Malawi is among the hardest hit countries in the world in terms of the HIV pandemic and its effects on families. The Southern Region has the highest HIV prevalence rate at 16.5%, followed by the Central Region at 8.6%, and the Northern Region with 6.5% (OPC, 2007). Recent publications indicate 78% of people living with HIV (PLHIV) reside in rural areas out of which 69% are in the Southern Region (OPC, 2009). Such a high level HIV prevalence has contributed to the high number of orphans and vulnerable children (OVC) currently requiring support. There are approximately 1.1 million orphans in Malawi, 560,000 of whom are estimated to have been orphaned as a result of AIDS-related deaths (UNAIDS 2008). The prevalence of OVC in the southern region is highest at 23% of the children below 18 years of age.

Integrated (HIV Effect) Mitigation and Positive Action for Community Transformation (IMPACT) project is a five year Global Development Alliance of international NGOs and private for profit partners in Malawi, led by Catholic Relief Services. The goal of IMPACT is to improve the quality of life and mitigate the impact of HIV on orphans and vulnerable children and persons living with HIV (PLHIV) in Malawi. Over the life of the project, IMPACT will improve the well being of 67,000 OVC and increase access of 33,000 PLHIV to treatment and care in nine districts in Southern and Central regions of Malawi.

IMPACT will use the CRS led Title II Food for Peace program (WALA), as a platform for wrapping around services for OVC and PLHIV. Building on the substantial infrastructure of the Food for Peace (FFP) supported Wellness and Agriculture for Life Advancement (WALA) Program, and leveraging considerable resources from the public and private sectors, IMPACT will bring together six WALA partners (Africare, CRS, Chikwawa Diocese, Emmanuel International, Project Concern International, Save the Children and World Vision), and three additional partners (Opportunity International Bank of Malawi (OIBM) and Telecommunications Network of Malawi (TNM), and an information technology provider, D-Tree) to provide wrap-around services for OVC and PLHIV in targeted areas. Several faith-based partners will participate in the project: Catholic Health Commissions for Lilongwe, Dedza and Zomba to provide services in nine selected districts in Southern and Central regions of Malawi.

The IMPACT consortium brings a 1.4:1 match of private resources to the project in addition to the economies of scale generated by cost-effective integration with the USG-funded funded Food for Peace Project. Implementing partners will work across nine districts and 39 traditional authorities (TAs) and sub- chiefdoms (SCs). Program catchment areas will be predominantly rural, with one small peri-urban area included in Lilongwe District.

IMPACT will improve the wellbeing of children 0 - 17 years by providing appropriate nutrition, education, economic empowerment and protection support. Four of the proposed activities are incorporated under the WALA program and will be expanded through the non-WALA partners in IMPACT: the Care Group Model, Community-Led Complementary Feeding and Learning Sessions (CLCFLS), supporting GoM's expansion of the community integrated management of childhood illness (C-IMCI), and village savings and loans (VS&L). In addition, IMPACT partners will empower communities to protect OVC from abuse and exploitation through birth registration, interactive education on child rights, preventing child abuse,

and providing additional HIV education tools for children. Communities will also be supported to improve education retention through targeted secondary school support and school savings opportunities, as well as to improve financial assets of households hosting OVC through access to lines of credit and formal savings opportunities through OIBM. IMPACT will introduce simple targeting tools to identify truly vulnerable children and ensure that they are prioritized for services. Collectively, the services provided under SO1 will improve the emotional, physical, and social environment surrounding OVC.

IMPACT will also provide a continuum of care that increases access to HIV counseling and testing for adults and children; supports community-based pre-ART services; and reinforces the importance of adherence and follow up of individuals who test positive, ART and PMTCT patients on ART. IMPACT pre- ART activities will also support MOH to revise existing guidelines and policies.

IMPACT will pilot two M&E innovations with strong potential to benefit other organizations implementing HIV programs in Malawi. The first will be coordinated by D-Tree and involves the use of mobile-phone based applications for service delivery, including the child status index, C/IMCI protocol, and HIV client support. The second will be the use of Station Days, a child-friendly, participatory M&E strategy that monitors service provision for children.

CRS/Malawi is the grant-holder for the WALA Program, a five year Food for Peace (FFP) funded program that began implementation in southern Malawi in July 2009. Over the life of the program, WALA will reach more than 215,000 in food insecure communities in areas heavily affected by HIV. Based on clear analysis of the population density, poverty level and high prevalence of HIV, CRS/Malawi and alliance partners will leverage WALA for broad support to provide food and livelihood assistance to vulnerable households. In this way IMPACT will maximize synergy between FFP and PEPFAR resources as recommended in the Title II and PEPFAR conceptual framework, enabling PEPFAR resources to be directed to provide care and support for OVC and PLHIV, while not modifying the food security focus of main WALA activities. The table below illustrates the PEPFAR and Title II linkages, showing the breakdown of the target groups and intervention areas supported under IMPACT and WALA respectively.

The synergy created by the overlap of PEPFAR with Title II program provides a unique opportunity to effectively reach to the most vulnerable households with OVC and PLHIV. For this program, CRS proposes to add private sector, information technology and faith-based partners to the WALA consortium.

This alliance will mobilize additional expertise, cash and in-kind resources from other Government ministries, faith based institutions as well as non-traditional private sector partners. The alliance will consider partnership with a local food processing plant to fortify corn soya blend with essential vitamins. Food resources from WALA will support this program and consortium partners will prioritize the nutritional

needs of HIV-positive pregnant and lactating women, OVC, infants exposed to HIV, and HIV patients in care and treatment programs, especially those who are severely malnourished at entry. IMPACT will work together with other USG implementing partners to increase synergies. IMPACT and Dignitas will work together on issues including defaulter tracing, adherence issues, follow up of HIV exposed infants and PMTCT. In terms of Bridge II, there will be overlap in six out of the nine districts targeted by IMPACT. Hence, the primary collaboration with Bridge II will focus on coordination and identification of geographic and demographic targets, sharing technical expertise as well as tools to maximize on coverage and standardize practices to the extent possible. The district assemblies will guide the geographic targeting by directing services where critical gaps exist. Finally, with AED, geographic overlap with the education grant is limited to only one district. IMPACT will work with AED to guide programming to under-served areas in the common district. These interventions support the Partnership Framework and the Malawi National HIV and AIDS Response. In addition, IMPACT will directly contribute towards the achievement of the Malawi National Plan of Action for Orphans and other Vulnerable Children (2005-2009) as well as the Draft Malawi HIV and AIDS Extended National Action Framework (2010 - 2012).

Budget Summary PFIP Year 1 Funding - $2,000,000 PFIP Year 2 Funding - $3,250,000

$666,0000 - Year 1 $1,250,000 - Year 2

PEPFAR funds to the CRS led consortium will support interventions that (i)) ensure PLHIV are retained in care and initiate treatment in a timely fashion; and (iii) reduce loss to follow up of PLHIV (pre-ART and ART) and PMTCT

Activity 1: Ensure PLHIV are retained in care and initiate treatment in a timely fashion Consistent with Goal II of the Partnership Framework IMPACT will support MOH to roll out community- based components of the national pre-ART program. PLHIV support groups and other pre-existing community structures will be the primary vehicle for all pre-ART activities. CRS/Malawi supported the HIV Unit of the MoH to conduct a preliminary workshop in August 2009 to develop a common understanding of the critical elements of pre-ART, from both the health facility as well as the community perspective. IMPACT will continue to support MoH to implement pre-ART activities at community and district levels, and support the reproduction of IEC materials, guidelines, training materials, launching events, sensitization sessions, etc. IMPACT will also train existing home-based care (HBC) volunteers in pre- ART concepts and ART adherence. These trained HBC volunteers will be responsible for working with support groups for PLHIV to raise awareness and facilitate access to key pre-ART services. They will also facilitate community-based tuberculosis screening, promote Cotrimoxazole prophylaxis for adults and children living with HIV and HIV-exposed infants; Community-based nutrition assessment and referral, including BMI calculation and individual nutrition planning; and prevention with positives. IMPACT will also conduct quarterly stakeholder meetings between volunteer representatives, health facility staff, and district health workers, and implementing partners to assess the referral and counter- referral system, discuss areas for improvement, and address any challenges This will be a critical mechanism to ensure that clients are monitored throughout the pre-ART period and initiate treatment at the appropriate time

Activity 2: Reduce loss to follow up of PLHIV on ART and PMTCT IMPACT will establish additional PLHIV support groups in areas with poor access, as well as strengthen

existing groups as a strategy for reducing loss to follow up of pre-ART and ART patients. The National Association of People Living with HIV and AIDS of Malawi (NAPHAM) will be engaged to conduct positive living training for PLHIV support groups in targeted areas. In another effort to improve adherence, IMPACT will employ a mobile-phone based automated system to issue reminders to ART patients with phones, who desire such service. Patients may enroll in this service after receiving positive HTC results and may withdraw at any time. Messages will not contain any personal identification information, however the issue of consent will be emphasized to avoid unintentional disclosure. Also, to address the specific challenge of treatment adherence during the initial months of ART (when side effects are often most difficult) IMPACT will explore the possibility of establishing an ART-pre-ART buddy system, where clients already on ART partner with pre-ART clients to share experiences of treatment initiation and disclosure. This informal psychosocial support may help facilitate the transition to ART and improve adherence.

To reduce long-term adherence challenges, parents will be encouraged to bring children living with HIV to support groups as well. This innovation has been piloted by several CRS church partners and has proven to be a very powerful tool for helping children raise issues of stigma, the challenges of taking medication on a long-term basis, and stresses they may face in every day life. To provide effective psychosocial support, children's groups will be encouraged to self-select by age group (generally 6 to 12 year olds meet separately from 13 to 17 year olds) depending on the issue to be discussed. To facilitate children's discussion, IMPACT will adapt "Chipo's Heroes," a child-friendly ART adherence comic. For PMTCT, the Care Group Model provides an ideal platform for reducing loss to follow-up with individual counseling at the household level. Care Group Volunteers will encourage pregnant women and their spouses to attend antenatal clinics together and undergo HCT as a couple. IMPACT HIV Promoters will also work with PLHIV support groups to emphasize the importance of PMTCT, particularly delivering in facility to have full access to pre and post natal medical support. Partner disclosure remains a fundamental challenge in many Malawian communities. IMPACT will conduct awareness raising activities in target communities about the importance of male involvement in the prevention of parent to child transmission of HIV. Where individuals request assistance for disclosure, trained HCT counselors and clergy will be called on to assist.

I. Budget Code: HKID

$1,333,0000 - Year 1 $2,000,000- Year 2

PEPFAR funds to CRS-led consortium will support interventions that ensure (i) OVC caregivers practise improved infant and young child feeding and caring techniques; (ii) OVC are protected from abuse and exploitation; (iii) OVC education retention rates in schools are improved; and (iv) OVC households have increased financial assets.

Activity 1: OVC caregivers practice improved infant and young child feeding and caring techniques IMPACT will promote improved infant and young child feeding and caring techniques in project communities through the implementation of the care group model, community led complementary feeding and learning sessions, and community integrated management of childhood illnesses (C-IMCI). Using the care group model developed by CRS - an internationally recognized behavior change strategy that uses peer education (mother to mother) approach - caregivers will be encouraged to practice essential nutrition actions and key health behaviors. Men will also be encouraged to participate in care group activities. The community complementary feeding and learning sessions will be held twice every year in every catchment area and will focus on feeding young children and pregnant women using locally available foods and nutrient rich recipes in order to prevent malnutrition. C-IMCI activities will involve training community members to recognize and refer children exhibiting danger signs of serious illness to health facilities, while treating basic morbidities at community level. In this way, communities and caregivers are empowered, while health facilities are less burdened.

Activity 2: Protect OVC from abuse and exploitation Assisting OVC to obtain legal identification will help assure their legal rights and reduce their risk to exploitation and abuse. Legal identification will also facilitate access to education, health, social, and financial services, as well as allow participation in civic activities later in life. To encourage birth registration, IMPACT will work with community child protection workers to raise awareness among local leaders and community members on the importance of birth registration and the mechanisms by which a child may be registered. IMPACT HIV promoters will also verify that OVC have been registered in the village headman registration system. Third, during periodic registration campaigns, IMPACT will assist the National Registration Bureau, Ministry of Gender Children and Community Development (MGCCD) and Registrar General Offices with logistics support in targeted traditional authorities to expand coverage. At national level, IMPACT will join the ongoing advocacy efforts of MGCCD, UNICEF, Plan International, and Human Rights Consultative Committee (HRCC). IMPACT will also strengthen the capacity of community OVC committees to identify and deal with child protection issues.

Activity 3: Improve OVC education retention rates To improve education access and retention, IMPACT will provide targeted support for secondary education costs. In order to identify the neediest households, IMPACT will adapt the OVC Enrollment

Tool, a simple targeting form developed by CRS partners in Kenya. This single-page worksheet analyses household livelihood factors and other considerations, including disability, chronic illness, age of caregivers, number of dependents, etc., to classify the level of support needed. Empowering OVC Committees with the tools and resources to objectively identify households with the greatest need helps develop community capacity and ownership. Based on discussions with the MOGCCD, implementing partners will liaise with District Assembly to check for common names in the district database of pupils awaiting educational assistance. To ensure that school support is well used, the OVC Village Committee members and OVC guardians will visit the schools to follow up on the OVC performance on a quarterly basis. The OVC Village Committee will then conduct home visits to discuss about the child's performance with the guardian and agree on an attendance and performance improvement plan. This will provide a form of psychosocial support for OVC. Use of the Child Status Index (CSI) will also assist in measuring performance. Where children receiving support are not performing well, OVC Committees will assess the situation to determine the main causes and develop an action plan to address the challenges.

Opportunity International Bank of Malawi (OIBM) will also offer Tsogolo Langa™ account (My Future) - a savings account that will allow parents, guardians or older OVC to save for school-related costs on a monthly basis for three months, and then instruct the bank to pay a school account directly. This facilitates guardians' payment of school fees and helps guardians develop financial discipline, budgeting and savings skills. Similarly, OIBM will offer "Micro school™" loans to private schools serving school- going children aged 2-13 in both early childhood and primary education. Such loans will ensure that the schools have the necessary infrastructure such as sanitation and water.

Activity 4: Increase financial assets of OVC households In Malawi, the informal sector supports the livelihoods of more than 80% of the population. Selected OVC aged 15 to 17 not qualifying to formal education will be offered the opportunity to enroll in informal vocational training. The Technical, Entrepreneurial and Vocational Education and Training Authority- the national regulatory body for vocational skills training - will implement this activity. TEVETA will facilitate community-based training using local artisans, and an attachment period to allow trainees to practice their newly learned skills. Trainees will receive supplies either at the start of the training to make them familiar with the tools of their trade, or at the end of their training as a graduation package. OVC Village Committees will use the OVC Enrollment Tool (OET) to identify and prioritize OVC to benefit from informal vocational training. IMPACT will also expand the WALA experience with village savings and loans schemes to OVC and PLHIV households through sensitization. In this way, older OVC as well as relatives, parents, extended family caregivers, particularly aunts and grandmothers assuming caring responsibilities for orphans would have the option to participate. As VS&L groups increase their savings, they may graduate to access loans for income-generating activities from OIBM. Such opportunities for formal savings and

business expansion help ensure that caregivers can sustain caring for the OVC in the future. Finally, OIBM will offer agriculture micro-credit to smallholder farmers. Where farmers are participating in the production of a cash crop under an out-grower scheme for an estate, OIBM will use its Good Agricultural Practices (GAP) service to finance them with farm inputs. In this way, livelihoods are sustained through the proceeds from the sales and improved food security. Weather Index Insurance, another OIBM product, mitigates the effects of drought or excessive rainfall on yields, provided that farmers are within 30kms radius of a weather station. As access to such services grows, this insurance will be offered to additional vulnerable households.