The primary objective of Howard University (HUTAP) activities in Malawi is to increase the Ministry of Health's (MOH) capacity to maintain and enhance its laboratory infrastructure in order to provide high quality HIV-specific as well as broader health services at the community, district and central health facilities levels. These programs will be guided by the experience and relationships HUTAP has built on the ground since 2003, and the training, human resource and infrastructure development, and quality assurance activities that are already in place.

Consistent with the purpose, principles and strategies outlined in the Partnership Framework, HUTAP's Year 2 (PFIP Year 2) activities will strengthen the national HIV care and treatment program in Malawi by providing technical assistance, procuring and placing laboratory commodities including equipment and consumables, building capability and capacity of laboratory service providers and institutions, and providing resources to support the scale-up and increased quality of the national HIV and AIDS response. In particular, HUTAP's activities to expand CD4 capacity in conjunction with adult and pediatric programs will improve the quality of treatment and care for Malawians affected by HIV (PF Goal II). In addition, continued, cross-cutting focus on training, quality assurance and infrastructural improvements will strengthen the diagnostic, treatment and surveillance capacity of the national laboratory system and enhance provision of health services nationwide in ways that MOH can sustain over time (PF Goal IV).

The program's key contributions to health systems strengthening are inextricably linked priority areas for laboratory as defined by PEPFAR and the Government of Malawi, most notably the Malawi National Laboratory Strategic Plan (MNLSP) for 2009-2014, which HUTAP played a key role in developing.

HUTAP will implement these activities using a mechanism that aims to empower the MOH to take ownership of the process. HUTAP will also provide leadership to key stakeholders in aligning their activities and securing their commitment to work toward developing and sustaining a lab system with the high-quality diagnostic, treatment and surveillance capacity necessary to support a robust national response to HIV/AIDS in particular and national health care delivery in general. Monitoring and evaluation of the implementation of Year 2 plans will be carried out to assure that set targets are met. The proposed family-centered ART Clinic at QECH will provide data on essential indicators for adult and pediatric HIV treatment. At the national level the M&E system will provide information to laboratories to better facilitate HIV testing for adults, pregnant women and infants. Data on pre-service and in-service training will form the basis for reports that we will be generating quarterly. Modifications to this database will allow for tracking of individual laboratory technicians and whether they are still actively utilizing the skills taught. Additionally, quarterly assessments of district hospital laboratories on their capabilities to provide essential quality laboratory services will be conducted, and quality assurance assessments will carried out bimonthly.

Under the Partnership Framework, we will undertake surveys, programmatic data review, and other forms of assessments to evaluate the effectiveness of the interventions to attained desired goals. HUTAP in collaboration with MOH and other partners will assess the effectiveness of the in service training and mentorship of laboratory technicians in improving, skills, competency and output. HUTAP will assess and determine the role of establishing and implementing a national laboratory quality assurance system in improving access and quality of care. We will also keep the nation of Malawi informed on monitoring the effectiveness of and threats to the ART program through the ongoing HIV drug resistance surveillance.

Completion and successful implementation of the National Laboratory Strategic Plan is crucial to the success of our goal and objectives, and HUTAP will support towards implementing of the plan in Year 2. Additionally, we will contribute to the overall HIV disease monitoring and strengthening Malawi's national response to HIV and AIDS through the HUTAP-supported epidemiologist and laboratory specialist placed in the national reference laboratory to provide on-site capacity building to their counterparts.

PFIP Year 1 Budget - $2,570,000 PFIP Year 2 Budget - $3,850,000

II. Budget Code - HTXS $235,000 More than 90,000 children in Malawi are living with HIV, and the vast majority was infected maternally. Without treatment, an estimated one in three infected newborns will die in their first year of life and one in two will die before the end of their second. According to UNAIDS, more than 90% of children acquire HIV during pregnancy, labor and delivery or through breastfeeding after birth. Increasing access to ART for pregnant women is thus one important element in fighting HIV/AIDS in children. However, very few women who are tested for HIV and are positive start ART.

The goal of HUTAP in PFIP Year 1 and 2 will be to develop the ART services at QECH and MCH into true family ART clinics. All health care workers will be trained in both adult and pediatric ART as well as aspects of ART for pregnant and post-partum women. This will make it possible for a single clinician to assist all family members on a single visit. The efficiency of ART services will improve when each staff member can provide ART care and treatment to patients of all ages and special groups.

In-Service Training-Addressed in OHSS-HRH budget code

Activity 1: Refurbishment The current ART clinic at Queen Elizabeth Central Hospital (QECH) was opened in 2004 to accommodate 1,000 people. Currently, there are approximately 6,000 patients seen at the clinic and the number continues to rise steadily. Compounding the lack of space is the design of the building which obstructs patient flow, poor ventilation which increases the risk of transmission of infection such as tuberculosis, and long lines and delays.

Year 1 funds will be used to expand the ART Clinic at QECH. This refurbishment project will create adequate space for patient registration and a waiting area, data management, and administration. Patient flow will be enhanced and the number of clinic rooms will be increased. Year 2 funds will be used to renovate and expand the existing ART clinic at Mzuzu Central Hospital (MCH) to provide family- centered ART and care.

Activity 2: Coordination of Diagnostic Testing and Referral Networks In Year 2, this activity will focus on strengthening the laboratory infrastructure at EID sites as entry points for quality laboratory testing that would support all HIV/AIDS-related treatment and care. Currently, several of the sites are linked to PMTCT and ARV programs at district hospitals and rural health centers. Strengthen laboratory capacity at other service-delivery sites through expansion of quality-based CD4 and routine testing; improvement of transportation mechanisms to ensure timely and reliable reporting of test results; provision of reagents and supplies to close gaps in laboratory services; and acquisition of laboratory equipment.

Currently, the program is relying completely on a local courier service to transport specimens for PCR and CD4 due to the limited capacity for these referral sites to provide these services. Many of these sites still lack the capacity to provide routine, consistent testing services. In Year 2, HUTAP will assist the MOH to build and strengthen a CD4 network and to expand PCR testing to at least one more site.

Activity 3: Human Resources Support Although ART services have been successfully scaled-up in Malawi, gaps still exist with respect to access to HIV care for children and pregnant women. One important reason for this is the shortage of skilled health care workers, particularly in government health facilities. In Year 1, HUTAP will address these shortages at the QECH ART clinic by hiring 4 Clinical Officers, 3 Nurses, 2 HIV Counselors, 1 Patient attendant, a Data Officer and Administrative Assistant. The additional staff will assist in improve the quality of services and increase access to ART particularly for infants, children and pregnant women at the clinic.

In Year 2-HUTAP will support the hiring an additional 8 staff (4 Nurses and 4 Clinical Officers to be placed at QECH and MCH as needed). HUTAP will retain the existing staff that was hired in Year 1 in Year 2.

I. Budget Code - PDTX $235,000.00 Until recently, the means to diagnosis HIV in infants <18 months old in Malawi was limited to research institutions. ART provision to HIV infected infants has therefore remained very limited, both country-wide and at Queen Elizabeth Central Hospital (QECH) in Blantyre and Mzuzu Central Hospital, the largest referral hospitals in the southern and northern regions, respectively and well-established HUTAP- supported sites. In PFIP Years 1 and 2, HUTAP will strengthen ART services at referral hospitals using a family centered approach to provide full-time coverage of pediatric ART and care. All current and new ART clinical officers and nurses will be trained in both adult and pediatric ART care as well as aspects of ART for pregnant and post-partum women. Similarly, activities will support the Essential Medical Laboratory Services (EMLS), for ARV and PMTC scale-up throughout Malawi. Labs supported by HUTAP will be linked directly to HIV service provision sites. This includes the central, district and health center level hospitals where testing and treatment are rendered. Effective sample transport mechanisms will be established to strengthen linkages for testing and treatment.

In PFIP Year 1 and 2, HUTAP will directly support these efforts at QECH and Mzuzu Central Hospital through the following activities:

In-Service Training-Addressed in OHSS-HRH budget code

Activity 1: Refurbishment The current ART clinic at Queen Elizabeth Central Hospital (QECH) was opened in 2004 to accommodate 1,000 people. Currently, there are approximately 6,000 patients seen at the clinic and the number continues to rise steadily. Compounding the lack of space is the design of the building which obstructs patient flow, poor ventilation which increases the risk of transmission of infection such as tuberculosis, and long lines and delays.

Year 1 funds will be used to expand the ART Clinic at QECH. This refurbishment project will create adequate space for patient registration and a waiting area, data management, and administration.

Patient flow will be enhanced and the number of clinic rooms will be increased. Year 2 funds will be used to renovate and expand the existing ART clinic at Mzuzu Central Hospital (MCH) to provide family- centered ART and care.

Activity 2: Strengthen Referral Networks In PFIP Year 1 and 2, HUTAP will assist to improve access to ART for HIV positive infants and children. Many HIV exposed infants born at referral hospitals reside near health centers that provide Pediatric ART and Care. After receiving diagnosis, referral to their nearest health center for ART would be one of the most effective ways asure these children receive treatment. This would also reduce the waiting time for patients to be seen by a clinician at the referral hospitals and and ease the burden of staff who provide ART services at these sites. In order to assure access to ART at these centers, staff will require training in infant ART care. There will also need to be an effective system in place to assure patients who are diagnosed at the hospital are receiving treatment.

As HIV programs are increasingly decentralized, district and sub-district level diagnostic capacity will also need to be radically increased. HUTAP, in collaboration with other partners, will devise a transportation system to assure a reasonable turnaround time for CD4 and PCR results to enhance the linkages to care and treatment and to reduce the loss to follow up rate that is currently over 30% in PMTCT/Early Infant Diagnosis (EID) programs.

Activity 3: Human Resources Support Although ART services have been successfully scaled-up in Malawi, gaps still exist with respect to access to HIV care for children and pregnant women. One important reason for this is the shortage of skilled health care workers, particularly in government health facilities. In Year 1, HUTAP will address these shortages at the QECH ART clinic by hiring 4 Clinical Officers, 3 Nurses, 2 HIV Counselors, 1 Patient attendant, a Data Officer and Administrative Assistant. The additional staff will assist in improve the quality of services and increase access to ART particularly for infants, children and pregnant women at the clinic.

In Year 2, HUTAP will support the hiring an additional 8 staff (4 Nurses and 4 Clinical Officers to be placed at QECH and MCH as needed). HUTAP will retain the existing staff that was hired in Year 1 in Year 2.

V. Budget Code - OHSS $1,000,000 (PF09 Funds)

Activity 1: Support the implementation of the laboratory pre-service curriculum HUTAP along with a key laboratory partners including the Laboratory Consortium, laboratory tutors, technicians, and curriculum development experts, will review and update the laboratory pre-service curriculum. This activity will focus on HIV testing and molecular techniques as well as testing for HIV monitoring, treatment and identification of opportunistic infections (OIs) and supply chain management. The competency-based curriculum will be designed to address gaps that will be identified from a needs assessment, and a series of curriculum review meetings that will take place in Year 1.

All pre-service activities will be done in collaboration with other USG funded partners including the Laboratory Consortium and JSI. HUTAP will focus its efforts on the Malawi College of Health Sciences while the lab consortium will focus on Malamulo College of Health and the College of Medicine. Both partners will hire a mentor and a local counterpart that will be based at the teaching institutions to assure that the implementation and monitoring of activities are carried out successfully. Each partner will procure the necessary equipment and supplies to support the practical training component. Prior to the implementation of the updated curriculum a training of trainers and clinical instructors on the new curriculum content, educational methodology and curricular implementation including an assessment plan will be carried out by partners. HUTAP will provide training on curriculum implementation, and technical content and the lab consortium will provide training on Good Clinical Laboratory Practices including lab management, quality assurance, lab safety and ethics. JSI will assist in developing the curriculum content and training in Supply Chain Management.

Activity 2: Support Lab Assistant Pre-service Training Program HUTAP will support the Lab Assistant program at Malawi College of Health Sciences. The Lab Assistant Program is an 18-month program designed to train a cadre of health practitioners to perform basic lab testing in rural health centers and other underserved facilities. During the program, students undergo a 6-month orientation at MCHS followed by 12 months alternating lectures and clinical attachments to district and central hospitals. During Year 1, HUTAP in collaboration with the MOH, CHAI, and other partners will review and update the curriculum that was developed in 2008, strengthen the infrastructure at the lab training schools including procurement of equipment, teaching and learning materials, and hiring additional tutors/staff to assure capacity to provide instruction to the students. In Year 1, HUTAP will begin the recruitment process which will involve advertising for prospective students to apply to the program, interviewing and selecting students. With Year 2 funding, HUTAP will support the enrolment of 25-30 students to the program. A 6-month orientation program which encompasses lectures and basic laboratory skill training will be provided to the students. The updated curriculum will be implemented and on-going program assessments will be conducted. Clinical attachments will be coordinated with high

through put labs in central and district hospitals to provide optimal hands on experience. Funding will support the recruitment, student orientation sessions, training, supervision, lab and teaching supplies, reagents, equipment, vehicle for transporting staff and students, allowances and accommodations for students while on clinical attachments, and staffing support to provide classroom and clinical instruction.

Activity 3: In-Service Training In Year 1, HUTAP will build the capacity of laboratory staff in HIV diagnosis and disease monitoring. Analyzer trainings will be conducted quarterly to cover topics such as HIV Rapid Testing, ELISA, Flow Cytometry and CD4 enumeration, PCR, and OI diagnosis. This activity will target laboratory technicians who are working at PEPFAR supported laboratories and from other laboratories linked to HIV service delivery sites. Two PCR trainings will be conducted in Year 1 for laboratory staff providing EID. With Year 2 funding an additional two PCR in-service trainings (new and refresher) will be conducted for 20 lab technicians. Four CD4 trainings, and four analyzer trainings targeting hematology and chemistry will be conducted during Year 1, and eighty lab technicians will receive in-service training in Year 1.

In Year 2, increased funding will allow HUTAP to build on its achievements in Year 1 where an additional 80 lab technicians will receive knowledge and skills updates through in-service training. In an effort to attain high quality ART services at QECH, refresher and certification courses on ART and care for HIV infected children and infants will be conducted in Year 1 biannually and will target 50 nurses and clinicians from QECH and the surrounding Blantyre district in Year 1. In Year 2, this program will be expanded to train 100 staff (Clinicians, Nurses, and Counselors) from ART clinics in the southern and northern Regions.

Activity 4: Human resource support During Year 1 and Year 2, HUTAP will retain two laboratory tutors at the Malawi College of Health Sciences to assist with the implementation of the updated pre-service curriculum and to provide supervision and training of students at designated clinical training sites.

Activity 5: Develop an Incentive Program for Clinical Staff As an incentive and motivation strategy, HUTAP will support short-term training for ART staff at QECH in Year 1. QECH staff in collaboration with HUTAP will identify courses offered locally (in Malawi) for ART clinic employees to upgrade their knowledge and skills. In exceptional cases, in Year 2 HUTAP support will be provided for staff to pursue short courses, workshops or conferences offered in another country within the region.

Activity 6: Provide Internships for Medical Lab Science students In an effort to retain medical laboratory science graduates placed at referral hospital laboratories, an

internship program was implemented in FY08 for top graduates of the laboratory training programs. Seven graduates, selected on the basis of performance, received advanced training at Kamuzu Central Hospital and Queen Elizabeth Central Hospital in PCR, CD4, hematology and chemistry. This program has proven highly successful and will be expanded In PFIP Year 1 and 2 to allow exceptional students to gain experience in all aspects of laboratory services. Students will also be required to rotate in central hospital and reference laboratories as well as research labs to gain advanced training in experience in research, molecular techniques, QA and management.

Activity 7: Provide Mentoring and Training for Laboratory Supervisors In Year 1, HUTAP will collaborate with MOH and partners to implement the WHO AFRO Laboratory Management Towards Accreditation (SLMTA) program to prepare laboratories for accreditation. This program will focus on training and mentoring laboratory supervisors and managers from central and district hospitals in quality assurance, supply-chain management, preventive maintenance of equipment and documents and records management. Through this training and mentorship, supervisors will be able to manage the laboratory more efficiently and to assure accuracy and quality in testing results. Supervisors will be trained to oversee quality assurance programs instituted for HIV testing. By the end of Year 2, at least two laboratories in central and district hospitals will achieve accreditation.

1. PMTCT Budget Code Narrative ($1,100,000.00)

Activity 1: Lab Systems-Quality Assurance (QA) and Point of Care Technologies

Assuring accuracy and reliability of HIV related testing is of paramount importance in the diagnosis and treatment of pregnant women, children and the adult population. With additional funding, HUTAP in collaboration with the MOH National Reference Laboratory at CHSU, the Diagnostics Division in the MOH Community Health Sciences UNIT Central Reference Lab (CHSU) and other laboratory partners will strengthen and expand the existing QA programs for HIV Whole Blood Rapid Testing, CD4, PCR and routine laboratory services. Through existing funding, HUTAP supports an HIV Lab supervisor based and the National Reference Laboratory at CHSU whose major responsibility is to coordinate and supervise the scale-up of HIV WB rapid testing and CD4 QA nationally. With the additional funds, HUTAP will provide support to strengthen the infrastructure of the NHRL through refurbishment and procurement of equipment and supplies, hire additional staff, conduct refresher and new training courses, develop standard operating procedures and QA guidelines.

Quality CD4 testing, as opposed to WHO staging, of pregnant women allows for more HIV-infected women to be initiated on ART and therefore the need to improve access to CD4 testing in the district and rural areas. HUTAP will also support the training of the testers through refresher courses and the purchase of QC materials and proficiency testing (PT) samples for all CD4 platforms currently available in Malawi with an emphasis on the NHRL. Between 2007 and 2009, HUTAP enrolled a total of 25 Government and Christian Health Association of Malawi (CHAM) laboratories in either the UK National External Quality Assurance Scheme (UKNEQAS) from United Kingdom or African Regional External Quality Assessment Scheme (AFREQAS) from South Africa. One of the major barriers to assuring quality testing at these sites is due to the frequent breakdowns due to the age and use of the machines. With additional funding, HUTAP will upgrade 4 CD4 machines to percentage capabilities that are attached to the CD4 EQA program. Additionally, we will support the infrastructure at the NHRL at CHSU to become the hub for the CD4 QA program. HUTAP will procure additional fridges, freezers and equipment needed as to enhance CHSU's ability to prepare, store, distribute specimens and administer proficiency testing (PT) for CD4 testing nationally. Infants of HIV-infected mothers identified through rapid testing at ANC sites are referred to Early Infant Diagnosis (EID) for DNA-PCR testing. HUTAP has been supporting the EID component of the PMTCT program in Malawi and with additional funding will expand the DNA-PCR testing to the referral hospital in the Northern Region of Malawi where it has just refurbished the laboratory. HUTAP will procure quality control (QC) materials to support implementation of the current DNA-PCR quality assurance protocol that requires retesting of all specimens that produced an initial positive result. Funds will also support the shipment of DBS samples and PT results through a major courier to CDC Atlanta. Additionally, HUTAP will build the capacity of the NHRL through refurbishment and procurement of equipment for PCR testing to establish CHSU as the QA focal point for DNA PCR and viral load testing for the country. HUTAP will collaborate with the Malawi Laboratory Consortium in conducting feasibility studies on the use, cost benefit analysis, and efficiency of Point of Care Technology for CD4 and PCR testing for use in the rural health care setting. This technology will bring critical laboratory services directly to patient care without relying on the need for courier systems for sample transport and extensive training, equipment and service contracts. With this funding, HUTAP will focus its efforts in these studies to the Northern region which it will be supporting through existing funding to strengthen laboratory services and implement activities. Activity 2: Sample Transportation and Referral Systems Currently, the PMTCT program is relying on a local courier service and ambulances and other modes of transport to transport samples for EID (DNA PCR) and CD4 to the referral laboratories due to the lack of a cost-effective, consistent and reliable national sample transportation and referral mechanism. Many of these sites still lack the capacity to provide routine and reliable testing services. Moreover, several of the sites offering PMTCT and ART services have weak systems in place for referring patients for care and treatment due to weak follow-up programs and slow turnaround time for test results once the specimens

are sent to these laboratories. HUTAP in collaboration with the MOH and other partners will implement a comprehensive sample transportation and referral system with scheduled pick-up and drop off of samples from all health facilities using a phased approach. Initially, the program will be established in one region. HUTAP will support the procurement of start-up equipment such as vehicles, motorcycles, uniforms, helmets, and specialized cooler boxes and devices to transport specimens as well as expand its office space to accommodate and manage program operations. HUTAP will also hire and train staff to manage the program and on the use of sample transportation and bio-safety. Funds will also be used for vehicle maintenance, fuel, and other logistics costs. The drivers and equipment will be absorbed into the MOH at the end of the funding period. Lessons learned from the initial scale-up of the program will be used to inform the MOH on the rollout of a nationwide sample transportation system that the MOH can sustain over time.

III. Budget Code - HLAB ($2,350,000)

With the scale-up of ART, EID, PMTCT, HIV counseling and testing (HCT), TB/HIV and malaria services, laboratory service to support these programs have increased in scope and complexity. Through PEPFAR Year 1 and Year 2 funding, HUTAP will provide assistance in strengthening lab services in Malawi through pre-service and in-service training, building human resource capacity through staffing and mentorship programs, Quality Assurance (QA), and creating an enhanced laboratory infrastructure to support CD4 and other tests for HIV diagnosis and disease monitoring.

Activity 1: Refurbish of Laboratories at Central and District Hospitals In FY08, HUTAP in collaboration with CHAI, Roche and the MOH renovated the Mzuzu Central Hospital (MCH) laboratory to provide PCR/Viral load testing in support of EID and other HIV services. There is now an EID testing hub in each of Malawi's three health regions. Using a tiered approach, HUTAP will complete the refurbishment of Mzuzu Central Hospital Laboratory to expand the lab capacity to provide basic lab services including CD4, Chemistry, Hematology, TB Microscopy and Cultures in Year 1. In Year 2, HUTAP will complete the refurbishment of 4 district hospitals in the Northern region, thereby establishing distinct capacity for services, protocols and communication at the central, district and community levels. This will enable stronger provision of laboratory services, from building high-level leadership, management and supervision down to providing more accessible and high quality care for patients. HUTAP will particularly target EID sites that are entry points for quality laboratory testing that would support all HIV/AIDS-related treatment and care.

In Year 2, HUTAP will expand EID lab services to Zomba Central Hospital through renovations and expansion of the existing lab. These activities will be complementary to the renovation activities being conducted by the USG-funded Laboratory Consortium.

Activity 2: Implement and Monitor Quality Assurance (QA) programs for HIV-related Testing Using Year 1 funds, HUTAP will increase the capacity at government, mission and Malawi Defense Force (MDF) hospital laboratories to carry out quality HIV diagnosis and disease monitoring by establishing national quality assurance programs for HIV, CD4, and PCR testing at 35 sites. During Year 2, this activity will be expanded to all ART sites (52) that provide HIV testing and disease monitoring. Funds will support enrollment of sites in External Quality Assurance (EQA) Programs, supervision, and logistics. This activity will be done in collaboration with the MOH National Reference Laboratory which has the mandate for implementing laboratory QA programs in Malawi.

Activity 3: Human Resource Support With Year 1 funds, HUTAP will retain three lab technicians and one EID laboratory coordinator to assist with the scale-up of EID laboratory services. HUTAP will also support in building the capacity of their staff to assume these roles by Year 2 through mentorship and technical and leadership trainings in Year 1. HUTAP, in consultation with the, will determine the need to support these positions in Year 2 based on results from program assessments and staffing needs. An HIV epidemiologist and lab supervisor are placed in the MOH in an effort to strengthen the Malawi Community Health Sciences Unit which houses the National Reference Laboratory and disease surveillance units. These positions will continue to be funded In PFIP Year 1 and 2.

Activity 4: Procurement of Reagents and Supplies, and Provision of Service Contracts for Equipment HUTAP, in collaboration with CDC, UNICEF, and the Clinton Foundation will continue to support the MOH in building the capacity of laboratories to provide testing services for HIV diagnosis and disease monitoring. Reagents and other consumables will be procured through HUTAP and the Clinton Foundation to supplement orders currently procured by the through the Global Fund and other pooled donors during Year 1. HUTAP will also work with the MOH in collaboration with JSI DELIVER to strengthen lab supply chain management and to assist with system design and training for a more effective program. In Year 2, HUTAP will provide support for additional resources only when gaps exist which will interrupt service deliver.

HUTAP has supported the over the past five years in maintaining equipment through the provision of service and maintenance contracts. As more equipment is procured it will be necessary for the MOH to maintain the current agreements and purchase new ones as needed. In Year 1, HUTAP will support the

MOH to provide contracts for 11 BD Facs count analyzers, four Chemistry analyzers, and two EPIC Flow cytometers. With Year 2 funding, HUTAP will provide funds for service contracts on additional equipment as required.

Activity 5: Support the development and implementation of the National Laboratory Strategic Plan The development of greater laboratory capacity in resource poor countries is an urgent need, as clearly stated in the 2008 WHO Maputo Declaration on Strengthening of Laboratory Systems, developed by consensus at a large meeting of government and international partners. This Document appeals to national governments to prioritize support for laboratory systems through implementation of a National Strategic Laboratory Plan that integrates laboratory support for the major diseases of public health importance including HIV, tuberculosis, and malaria. HUTAP is committed to play an instrumental role in developing and implementing Malawi's National Lab Strategic Plan (NLSP) during Year 1 and Year 2 through hosting meetings in collaboration with MOH to review, update and disseminate the plan to stakeholders.

Activity 6: Strengthen the Malawi Defense Force laboratory service The Malawi Defense Force (MDF) plays a pivotal role in providing health care services not only to its uniformed cadres and their families, but also to the large civilian communities in its catchment areas. The MDF has one central laboratory at the Kamuzu Barracks in Lilongwe and three regional laboratories in the southern, central and northern regions.

USG through the Department of Defense has worked with the MDF on strengthening their HIV-related laboratory through providing critical equipment to support HIV diagnosis, CD4 monitoring, and basic chemistry and hematology as well as TB and malaria diagnosis. In addition, USG has provided technical support to MDF in making its service provision more cost effective through standardization and integrating it into the national laboratory strategy.

In Year 2, USG will scale-up its support to the MDF at all four high through-put labs by providing physical infrastructure improvements, training relevant staff, and establishing a network between the MDF institutions and public and private institutions that would assure the quality and reliability of test results. The training efforts and the utilization of common Standard Operating Procedures (SOP) between the Ministry of Health and the MDF facilities will assist in integrating health service delivery as the MDF will be providing services to populations that are not reached by the MOH.

These objectives will be carried our by implementing the following activities: Activity 1: Develop an appropriate assessment tool and conduct a rapid assessment of physical and programmatic laboratory needs of the four MDF institutions. Develop a plan for program implementation

Activity 2: Based on the assessment make relevant repairs and physical space improvements to support the laboratories Activity 3: Provide in-service training and mentorship for 16 medical laboratory technologists from the 4 institutions Activity 4: As a special focus area of training, develop a training and mentoring program for CD4 testing and QA at the 4 institutions Activity 5: Establish a laboratory quality assurance network between the 4 institutions and public and private laboratories that would include enrollment and integration in international and national EQA program for critical tests performed in these institutions