PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
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
Management Sciences for Health (MSH) recently won the TASC III award. This activity will support the
Government of Malawi's (GoM) goal of promoting reproductive health through informed choice and
integration with HIV/AIDS. The program has three main components: behaviour change and
communication; outreach; and health provider capacity building. The overall purpose of this task order is to
promote through informed choice, safer reproductive health practices by men, women and young people,
and increased use of high quality, accessible Family Planning/Reproductive Health (FP/RH) and HIV/AIDS
services.
Background
Integration of HIV and FP has proven to be an effective approach to stimulate new activities and meet
active demand for HIV Counseling and Testing (HCT) by overcoming constraints to accessing services. The
overall purpose of this task order is to promote integration of family planning and HIV/AIDS through
increased use of high quality, accessible FP/RH services, and HIV/AIDS services. The activities to be
implemented in FY 2008 are part of an initiative to be undertaken starting in October 2007 through TASC-III
in eight districts with Child Survival and Health Population funds (POP) and 2007 Emergency Plan (EP)
funding. In achieving the purpose, the program will undertake various activities in three programmatic areas
of other prevention, HCT, and systems strengthening to accomplish the following results: increased
community knowledge and interest in FP and HIV/AIDS services; improved social norms for
SRH/FP/HIV/AIDS; increased access and utilization of FP/HIV/AIDS services in communities; increased
integration of HIV issues into FP services and vice versa; improved linkages between point of service and
the community and household levels; and a strengthened enabling social environment for FP/RH and
HIV/AIDS services and behaviors. Achievement of these results shall be carried out principally through
partnerships with the district health offices in Malawi.
Cross cutting among health issues is the high fertility rate, which undermines the poverty reduction efforts,
contributes to high maternal and infant mortality levels, and exacerbates the AIDS-related orphan problem.
Considerable progress has been made over the last decade in reducing total fertility from 6.7 in 1992 to 6.0
in 2005. At the same time the contraceptive prevalence rate (CPR) for modern methods has raised from
7% in 1992 to 28% in 2004. FY 2008 HIV/AIDS funds will wrap around larger programs in Family
Planning/Reproductive Health which are funded with POP Child Survival and Health funds.
Activity 1: Dual Protection
TASC-III will integrate HIV/AIDS, family planning and sexually transmitted infections (STI's) prevention
through promotion of dual protection, encompassing condom promotion and other behavioral change efforts
to reduce pregnancy and STI/HIV risk. Integration of family planning counseling and services (or referral for
services) into HCT centers for women and men who wish to avoid future childbearing will include programs
focused on mother to child transmission.
Activity 2: Gender
TASC-III will incorporate a gender approach into family planning and HIV/AIDS services by training
providers to address gender-related barriers/issues, including identifying signs of gender-based violence
that should be addressed as part of family planning and HIV/AIDS counseling. Steps will be taken to ensure
that protocols address legal and support services in the community to mitigate impact (e.g. partner testing
and notification to support disclosure).
Activity 3: Behavior Change Communication
Behavior change communication (BCC) will be incorporated into TASC III activities and shall portray
adequately family planning and HIV testing and treatment as mainstream health interventions. BCC
messages should include those targeted at men as clients, allies/supportive partners, and agency of change
toward more positive norms.
New/Continuing Activity: Continuing Activity
Continuing Activity: 17788
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
17788 17788.08 U.S. Agency for Management 7874 7874.08 MSH TASC III $125,000
International Sciences for
Development Health
Table 3.3.03:
Government of Malawi's goal of promoting reproductive health through informed choice and integration with
HIV/AIDS. The program has three main components: behavior change and communication, outreach, and
health provider capacity building. The overall purpose of this task order is to promote through informed
choice, safer reproductive health practices by men, women, and young people, including increased use of
high quality, accessible family Planning/Reproductive health (FP/RH) and HIV/AIDS services.
Integration of HIV/AIDS and FP has proven to be an effective approach to stimulate new demand as well as
meet active demand for HIV counseling and testing (HCT) by overcoming constraints to accessing services.
The overall purpose of this task order is to promote integration of family planning and HIV/AIDS through
increased use of high quality, accessible FP/RH and HIV/AIDS services. The activities to be implemented in
FY 2008 are part of an initiative to be undertaken starting in October 2007 through TASC III in eight districts
with USAID Child Survival Health Population funds (POP) and 2007 Emergency Plan (EP) funding. The
program will implement various activities in three program areas: Condoms and Other Prevention,
Counseling and Testing, and Other Policy and Systems Strengthening, to accomplish the following results:
•Community knowledge and interest in FP and HIV/AIDS services increased
•Social norms for SRH/FP/HIV/AIDS improved
•Access and utilization of FP/HIV/AIDS services in communities increased
•Increased integration of HIV issues into FP services and vice versa
•Linkages between point of service and the community and household levels improved
•An enabling social environment for FP/RH and HIV/AIDS services and behaviors strengthened.
Achievement of these results shall be carried out principally through partnerships with the district health
offices in Malawi.
Expansion of HCT is a critical step towards achieving Malawi's ambitious universal access targets of having
at least 250,000 patients with advanced HIV disease alive and on ART by 2010. Malawi's Universal Access
target for HCT is to attain a testing rate of 993,000 people per year by 2010. Although the country has
recorded a large increase of testing sites from 39 in 2001 to 351 in 2006, and a correspondingly sharp
increase in number of people tested annually from about 52,000 to 661,400; knowledge of HIV sero-status
among adults over 15 years is only 15%. The expansion of HCT services in Malawi still faces many
challenges including inadequate human resource capacity for program coordination at a national level,
shortage of trained counselors, and weak coordination of testing activities in medical settings. Other
challenges include low testing rate for couples and children.
Activity 1: Community Based Counseling and Testing
TASC III will initiate community-based family planning and CT services in eight districts and scale up
operations by expanding coverage, access, and consistent use of FP/RH and HIV services. The focus of
the expansion should be in rural and underserved areas and among high risk populations defined by high
unmet demand for services or marginalized groups. Consideration will be given to cost effectiveness and
potential health impact in identifying areas and population for expansion. TASC III will focus on consistent
family planning use and look for windows of opportunity to leverage increased access to HIV/AIDS services,
particularly in HIV counseling and testing and positive living as well as addressing gender related reasons
for lack of access such as women's limited financial resources and lack of partner support for contraceptive
use.
Activity 2: Post Test Clubs
TASC III will support post test clubs that are designed to decrease stigma and discrimination experienced
by PLWHA. Innovative approaches to expand use of HIV and other RH services available to women
through community-based distributors (CBDs) thereby increasing women's access to services in rural areas
shall be strengthened. CBDAs will include HIV/AIDS prevention messages, support testing, treatment
seeking, and adherence behaviors.
Continuing Activity: 17790
17790 17790.08 U.S. Agency for Management 7874 7874.08 MSH TASC III $125,000
Program Budget Code: 15 - HTXD ARV Drugs
Total Planned Funding for Program Budget Code: $650,000
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
Context
Of the approximately 120,000 people currently alive and on antiretroviral therapy (ART) in Malawi, greater than 95 percent are
receiving the country's recommended first-line regimen of a twice daily fixed-dose combination of d4T/3TC/ NVP. With the
exception of pediatric ARVs which are procured partially with UNITAID funding until 2010, ARVs for the national program are
procured exclusively with Global Fund for AIDS, TB and Malaria (GFATM) resources through UNICEF, and supplied to sites
through SDV, a private company funded by UNICEF with GFATM resources.
SDV operates through a parallel system outside of the weak national Central Medical Stores (CMS) system, which is responsible
for supplying almost all other health commodities in Malawi, including HIV test kits and OI drugs. Unlike programs which depend
on commodities through CMS, Malawi's ART program has not experienced any ARV stock-outs to date, although the increasing
demand on the current supply chain for HIV/AIDS-related commodities requires streamlining certain pharmaceutical management
and monitoring functions. This will be particularly true in the future as the number of patients on ART continues to rise and the
proportion of patients requiring alternative and second-line regimens increases.
The Government of Malawi (GOM) has expressed a strong desire to integrate ARVs into the CMS procurement and distribution
system, but an assessment in 2008 by the USG-funded Deliver project indicated that CMS currently did not have the capacity to
take on the responsibility of procuring and distributing ARVs in the near future. The findings of this assessment, which were widely
accepted by the GOM and other stakeholders, including the GFATM, led to the recent decision by Malawi to competitively
advertise for a third-party procurement agent. This agent would replace UNICEF in procuring ARVs and possibly other GFATM
commodities, and provide technical assistance to strengthen the capacity of CMS. The goal of this arrangement is for CMS to be
capable of managing ARV and other HIV-related supplies procurement within 3-5 years. At the request of the Ministry of Health
(MOH), USG is supporting a consultant to prepare the terms of reference for the third-party agent, and it is expected that this
agent will be in place by the spring of 2009.
In addition to the issues related to procurement and supply of ARV drugs, there are operational challenges which need to be
addressed including how to optimize use of the specific drug regimens recommended by the current guidelines, and to ensure that
patients receive alternative and second-line regimens when these are indicated as a result of toxicity or treatment failure. MOH
adopted new treatment guidelines in April 2008 which built on the highly successful public health approach to the delivery of ART,
and recommended continued use of d4t/3TC/NVP as the first-line regimen. However, during a PEPFAR Adult Care and Treatment
TWG assessment held in October 2008, interviews with clinicians and nurses providing ART in Malawi confirmed widespread side
-effects related to the use of the first-line regimen, including debilitating peripheral neuropathic pain due to d4T, and severe rashes
due to NVP. While the current guidelines include relatively straightforward guidance for switching for NVP hypersensitivity based
on visual examination of rash, MoH has set a high bar for switching from d4T to ZDV for peripheral neuropathy. These criteria
have led to a reluctance of providers to switch to a ZDV-based first-line regimen to address d4T toxicity. This reluctance to switch
was confirmed in a recent GOM survey that found only 4 percent of patients on ART have switched to an alternative ARV
regimen, in contrast to rates of 20 percent or higher in studies from Uganda, Kenya and South Africa.
In addition to a reluctance to change regimen based on side-effects, minimal attention is being made to treatment failure; less
than 1 percent of patients on ART have been switched to second-line regimens with treatment failure cited as the cause for
change. Although the public health approach in Malawi has appropriately concentrated efforts on expanding the use of first-line
regimen, a growing number of patients are no longer benefiting from first-line therapy. Current Malawi guidelines for switching
patients from first- to second-line therapy requires multiple steps, including referral to a central facility, which may be contributing
to the lower than expected uptake of second-line ART.
Previous USG Support
Given the fact that procurement of ARVS has been funded by other donors in Malawi, PEPFAR is currently utilizing its limited
FY08 resources in two areas: Funds were given to the USAID/Deliver project to perform a comprehensive assessment of ARV
procurement and related supply chain issues in Malawi, and to MSH, to strengthen the management of ARVs through the
Strengthening Pharmaceutical Services (SPS) project. Activities under the SPS project are at the facility-level, and include training
and mentoring the health workers in pharmacies and clinics on appropriate management of ARV drugs, and equipping them with
tools and systems to support them in their positions.
With FY08 resources, 340 health workers (at least two from each ART site) from the public sector as well as the private sector are
being trained through SPS in partnership with the Malawi Business Coalition against HIV/AIDS. Training focuses on adherence
monitoring, recognizing suspected Adverse Drug reactions (ADRS) and how to report them, medication counseling, and
pharmaceutical stock management. SPS is also developing standardized drug management procedures for ART management in
both public and private sector facilities, and will introduce these standardized procedures in all 170 ART sites. SPS is also
introducing an electronic ART dispensing tool for use in district hospitals.
FY09 USG Support
USG will continue to focus on improving the management of ARVs and other HIV-related pharmaceutical products at the health
facility level through a Monitoring, Training, and Planning (MTP) approach in FY09. USG will also expand complementary efforts
on the national level to support technical leadership, enabling appropriate use of ARV drugs consistent with the Malawi's new ART
guidelines. Through more accurately quantifying the extent to which patients need to switch regimens, either for toxicity or
treatment failure, SPS efforts will also support the MOH and ARV procurement agent's forecasting for ARVs.
i. On-site mentoring to strengthening pharmaceutical management at ART facilities
SPS will use FY09 funds to train staff in pharmaceutical management at new ART sites beyond the 170 sites which are receiving
training with FY08 funds, and provide training for health care workers at sites where already trained pharmacy staff have now left.
However the focus for FY09 funding will primarily be on site-based mentoring of multidisciplinary teams, including pharmacy staff
but also clinical service providers to help ensure they are following correct procedures with regard to stock management,
dispensing, medication counseling, adverse event reporting, medication errors, and side effects management. SPS staff will visit
all ART sites in the country at least twice yearly, with larger sites receiving quarterly visits, and will report any relevant findings to
the MOH Pharmaceutical Services on a regular basis so it can take any further actions if needed.
ii. Provide technical assistance to help optimize implementation of new ART guidelines
As noted above, health care workers in pharmacies are strategically placed to monitor for Adverse Drug Reactions (ADRs) and
provide other support and counseling which can help improve the clinical management of patients who are having side-effects on
their current regimens. One key recommendation which arose during a visit from the PEPFAR Adult Treatment TWG in October
2008 was for PEPFAR/Malawi team and its partners to assist the MOH in efforts to reduce the severity and incidence of side
effects, particularly chronic side effects, through giving providers the capacity and support to make the decision to switch to
alternative regimens.
SPS will work closely with mentoring pharmacy staff as well as other health care providers at ART facilities throughout the
country, in order to ensure they are helping to monitor for d4T and NVP-related toxicities, appropriately informing clinical officers
and nurses who prescribe these medicines about toxicities that may not have recognized during clinic visits and reporting
information to MoH about the prevalence of these toxicities and frequencies of drug regimen switches to the better inform ART
policy and planning. Pending further discussions with the MOH, SPS can help develop standardized tools to assist sites in more
accurately quantifying the frequency and severity of ADRs. SPS can also assist in the process of identifying highly functioning
ART sites which have the capacity to initiate and monitor patients on second-line ARVs, ensuring they have both appropriate
standardized operating procedures (SOPs) in place and consistent availability of alternative and second-line ARVs, including
ZDV, efavirenz (EFV), tenofovir (TDF), and lopinavir/ritonovir (LPV/r).
iii. Review and dissemination of the Essential Drugs List (EDL)
The procurement of all medicines and medical supplies in Malawi is done in accordance with the Malawi National Drug List and
the Essential Health Package. The National Drug Committee is charged with the responsibility of selecting drugs and reviewing
the Essential drug list and standard treatment guidelines (STG). In 2009, MSH/SPS will support an annual review/updating and
dissemination of the Malawi Essential Drugs List (MEDL) and Malawi Standard Treatment Guidelines (MSTG) to incorporate the
new drugs being used for treatment of many conditions, including HIV/AIDS, opportunistic infections, and in PMTCT. This will be a
wraparound initiative with the Presidential Malaria Initiative (PMI), as the review and dissemination will include the new Malaria
drugs (i.e. ACT) into the MEDL and MSTG. PEPFAR funds for this activity will be used to support 3 review workshops of the
National Drug Committee, and dissemination of guidelines through training of 1325 health workers on the proper use of the
guidelines.
iv. Incorporating HIV pharmaceutical use into pharmaceutical training curricula
In FY09 SPS will support the incorporation of a management for HIV/AIDS medicines module in the pre-service pharmaceutical
training curriculum for all health workers. The revised curricula will address issues of pharmaceutical management of HIV/AIDS
medicines, including prevention of adverse drug reactions, the promotion of drug safety including rational use, preventing
medication errors, and minimizing factors that contribute to therapeutic ineffectiveness. Examples of topics include non
adherence, poor quality drugs, drug interactions, and microbial resistance. These topics will be covered during pre-service
training for health workers directly involved in ART as well as other health staff working in primary health care settings. The
activity will target the Malawi College of Health Sciences and Christian Health Association of Malawi (CHAM) training schools.
iv. Building capacity of CMS and the MOH pharmaceutical services unit
FY09 PEPFAR funds will support the USAID/Deliver project to build the capacity of CMS to manage procurement and supply of a
wide range of pharmaceutical products, including HIV-test-kits and OI drugs. While ARV drugs will remain in a parallel system
outside of CMS in the near future, these capacity building efforts will potentially bear fruit over the long-term if ARV drugs can
eventually be transitioned successfully into the CMS systems after 2010. (Please see OPSS section for more information). SPS
will also coordinate national stakeholders for policy decisions leading to the development of an ART inventory management
system in the MOH pharmaceutical management services unit to track ART consumption at facility level, identification, and
installation of inventory management software that can accommodate the ART management information system.
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. Support for health commodities is a priority area under consideration.
In collaboration with the GOM, USG would prioritize the expansion of long-term capacity building efforts at CMS to move towards
Malawi's stated goal of fully integrating ARV drugs into the broader national supply chain system over the next five years.
Additional funds could also be used to expand a more robust surveillance system for ADRs and treatment failure in cooperation
with SPS and other partners. This would inform ongoing discussions with the National HIV Technical Working Group which
addresses issues related to regimen changes. USG will also integrate into training programs, initiatives that target members of
the military for support.
Table 3.3.15:
Government of Malawi (GoM) goal of promoting reproductive health through informed choice and
communication, outreach, and health provider capacity building. It is a wrap-around activity which will
promote linkages between HIV/AIDS and Reproductive Health (RH).
Integration of HIV and Family Planning (FP) has proven to be an effective approach to stimulate new, and
meet active, demand for HIV Testing and Counseling (HCT) by overcoming constraints to accessing
services. The overall purpose of this task order is to promote integration of family planning and HIV/AIDS
through increased use of high quality, accessible Family Planning/Reproductive health (FP/RH) and
HIV/AIDS services.
The activities to be implemented in FY 2008 are part of an initiative to be undertaken starting in October
2007 through TASC-III in eight districts with POP (CSH population funds) and 2007 Emergency Plan (EP)
funding. In achieving the purpose, the program shall undertake various activities in three programmatic
areas of other prevention, counseling and testing and systems strengthening to accomplish the following
results: Increased community knowledge and interest in FP and HIV/AIDS services; improved social norms
for SRH/FP/HIV/AIDS; increased access and utilization of FP/HIV/AIDS services in communities; increased
the community and household levels; and strengthened social environment for FP/RH and HIV/AIDS
services and behaviors. Achievement of these results shall be carried out principally through partnerships
with the district health offices in Malawi.
Activity 1: District Health Management Team (DHMT) Support
TASC-III will strengthen District and Community Provision and management of FP/RH and HIV and AIDS
services by supporting the district health management team (DHMT) so that they provide their mandated
supervisory and support functions to the health centers. By directing efforts towards the district level, the
program can create sustainable supervision and management capacity.
The TASC-III order activities will also focus on strengthening the capacity of the DHMT members to support
community based providers, as well as DHMT's capacity in performance monitoring and improvement as
related to HIV.
Continuing Activity: 17791
17791 17791.08 U.S. Agency for Management 7874 7874.08 MSH TASC III $250,000
Table 3.3.18:
