MOH "food by prescription" programs available at most ART sites. PLWHA support groups and HBC

volunteers will also provide nutrition counseling (and food support from wraparound programs where available), and support

PLWHA and their families to maintain home gardens for improved nutrition. Using FY08 "plus-up" funding, public private

partnerships will be implemented in FY09 with Project Peanut Butter to increase local production of ready-to-use therapeutic foods

to manage malnutrition in PLWHA, and with Land-O-Lakes to provide milk and HIV prevention services to households with

chronically ill patients and vulnerable children.

viii. Monitoring and Reporting for PEPFAR

In Malawi, a person may be counted as a care and support client if HIV-infected (diagnosed or presumed), or HIV-affected, and

provided with at least one clinical and one non-clinical care and support service directly supported by PEPFAR funds at any

service delivery level. This definition strengthens the provision and referral to key clinical care services for HIV-infected individuals

in both facility and community-based settings. These numbers are calculated from routine data accompanied by quarterly

supervision visits and verified in the annual situational analyses. All services are provided through public and private facilities, and

double-counting only pertains to clients who transfer to a different treatment site. The scale-up of the electronic data system with

FY09 funds will better capture this information.

ix. Quality of Care and Support Services

PEPFAR quality activities will focus on improved supportive supervision and feedback to program volunteers, and improved

outcomes for PLWHA through improved retention in care and treatment. PEPFAR will also collaborate with MOH and other

partners to standardize program monitoring indicators and data collection and reporting tools on care and support.

x. Support to the Malawi Defense Force (MDF)

FY09 funding would be used to expand the reach of MDF's HBHC program by procuring motor bikes and motor ambulances for

use by MDF's caregivers; and expand the current program to include home-based testing and other services. PEPFAR funds will

also enhance the clinical skills of military personnel using the training programs at the Infectious Disease Institute in Uganda. In

particular, the Training of Trainers course will be used to allow attendees at IDI to bring their newly gained knowledge back to

other personnel at their military hospitals.

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. Adult Care and Treatment is a priority area under consideration.

Additional USG compact funding would improve access to, and quality of, HIV care and treatment services. In collaboration with

the MOH and other partners, USG will support national efforts to create and improve the quality of services to pre-ART and ART

patients. Specifically, USG and partners will assist in rolling-out a basic palliative care package including quality-assured

immunological staging to identify PLWHA in need of earlier initiation of ART, improve pain management and access to opioids,

strengthening of longitudinal follow-up and referrals, optimizing linkages and integration between PMTCT, TB, and HIV care and

treatment services, and delivering quality laboratory services for patient monitoring. This support will increase the survival of

adults and children as Malawi moves towards reaching the goal of 250,000 people on ART by the end of 2010.

USG proposes a new care and support RFA to expand clinical, prevention, social, spiritual and psychological services for persons

living with and affected by HIV/AIDS, including a pilot of cervical cancer screening and treatment, thus filling an enormous gap in

the care for pre-ART and ART patients. The program will also strengthen national M&E systems and provide opportunities for

operations research on care and support.

USG will support the GOM Community Nutrition and HIV/AIDS Worker Initiative. This is a plan to pilot a new cadre of lower-level

community health workers who will assist in providing care for PLWHA and conducting activities at the community level to improve

nutrition. This activity will require careful application of USG Malawi's sustainability strategy, and may require a cooperative

agreement with the GOM.

Table 3.3.08: