Goals and Objectives Partners in Hope (PIH) Medical Center and our partners propose to improve the quality of HIV care in Malawi by increasing the capacity of Christian Health Association of Malawi (CHAM) facilities to deliver care, sustained by integrating and strengthening linkages within the continuum of care, innovative mentored training, and through the performance of operational research to inform the future of the Malawi National programs and policies.

Linkage to Partnership Frameworks Between USAID And Government of Malawi EQUIP addresses all four goals of the Partnership Framework as follows: To reduce new HIV Infections in Malawi and Support the above listed goals in Prevention, Treatment and Care by providing discrete systems strengthening support in human resources With CHAM hospitals as the key partners, we propose integrating and strengthening the linkages among different HIV-related health services in the region to develop a 'continuum of care' including: HIV testing and counseling, pre-ART care, antenatal care and prevention of mother-to-child transmission, family planning, maternal child health, early infant diagnosis, and pediatric ART. To improve the quality of treatment and care for Malawians impacted by HIV We intend to train individuals from CHAM to serve as mentors at other sites in their regions (forming CHAM clusters). A train-the-trainer program will provide the clinicians, public health personnel, and administrators the necessary tools and skills to teach in their respective areas of expertise that include clinical training, administration, monitoring and evaluation, and operational research. To mitigate the economic and psychosocial effects of HIV and AIDS and improve the quality of life for PLHIV Our project will include capacity building to establish and/or strengthen PLWA and prevention-for- positives support programs within the CHAM clusters.

Geographic Coverage The EQUIP team will request CHAM and MOH zonal offices to identify and select geographic locations using pre-determined CHAM selection criteria. PIH and its partners will perform an initial assessment of possible sites for feasibility and overall needs. The project will support 6 CHAM clusters comprised of one CHAM hospital and at least 3 health care satellites per hospital. Initially we will focus on the two central zones and expand into the northern zone.

Health System Strengthening and Linkage with Government Activities Our application includes a letter from the MOH supporting our proposal to establish strong ties between CHAM participants and District and Zonal health structures. We will conduct an initial assessment of each district and zonal health office in each CHAM site region. Based on this review, EQUIP personnel will tailor a program whereby district and zonal health officers and employees can be supported and trained in areas of need. These activities may be carried out by our partners (such as Baylor for pediatrics, EGPAF for PMTCT, or TOGA for laboratory infrastructure).

Cross-Cutting Attributions and Key Issues a. Human Resources for Health (HRH): We will create a train-the-trainer program whereby clinicians, public health personnel, and administrators are given skills to teach in their respective areas of expertise including clinical training, administration, or monitoring and evaluation. b. Food and Nutrition, Policy, Tools, and Service Delivery: PIH's current activities include an extensive Nutrition Education Program that will be integrated into the EQUIP curriculum. c. Gender, reducing Violence and coercion: In the execution of our prevention, treatment and care program such efforts will include screening and counseling for gender based violence (GBV); strengthening referrals from HIV/AIDS services for GBV services and vice-versa; strengthening rape care services including the provision of PEP; and interventions aimed at preventing GBV including interpersonal communication.

Cost Efficiency The EQUIP proposal begins with one site and expands, over time, to six. The intent is to develop best

practices and refine our activities and tools as we accelerate the program. By doing so, we can identify and integrate cost efficiencies into the program as we proceed.

Monitoring and Evaluation At the end of year one, PIH will have performed detailed baseline assessment of two CHAM site/clusters. The baseline information will include documentation of personnel, resources, supplies, facilities, health care linkages (if they exist), services in different domains of the continuum, and policies for different domains of patient care. By the end of the first year the mentoring program will also be implemented. We will measure job satisfaction, perceived and actual level of clinical skills, and perceived job responsibility through a series of interviews and questionnaires. These will be measured serially such that at the end of five years we will be have a compendium of information about knowledge and skills that result from this program. Budget Summary PFIP Year 1 Funding - $1,365,662 PFIP Year 2 Funding - $2,263,000

Activity 3: Improving Adult HIV and AIDS Care, Support and Treatment at CHAM Sites (HBHC, HTXS) EQUIP will train personnel involved in HIV and AIDS care including clinicians, administrators/data managers, and laboratory technicians and staff. Individuals from designated CHAM sites who are selected to participate in EQUIP's train-the-trainer program will initially spend six weeks of intensive training at PiH Medical Center to be followed by regular interactions on-site with program staff. EQUIP will work alongside hospital leadership and Zonal Directors to improve linkages among the continuum of HIV services, and pilot incentives for connecting HIV+ patients in HCT centers with other services (especially pre-ART and ART). Eventually all sites will receive advanced training in HIV/AIDS management including management of OI, clinical staging, ART initiation, managing ART side effects, assessment and management of ART treatment failure.

The EQUIP consortium will create active pre-ART programs ensuring access and adherence to cotrimoxazole prophylaxis. CHAM staff will be trained and will implement programs to identify and manage malnutrition in HIV infection patients and train clients in safe water systems and hygiene. EQUIP-trained PLWA and HCT counselors will offer psychosocial and spiritual counseling at CHAM hospitals and affiliated sites. Interventions at CHAM Hospitals will reduce transmission of HIV infection through establishing prevention for positives programs (see Activity 2).

This activity includes the Cross-Cutting Attribution Human Resources for Health since it includes training health care workers in the areas of management and leadership development and performance assessment/quality improvement. This activity also addresses Food and Nutrition: Policy, Tools, and Service Delivery by developing protocols and policies for the inclusion of nutrition programs as part of HIV/AIDS care programs at each CHAM cluster. This component will include the training health care workers and counselors in performing nutritional assessments, counseling, and implementation of nutrition programs.

Products/Deliverables: • 11,000 HIV+ persons receiving cotrimoxazole prophylaxis • 600 HIV+ clinically malnourished clients receiving therapeutic or supplementary food • 4 health care facilities that have the capacity and conditions to provide advanced-level HIV testing and HIV/AIDS clinical management • 8 health care facilities that have the capacity and conditions to provide basic-level HIV testing and HIV/AIDS clinical management

Activity 3: Improving Adult HIV and AIDS Care, Support and Treatment at CHAM Sites (HBHC, HTXS) EQUIP will train personnel involved in HIV and AIDS care including clinicians, administrators/data managers, and laboratory technicians and staff. Individuals from designated CHAM sites who are selected to participate in EQUIP's train-the-trainer program will initially spend six weeks of intensive training at PiH Medical Center to be followed by regular interactions on-site with program staff. EQUIP will work alongside hospital leadership and Zonal Directors to improve linkages among the continuum of HIV services, and pilot incentives for connecting HIV+ patients in HCT centers with other services (especially pre-ART and ART). Eventually all sites will receive advanced training in HIV/AIDS management including management of OI, clinical staging, ART initiation, managing ART side effects, assessment and management of ART treatment failure.

The EQUIP consortium will create active pre-ART programs ensuring access and adherence to cotrimoxazole prophylaxis. CHAM staff will be trained and will implement programs to identify and manage malnutrition in HIV infection patients and train clients in safe water systems and hygiene. EQUIP-trained PLWA and HCT counselors will offer psychosocial and spiritual counseling at CHAM hospitals and affiliated sites. Interventions at CHAM Hospitals will reduce transmission of HIV infection through establishing prevention for positives programs (see Activity 2).

This activity includes the Cross-Cutting Attribution Human Resources for Health since it includes training health care workers in the areas of management and leadership development and performance assessment/quality improvement. This activity also addresses Food and Nutrition: Policy, Tools, and Service Delivery by developing protocols and policies for the inclusion of nutrition programs as part of HIV/AIDS care programs at each CHAM cluster. This component will include the training health care workers and counselors in performing nutritional assessments, counseling, and implementation of nutrition programs.

Products/Deliverables: • 11,000 HIV+ persons receiving cotrimoxazole prophylaxis • 600 HIV+ clinically malnourished clients receiving therapeutic or supplementary food • 4 health care facilities that have the capacity and conditions to provide advanced-level HIV testing and HIV/AIDS clinical management • 8 health care facilities that have the capacity and conditions to provide basic-level HIV testing and HIV/AIDS clinical management

Activity 5: Expanding Testing and Counseling Facilities at CHAM Hospitals (HVCT)

The EQUIP Malawi program will train HCT counselors for six weeks at PIH Medical Center in an

intensive program that will focus not only on HIV testing but also on comprehensive HIV prevention

delivery (see Activity 2). Counselors trained at PIH will follow-up at the site per the EQUIP training

schedule to mentor and supervise the HCT program. Training will focus on boosting provider-initiated

HCT at the base CHAM hospital and satellite clinics. EQUIP personnel will work within each CHAM

cluster to increase the number of centers providing HCT services and pilot semi-quantitative CD4

measurement at these sites. HCT sites will be integrated with STI and family planning programs such

that HIV prevention messages can be combined with screening for STIs and family planning for the

prevention of unwanted pregnancy.

Products/Deliverables:

• 16 sites providing HIV Counseling and Testing services

• 3500 HIV+ individuals trained in correct and consistent condom use

• 16 HCT counselors trained

Activity 6: Capacity Building for Pediatric Care and Support and Treatment at CHAM Hospitals (PDCS) EQUIP Malawi's partner, Baylor will incorporate early infant diagnosis (including dried blood spot testing) linked to PMTCT and community-based follow up of infants born to HIV+ mothers training as a key component of the EQUIP program. They will then work alongside CHAM clinicians and staff to improve capacity for services within the CHAM hospital and implement existing and pilot new mechanisms to improve referral and retention of HIV-exposed infants in care within CHAM clusters. For example, expanding pediatric programs will include expanding provision of ART to HIV-infected infants and eligible children and regular clinical and CD4 monitoring of all HIV+ children. Alongside PIH PLWA-support staff, CHAM facilities will increase capacity to monitor growth and nutritional status of HIV infected children. Another emphasis of EQUIP/Baylor activities will be to improve integration of pediatric HIV services with MCH, under five, Tb and nutrition programs. This activity is related to the Key Issue: Health Related Wraparounds: Child Survival Activities. A major focus in this activity will be ensuring that children benefit from linked services such as linking PMTCT, EID, community-based follow-up of infants born to HIV+ mothers, providing ART and regular CD4 monitoring to children, nutritional programs, MCH, Under-5, and Tuberculosis treatment .

Products/Deliverables: • 5 service outlets providing linked care pediatric care and support programs

• 432 infants of HIV-positive women receiving EID • 388 mothers of HIV-positive infants receiving results of EID • 40 HIV-positive infants receiving ART according to national and international standards

• 40 HIV-positive infants receiving CD4 testing (at least 6 monthly) • 40 mothers of HIV-positive infants receiving results of CD4 testing • 388 HIV-positive infants receiving nutritional/growth assessments and supplementation

Activity 7: Strengthening Pediatric HIV/AIDS Treatment at CHAM Hospitals (PDTX) EQUIP-Malawi will train CHAM personnel and oversee the implementation and integration of Early Infant Diagnosis and pediatric ART programs at all CHAM clusters. Clinical training will include basic pediatric ART curriculum for sites not currently providing pediatric ART. All sites will eventually have personnel who receive advanced training in HIV/AIDS management including pediatric clinical staging, management of OI, ART initiation, managing ART side effects, assessment and management of ART treatment failure in children.

Products/Deliverables: • Number of service outlets providing basic pediatric ART according to national and international standards • Individuals trained in providing basic pediatric ART according to national and international standards • Individuals trained in advanced HIV/AIDS management defined as pediatric clinical staging, management of OI, ART initiation, managing ART side effects, assessment and management of ART treatment failure in children.

Activity 8: Improving Laboratory Infrastructure at CHAM Sites (HLAB) Through its partnership with TOGA Laboratories, EQUIP Malawi will purchase and supervise installation of laboratory equipment for on-site measurements of CD4, monitoring of ART side effects (especially Hb, lactate and creatinine) and OI testing at each CHAM facility. The program provides for training and technical support for CHAM Cluster laboratory staff through the laboratory at Partners in Hope Medical Center. Training includes accurate diagnosis of OIs, CD4 testing, laboratory monitoring of ART side effects, lab management and quality assurance.

Products/Deliverables:

• Purchase and supervise installation of laboratory equipment at three sites • Provide training and technical support for laboratory staff at PIH and three sites • PIH and three CHAM facilities performing on-site laboratory measurements of CD4, monitoring of ART side effects (especially Hb, Lactate and Creatinine) and OI testing • PIH and three CHAM facilities performing quality assurance of on-site laboratory measurements of CD4, monitoring of ART side effects (especially Hb, Lactate and Creatinine) and OI testing

Activity 9: Installing and Integrating Strategic Information Systems in CHAM Facilities (HVSI)

EQUIP Malawi, through a sub-contract in collaboration with TOGA Laboratories, will place site-level

health information systems in targeted CHAM clusters. Services will include training of staff in use of

health information system for HIV/AIDS monitoring and for operational research.

Products/Deliverables:

• PIH and three CHAM sites in the program with health-information systems

• 24 personnel in CHAM facilities trained in using health information systems

Activity 10: Health Systems Strengthening (OHSS) PIH will work with each CHAM facility to improve the diagnostic laboratory services to perform the laboratory testing required for diagnosis and monitoring of HIV and ART patients according to the national guidelines. This will include CD4 testing, hemoglobin, creatinine and AFB smear for microscopy. In partnership with TOGA, PIH will also implement an external quality assurance/proficiency testing (EQA/PT) program for CD4 and TB sputum microscopy.

Products/Deliverables: • Four CHAM facilities will be able to perform laboratory testing required for diagnosis and monitoring of HIV and ART patients according to the national guidelines. • Four CHAM facilities will pass annual quality assurance/proficiency testing (EQA/PT) for CD4 and TB sputum microscopy

Activity 2: Building Comprehensive and Integrated HIV Prevention Programs at CHAM Sites (HVOP) EQUIP will build prevention programs at CHAM hospitals and affiliated clinics by training counselors and establishing community outreach programs. We will build capacity such that every CHAM hospital and satellite clinic in the program offers HCT as part of a multi-faceted HIV prevention program. Activities will promote a comprehensive approach to HIV prevention, including a component on prevention with positives (PwP) and sero-discordant couples. We will develop and field test messages, literature, and videos that address issues relevant to PwP and relating to primary as well as secondary partnerships, with special emphasis on sero-discordant partners and multiple and concurrent partnerships (MCP). We will develop training materials to prepare clinicians to deliver general prevention messages as well as PwP messages in clinical encounters, and expect that the issue of PwP be addressed in every clinical encounter with HIV infected patients. The EQUIP team will draw upon our experience with the use of Community Health Workers (CHW) empowering them to follow up HCT clients. Our prevention program will include training and implementation of screening and counseling for gender based violence (GBV); strengthening referrals from HIV/AIDS services for GBV services; and interventions aimed at preventing GBV including interpersonal communication.

This activity includes the Cross-Cutting Attribution Human Resources for Health since it involves training health care workers in HCT and the delivery of HIV prevention programs, as well as Gender: Reducing Violence and Coercion, as it incorporates programs for the prevention and management of GBV.

Products/Deliverables: • 12,600 PLHIV reached with a minimum package of Prevention with PLHIV (PwP) • Establishment of community outreach prevention programs in each of the CHAM clusters • 1200 HIV negative partners in sero-discordant couples counseled in HIV prevention

PMTCT Budget ($723,223.00)

Activity 1: Capacity Building of PMTCT Services at CHAM Sites (MTCT) Prior to initiation of activities, a detailed assessment of each CHAM site will be performed to understand the availability (if any) of ANC and PMTCT services. These activities as well as the training and implementation of ANC/PMTCT services will be performed in collaboration with EGPAF.

We will ensure that each CHAM hospital as well as every satellite health center included in the program has the capacity to deliver services including HCT for pregnant women, expedited initiation of ART for those women who qualify by CD4 cell count and/or WHO clinical staging, and PMTCT interventions for women who do not meet current criteria for ART. To achieve these goals EQUIP and EGPAF will perform training of individuals to perform clinical services (in ANC/PMTCT) and administrative services (to ensure referrals for ART are systematically performed). We also propose to expand capacity at each CHAM hospital for these ANC/PMTCT services by facilitating on-site CD4 testing. EQUIP and EGPAF will promote greater involvement of male partners of HIV+ women by developing outreach programs with specific focus on engaging male partners in HCT.

This activity incorporates the Cross-Cutting Attribution Human Resources for Health since it includes training clinicians, administrators, and laboratory technicians to deliver a comprehensive program for HIV-infected pregnant women. Key issues include gender, and building capacity for care of HIV-infected pregnant women will increase gender equity in HIV/AIDS activities and services.

Activity 2: The EQUIP consortium will receive additional FY10 PMTCT funds in the amount of $175,000 to support operations research activities designed to identify and refine best practices for improving access of eligible HIV+ pregnant women to ART in the Malawian context and for implementing postnatal prophylaxis of infants under the new Malawian and WHO guidelines. This topic would fall under the top PMTCT/peds PEPFAR HQ OR priority: "What are the effective strategies for provision and monitoring of CD4 testing and antiretroviral treatment, if eligible for pregnant women" and "For postpartum prophylaxis during breast feeding: What are effective strategies for implementation, and what is the comparative effectiveness of infant vs. maternal prophylaxis?". This operations research will also be supported with private resources donated through UCLA and others, thus making it more feasible to generate. The specific design of the operations research study will be developed in the first half of Fy10 and shared with the HQ PMTCT/peds TWG for their input.

Activity 8: Improving Laboratory Infrastructure at CHAM Sites (HLAB) Through its partnership with TOGA Laboratories, EQUIP Malawi will purchase and supervise installation of laboratory equipment for on-site measurements of CD4, monitoring of ART side effects (especially Hb, lactate and creatinine) and OI testing at each CHAM facility. The program provides for training and technical support for CHAM Cluster laboratory staff through the laboratory at Partners in Hope Medical

Center. Training includes accurate diagnosis of OIs, CD4 testing, laboratory monitoring of ART side effects, lab management and quality assurance.

Products/Deliverables: • Purchase and supervise installation of laboratory equipment at three sites • Provide training and technical support for laboratory staff at PIH and three sites • PIH and three CHAM facilities performing on-site laboratory measurements of CD4, monitoring of ART side effects (especially Hb, Lactate and Creatinine) and OI testing • PIH and three CHAM facilities performing quality assurance of on-site laboratory measurements of CD4, monitoring of ART side effects (especially Hb, Lactate and Creatinine) and OI testing

Activity 4: Improving TB/HIV Care at CHAM Sites (HVTB) The EQUIP Malawi program will emphasize development of clinical protocols for improved diagnosis of TB in HIV patients. This will be accomplished by training of health providers in TB diagnosis and treatment. Each CHAM site will also be equipped with improved screening tools such as standardized questions and laboratory services to support TB diagnosis and monitoring during treatment. Laboratory personnel will be trained by technical experts from Partners in Hope Medical Center.

This activity covers the key issue of TB and includes the Cross-Cutting Attribution Human Resources for Health since it includes training health care workers in TB diagnosis and treatment, as well as training laboratory technicians in TB diagnostics. Products/Deliverables: • 80 % of HIV+ patients screened for TB in HIV care or treatment settings • 20% of HIV+ patients in HIV care or treatment (pre-ART or ART) initiated TB treatment • 75% of HIV test results recorded in the TB register in patients being treated for TB

Activity 5: Expanding Testing and Counseling Facilities at CHAM Hospitals (HVCT) The EQUIP Malawi program will train HCT counselors for six weeks at PIH Medical Center in an intensive program that will focus not only on HIV testing but also on comprehensive HIV prevention delivery (see Activity 2). Counselors trained at PIH will follow-up at the site per the EQUIP training schedule to mentor and supervise the HCT program. Training will focus on boosting provider-initiated HCT at the base CHAM hospital and satellite clinics. EQUIP personnel will work within each CHAM cluster to increase the number of centers providing HCT services and pilot semi-quantitative CD4

measurement at these sites. HCT sites will be integrated with STI and family planning programs such that HIV prevention messages can be combined with screening for STIs and family planning for the prevention of unwanted pregnancy. Products/Deliverables: • 16 sites providing HIV Counseling and Testing services • 3500 HIV+ individuals trained in correct and consistent condom use • 16 HCT counselors trained