NOTICE - Per the recommendation from OGAC that Malawi as an FY2008 Compact Country, submit a mini

-COP (i.e. program area level narratives only), this activity level narrative has not been updated prior to the

submission of the FY09 Full COP. The Malawi country team anticipates updating narratives upon

completion and final approval of the negotiated 5-year Compact between the United States Government

and the Government of Malawi.

Summary

Through sole sourcing, USG Malawi will partner with the National TB Program (NTP) to develop a national

implementation plan based on a new TB/HIV strategy, extend pilot TB/HIV services, monitor trends in

TB/HIV co-infection, and strengthen the monitoring and evaluation (M&E) of TB/HIV activities.

Overall these planned activities are expected to result in

• Improved coordination of National TB/HIV collaborative activities

• Increased HIV testing of TB patients

• Increased screening for TB in HIV service settings (especially CT and ART)

• Improved documentation of integrated TB/HIV services

• Improved monitoring of TB/HIV co-infection

• Effective supervision of decentralized treatment of MDR-TB cases of identified through the national

surveillance system

Background

A well functioning national coordinating body is critical for effective implementation of TB/HIV activities.

Malawi's TB/HIV coordinating body was established in 2003 as a precondition for implementing the first 3-

year TB/HIV development plan. The body functioned well initially but became weaker over time and was

non functional by the end of 2005. With technical support from USG Malawi, in mid 2007, NTP and the

HIV/AIDS Unit initiated consultations with stakeholders to re-establish a national TB/HIV coordination body

and terms of reference revised in line with current priorities. The coordinating body has constituted a task

force to develop a new National TB/HIV strategic plan that replaces an earlier version which expired in

2005. Prioritization of activities for the new plan period has been done with significant technical input from

USG partners and the new strategy will be in place by the end of 2007.

The USG, MSF-Belgium, and other partners already are supporting a number of successful pilot projects

that integrate TB/HIV activities in different settings. For example, Lighthouse uses partial funding from USG

to implement a model pilot TB/HIV project which integrates HIV testing and counseling (CT) and referral to

ART services as a standard package of care for TB patients. Within the same comprehensive care project,

patients on ART are screened for TB using a standard checklist at every visit and referred to a TB clinic if

TB is evident or suspected. Similarly, all HIV positive clients identified at a co-located VCT center are

screened for TB using a standard checklist and referred for TB services if responses meet a set of

predetermined criteria. Similar activities are being implemented in a number of other sites though practical

details vary depending on infrastructure and human resource capacity. If rolled out, these activities

collectively can reduce the burden of TB in HIV patients and the burden of HIV in TB patients.

Malawi has implemented TB/HIV activities since 1999, when NTP started piloting the World Health

Organization (WHO) coordinated Pro-TEST project. Lessons from this project were applied in developing

the country's first 3-year TB/HIV plan whose implementation was driven solely by NTP. Using FY 2008 EP

funds, NTP will build on positive gains made over the past four years by assisting with an update of

Malawi's first TB-HIV strategic plan that expired in 2005. The focus will be to assist the National TB/HIV

coordinating body in: guiding implementation of the new National TB/HIV Strategy, leveraging resources for

core HIV and TB activities to roll out successful pilot programs that integrate CT in TB settings and TB

screening in HIV settings especially CT sites, ART Clinics, and medical wards. Also the TBD partner will

develop a minimum package of TB infection control measures to be implemented in congregate medical

settings. The infection control measures will only be phased in at five high volume ART and TB sites initially.

All planned activities are new and fit within a broader national TB/HIV effort implemented jointly with

Lighthouse and TB Country assistance Program (TBCAP) and non USG supported partners under the

umbrella of a single national TB/HIV coordinating body (Activity ID# 17384; Activity ID#5948). The activities

are linked to HVCT as a primary source of human resources and commodities for HIV testing and HTXS for

cross referral of HIV-positive TB patients, and screening of ART patients for TB.

Activity 1: Support National Coordination of TB/HIV Activities in Malawi

NTP will use FY 2008 EP funds to support national coordination of TB/HIV by providing resources for

quarterly meetings, supervision, and ongoing program monitoring at National, Zonal, and district levels. The

TBCAP project is already providing significant support for these TB/HV activities in two focus districts. To

avoid duplication of efforts and build on the ongoing efforts TBCAP is included in the membership of the

national TB/HIV coordinating body and the planned activities will target districts that are not covered by

TBCAP.

Activity 2: Roll Out Successful Pilot TB/HIV Activities

NTP will use FY 2008 EP funds to support the screening of HIV-infected patients for TB at 36 HIV

registration sites, and promote counseling and testing for TB patients at 47 TB registration sites that do not

currently provide these services. The process will involve training TB officers on routinely offering HIV

testing to TB patients; strengthening referral linkage between TB, ART, and VCT sites; and promoting

initiation of ARV therapy within TB settings where possible. Cotrimoxazole for prophylaxis in HIV positive TB

patients will be dispensed along with TB drugs.

Activity 3: Implement TB Infection in Medical settings

Activity Narrative: In Malawi, TB infection control is not in place in most settings where people are treated for HIV yet many

patients with potentially contagious TB congregate with vulnerable individuals in these sites. TB infection

prevention is not addressed adequately in the national strategy for infection prevention in medical settings.

NTP will use FY 2008 to support development of a national plan for tuberculosis infection control based on

the addendum to WHO guidelines for TB prevention in Health facilities. Specific activities will include

technical meetings to adapt the WHO addendum to Malawi settings, printing, and dissemination of a TB

infection prevention plan, situation analysis, and phased implementation of the plan based on outcome of

situation analysis. The minimum package of TB infection control measures will be phased in at five high

volume ART and TB sites during FY 2008.

Activity 4: Support Supervision and Monitoring of Decentralized Treatment of MDR-TB

Treatment of MDR TB is an effective strategy for reducing risk of TB among people living with HIV.

Currently the exact magnitude of MDR-TB in Malawi is not known because a drug resistance survey has

never been conducted. However, MDR-TB cases have been reported from routine surveillance of smear

positive re-treatment TB cases. Since 2000, the Central Reference Laboratory (CRL) has reported

cumulatively 72 MDR-TB cases of whom only 12 are known to be still alive. Patients with MDR-TB have not

received treatment in the past due to lack of second line anti-TB drugs and lack of capacity at the Central

Reference Laboratory (CRL) to consistently and reliably support monitoring of treatment responses. CRL

has no capacity to conduct drug and sensitivity testing on second line drugs. The current practice in Malawi

is to offer MDR-TB patients Ethambutol and Isoniazid to reduce infectiousness while offering education on

cough hygiene and the importance of restricting contact with other people.

Given the large pool of people living with HIV in Malawi, even few MDR-TB cases constitute a major public

health concern. Malawi has therefore developed guidelines for management of MDR-TB and has procured

a small supply of second line drugs to treat known MDR-TB cases. FY 2008 funds will be used to print and

disseminate guidelines for management of MDR-TB and to consolidate and roll out program of MDR-TB

treatment as a joint effort between NTP and the HIV/AIDS program. While TBCAP will support surveillance

for MDR-TB, strengthen the Central Reference Laboratory, and enhance surveillance for MDR-TB, NTP will

use FY 2008 EP funding to strengthen supervision of a decentralized management plan for MDR-TB.

These activities will complement core TB activities funded by non-EP funds that include training of providers

on management of MDR-TB.

Activity 5: Strengthen Monitoring and Evaluation of TB/HIV Activities

Testing for HIV, Cotrimoxazole prophylactic therapy and referral for ART services are being integrated

increasingly into management protocol for TB in Malawi. Recording and reporting of these services has

been incomplete and inconsistent due to lack of standard tool to capture all the required HIV information. A

revised TB patient master card has been developed and successfully piloted by Lighthouse and other

partners. In addition to TB data this new tool captures information on HIV status from previous testing, HIV

status from testing at TB registratio sites, ARV treatment status, and whether started before initiation of TB

treatment or in the course of TB treatment. The applicant will use FY 2008 to print and disseminate the new

TB Master card and support its introduction at all TB registration and treatment sites. FY 2008 funds will

support joint system of supervision, data collection, and monitoring for NTP and HIV programs using this

new tool as an entry point.

New/Continuing Activity: Continuing Activity

Continuing Activity: 15410

Continued Associated Activity Information

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

System ID System ID

15410 15410.08 HHS/Centers for Ministry of Health, 7131 7131.08 National TB $200,000

Disease Control & Malawi - National Program (NTP)

Prevention TB Program

Table 3.3.12: