Lighthouse Trust provides a range of services in HIV, which encompass all aspects of the Partnership Framework between the US Government (USG) and the Government of Malawi (GOM), and in providing services at two major hospitals and supporting services at several smaller health centers in the capital city Lilongwe, is also contributing to the strengthening of the broader health system. Lighthouse is in the process of expanding their focus on HIV prevention through a formalized Prevention with Positives program, scaling up HIV care and treatment, providing care and support to HIV-affected and infected children, and addressing Health systems strengthening through HIV in-service training and mentoring, and through increasing the laboratory services available to those in care and treatment. Lighthouse started in 1997 as a voluntary group of staff working at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. Lighthouse Mission Statement is that it exists to fight against AIDS in Malawi by providing a continuum of quality care and support and by working to build capacity in the Health Sector.

This is achieved through three technical objectives: 1. To provide Integrated HIV and AIDS Treatment, Care and Support services, maintaining capacity and improving quality. 2. To develop a systematic approach to health care delivery at the Lighthouse through defined and documented protocols and procedures that would serve as a model that informs similar interventions elsewhere. 3. To establish the Lighthouse as a training institution that builds capacity to deliver care and support for HIV and AIDS in Malawi.

Lighthouse as a Malawian Trust functions as part of the public services at Kamuzu Central Hospital and Bwaila Hospital in Lilongwe. Lighthouse has become a major HIV service provider with operations in HIV- testing and counseling (HTC), antiretroviral treatment (ART) and other facility-based clinical care.

Lighthouse provides community home based care (CHBC) interventions through a network of community volunteers.

During the first five months in 2009, Lighthouse has: Tested 17,729 clients, and identified 4,117 people living with HIV (PLHIV); registered 2,527 new patients, of which 1,646 started ART bring to a total of almost 10,000 patients alive on ART; CHBC nurses looked after 210 patients in their houses; and our 450 community volunteers provided psychosocial support to 2,657 patients in the community. Lighthouse operations follow national guidelines and our policies are designed to be implemented at the district level. Combined with strong monitoring and evaluation, this gives us the opportunity to be leader among HIV providers in the public sector. Key policies rolled out by the Ministry of health were piloted and evaluated at Lighthouse. The Ministry of health (MOH) and the National AIDS commission are our largest donors. The US government contributes significantly through CDC and PACT to Lighthouse's success.

Malawi continues to scale-up ART, however patients are still presenting late, and new HIV infections have not significantly reduced nationally. PLHIV need to access HTC, ART and prevention messages earlier in the course of their disease.. With FY09 through to FY10 financial support we plan to mobilize our facilities and community to achieve earlier and timely initiation of ART through establishing comprehensive pre- ART services. From outreach points we will deliver messages on prevention with positives (PwP), including positive living, condom use, and other issues such as ART and CPT adherence. Patients will receive Cotrimoxazole preventive treatment, and link to the Lighthouse clinic for WHO staging and regular CD4 count testing. They will also receive food supplements and insecticide treated bed nets. Volunteers will regularly visit them in the community as we do for ART patients. By providing these services, patients will enter the continuum of care earlier and we will carefully monitor the outcomes of this pre-ART cohort. Longitudinal care of PLHIV is also strengthened by our focus on women referred for ART from antenatal care (ANC). We will actively trace women who do not show up to register at Lighthouse, as well as women who did not collect the positive HIV-PCR results of their infants. ANC-women will be entry points of family-centered care, especially at Bwaila Hospital.

Resources in the community are limited; mobilization of community members requires additional resources. With FY10 funding we want to facilitate the set up of PLHIV-support groups to achieve greater involvement and ownership of our patients. Support group members will be trained how to provide IEC messages for positive living and referral network.

Lighthouse will build on existing cadres: volunteers, Lighthouse HTC-, clinic- and CHBC- staff, and a strong monitoring and evaluation team with an established system for registering and following up patients. Our targets for PFIP years 1 and 2 are entered in the Indicator table.

Budget Summary PFIP Year 1 Funding - $397,000 PFIP Year 2 Funding - $800,000

Budget Code - HBHC ($385,000) Lighthouse has an established system of managing patients on ART at its two clinics. However, proactive identification of patients before ART initiation from HTC services needs to be strengthened. We manage patients under primary care but the minimum package has not been prescribed yet by Ministry of Health. HBHC activities are closely interlinked with HVOP activities, and the two narratives will reflect that.

In Year 1 we would like to pilot management intervention for Pre-ART patients linking them from facility based HTC, community based HTC and the clinic for comprehensive care and support. This will involve treatment for opportunistic infections, screening for TB and STIs, as well as screening for pregnancy, and providing family planning services among patients at every visit. We will use Lighthouse services to define a model intervention for Pre-ART service delivery.

Lighthouse comprehensive care center houses one of the busiest ART clinics in Malawi registering over

8, 000 contacts with HIV positive patients on ART each month. This clinic presents an opportunity where HIV preventive interventions will be delivered routinely to ART patients at each visit. Lighthouse has an existing patient education and counseling program into which prevention messages for positives will be incorporated. The Training unit will work with HBC and clinic staff to develop focused messages targeting individuals with HIV. This will also be a model intervention for Prevention with Positives (PwP) which aims at reducing HIV transmission.

Some activities lined up for Year 2 as a scale up from the FY09 are described below. Lighthouse provides facility based HIV Care services at the Lighthouse center, Martin Preuss Center, Maula Prison, two Lilongwe rural health centers and community-based HIV services with Lilongwe city strategic areas. We use a family-centered approach for a continuum of care to HIV positive persons including adolescents. This care is aimed at improving quality of life and prevention for positives. Methods of program and monitoring and evaluation are described in technical budget area HVSI.

Activity 1: Lighthouse establishes a model for pre- ART service delivery in Malawi

Patients frequently come to our ART clinic or are referred from HTC in advanced stages of HIV-infection. Therefore, early mortality among patients starting on ART remains high and their prognosis is low. However, regular follow-up of patients including WHO-staging, immunological monitoring, and provision of Cotrimoxazole prophylaxis would add an additional workload to our already overstretched ART-clinic staff. With the view to universal access, and the goals of reduction of early mortality among patients on ART, durability of the 1st line regimen, and intensified Prevention-with-Positives (PwP), there is need to develop a model to deliver pre-ART services to patients not yet eligible for ART. In collaboration with MOH, we plan to develop a comprehensive service package for this underserved group, including provision of CPT, TB screening, STI screening, nutritional screening and counseling and provision of therapeutic feeding and food supplements if eligible, regular CD4 monitoring in order to improve their clinical condition, to delay their disease progression, and to identify ART eligibility. In addition, we will set up a robust M&E system for pre-ART services and link with the MOH, With MOH, we will explore options to develop, implement and evaluate these procedures to inform national policy on the feasibility of this new area. At ANC in Bwaila hospital, the PMTCT program traces HIV infected pregnant women with CD4 count below 250/µl, which do not pick their results. However, those women, who picked their result but did not register at the ART clinic at MPC, are not yet actively followed-up. With funding available, we will close this gap and give these women a continuum of quality care at MPC and at the same time make PMTCT much more effective.

Activity 2: Prevention with Positives (PwP)

Lighthouse comprehensive care clinic houses one of the busiest ART clinics in Malawi registering over 8,000 contacts with HIV-positive patients on ART each month. This clinic presents an opportunity where HIV preventive interventions will be delivered routinely to ART patients at each visit. Lighthouse has an existing patient education and counseling program into which PwP messages will be incorporated. The Training unit will work with HBC and clinic staff to develop focused messages targeting individuals with HIV. The messages will be delivered through group education sessions, one-on-one counseling, and IEC materials. The primary focus will be on assisting HIV infected individuals to disclose their HIV status to partners, reduce their risk of transmitting HIV, and reduce the risk of primary STI infection or HIV re- infection. This package aims at reducing HIV transmission (prevention with positives) and will rely on support and involvement of the community through linkage with our existing Ndife Amodzi program.

Activity 3: Promotion of Water Guard Technology for safe water

Health interventions at community level to prevent opportunistic infections are very crucial especially for PLHIV. Lighthouse in collaboration with Population Services International (PSI) piloted Water Guard water purification technology in one CBO (Chimoka) in FY08, which reported high incidences of cholera previously. This targeted HBC patients' households to improve access to safe water thereby reduce incidences of diarrhea disease in immuno-compromised patients in home based care program. The initiative started with one day training of 40 volunteers from the pilot sites in water guard technology usage, which in turn transferred skills gained to primary care givers so as to effectively prevent water borne diseases in the households. Because of anticipated on-going exposure to cholera in some of the higher-density residential areas, Lighthouse plans to comprehensively continue providing Water Guard to HIV-infected individuals and their families. In FY10, Lighthouse will purchase and distribute 1,800 bottles of water guard which will benefit 150 patients.

Activity 4: Strengthen linkage between community and Lighthouse facilities

There is a need to further strengthen LH links and contributions to the community in order to enhance HIV prevention through behavioral change, improved knowledge of volunteers and community care supporters, and economic empowerment. Health interventions at community level to prevent opportunistic infections through use of clean water, insecticide bed-nets for malaria and nutritional support as well as distribution of prophylaxis for common opportunistic infections by CPT will reduce the disease burden and progression of HIV infection among our patients. Our linkages with the community and the active pool of the volunteers will assist in the establishment of outreach points for pre-ART clients which will be recruited through the NA-program.

Activity 5: Training and supporting Community Volunteers for the HBC Program

Lighthouse plays a significant role in the development of palliative care policies and services. In 2007, Lighthouse made significant inputs in the development of Malawi's National Curriculum for Palliative Care Training. With the current PEPFAR funding through Pact - Malawi Lighthouse has managed to train 473 volunteers and staff in community home based care and other in - service trainings which were conducted in response to the needs assessment done by the training department. In year 1 LH plans to train 450 volunteers, 7 community care supporters and 4 nurses. We also plan to train 40 expert patients in positive living. As a way of preventing malnutrition, Lighthouse plans to engage agriculture extension workers to train 90 volunteers on crop diversification, manure making and food preparation. Early detection of malnutrition is critical in caring for PLHIV. In view of this, Lighthouse in Year 2 will procure weighing scales for use by nurses and Community Care Supporters. This will assist them to do weekly and monthly weighing of all HBC patients and Ndife Amodzi clients respectively thereby closely monitoring nutrition status and provide nutritional support (RUTF) and Likuni Phala where necessary.

Budget Code - HTXS ($200,000) Currently, Lighthouse has about 10,000 patients on ART between their two sites; both serving high- density population areas and the greater city. Lighthouse will continue to provide comprehensive quality care to PLHIV. With FY09 funding we expect to enroll 4,300 new patients in the program and retain in cumulative care 12, 794 adults and children by September 2010. Our initiatives of group adherence sessions will continue to enhance treatment adherence. Our Back to Care Program (B2C) will continue to actively trace patients who miss appointments for at least 21 days.

Activity 1: Lighthouse Clinics at KCH and Bwaila together manage 15,741 patients on HAART by the end of 2010

The work load at Lighthouse and MPC clinics continues to grow steadily, with over 8, 000 visits per month. The introduction of CD4 count testing for all new HIV-positive clients has made a significant contribution to the numbers starting ART, and between the two sites, Lighthouse now starts more than 300 patients on ART each month. Currently about 10,000 patients are alive on ART requiring one, two or three month's reviews. We ensure that 66% of the patient reviews are made by nurses, leaving the more complex cases for the few clinicians available. We plan to pilot pediatric ART review to be done by

nurses. At our Martin Preuss Centre (MPC), based at Bwalia Hospital, we will continue to provide TB/HIV integration for Malawi's largest TB Registry, and facilitate access for HIV infected women (and their families) identified through the country's largest PMTCT program. The MPC now manages over 4,000 patients on ART. 95% of TB patients now know their HIV status as they start treatment, and 64% of HIV-positive TB patients enroll in ART at the MPC. Average new monthly ART registrations at MPC (234) are exceeding those at LH (134), showing the steady and rapid growth of the new site.

In collaboration with the University of North Carolina, we provide CD4 testing for all HIV-positive pregnant women identified through UNC's PMTCT program and will continue in Year 2. More than half of those women identified as eligible for ART (CD4 < 250) successfully start ART at the MPC whilst still pregnant, up from less than 10% in 2006.

Activity 2: Lighthouse clinic decentralizes ART follow-up working with HIV Unit to develop methodology The current major theme for Lighthouse services is decentralization. This is aimed at decongesting our centralized services, allowing us to provide higher quality care to those who need it most. One key activity is to support ART delivery at two health centers in Lilongwe district. One such center (Chileka) has been approved by the MOH for the next round benefiting from our mentoring role. Although no additional staff are planned for these centers, Lighthouse through funding from Year 2 will provide minor refurbishment of rooms, furniture, and equipment; will support and train staff; and will provide on-site supervision. Ultimately, these sites will become satellite ART clinics of the Lighthouse.

Activity 3: Ndife Amodzi (Pact funded)

The Ndife Amodzi (NA) program is a USAID - PACT funded effort aiming at exploring effective ways to involve the community in the support of ART patients by using Community Volunteers to promote adherence, early referral, and positive living, and to support the monitoring of ART patients. Meaningful involvement of PLHIV is critical to any work in HIV and AIDS. Currently Lighthouse CBOs have expert clients working as volunteers. In FY10, we plan to work with them more vigorously in community sensitization activities including NA promotion in all health facilities that are running the program (including Lighthouse clinics). Two PLHIV will be placed at each facility twice per week. Their role will be to sensitize and refer ART patients into the program. This will enhance enrolment and ownership of the program amongst clients themselves. Specific activities will include: developing expert patient specific IEC materials including topic guides; Training expert patients and members of staff in the HBC program in positive living in addition to the current volunteers who promote Ndife Amodzi in the clinics; schedule formal support group meetings; Expert patients conducting the NA promotion and patient education; all these will require proper documentation and supervision by the CHBC leadership.

Lighthouse through NA will establish Community Based Distribution Points (CBDP) that will be managed by PLHIV support groups where integrated services like HTC, pre-ART (including Cotrimoxazole prophylaxis), PMTCT, condom distribution and RUTF will be provided. The existing Community Care Supporters will be responsible for community mobilization, sensitizing the general public on HIV prevention and services accessible at CBDP. Clients will also be referred from PLHIV support groups, Lighthouse clinics and other ART facilities to the CBDP. HTC Counselors, nurses, clinicians, and CCS will come to the sites every month to offer services at community level. This will therefore assist in reducing frequency of client visits to ART clinics thereby decongesting them. This will also promote open disclosure among patients which will impact on stigma and discrimination in the community.

Through HHS/CDC-supported senior staff and HHS/HRSA technical assistance staff, Lighthouse aims to establish Ndife Amodzi as an effective and appropriate 'minimum standard' of HBC and an effective reporting mechanism for HBC nationally, working in partnership with donors, other NGOs and the MOH.

Activity 4: Capacity building to maintain quality provision of HIV Treatment

Lighthouse acknowledges HIV treatment as a dynamic field. It keeps in-service training for its staff high on the agenda to keep them up to date. These trainings cover updates in internal medicine, ART refresher and monitoring methodologies for HIV management. In Year 2, these internal trainings, mentoring and supervision will continue.

Traditionally, Lighthouse also provided two-week clinical attachments for over 75% of all clinicians and nurses trained to provide ART services in Malawi primarily for the central and northern regions. As the next round of ART sites get going with trainings, we expect that newly trained staff will work with already trained staff in their districts for their attachment. However, as we continuously get requests from specific institutions to place people on at clinical attachment at the Lighthouse, we will continue to support this activity. The expertise of Lighthouse clinical staff will be complemented by the training team to ensure the maximum impact of the two-week attachments.

Budget Code - HVSI ($30,000)

We monitor our programs rigorously using our more established M&E unit which has a robust real time

Electronic Data System supported by another PEPFAR supported partner - Baobab Health Trust. With FY09 we plan to revise the current Lighthouse modules to be used among child counseling and pediatric treatment. This will also go further to incorporate the module into the TB clinic and the newly built Bwaila Maternity unit which is close to MPC. This will offer an opportunity to link up directly the PMTCT mothers into Care and method for follow up of those who have be lost to follow up. It is envisaged that new features for the national roll out will be tested and piloted at the Lighthouse before they are deployed. We plan to do an evaluation of the functionality of the EDS at the Lighthouse. This will be carried over into FY10.

Activity 1. Consolidate the Lighthouse Electronic Data System (EDS)

A rigorous monitoring and evaluation of the proposed activities will be done using our robust Electronic Data System (EDS) and reports will be submitted using the PEPFAR indicators. We are working with Baobab Health Trust to consolidate our EDS. There is a plan to revise the current Lighthouse modules to be used among child counseling and pediatric treatment. This will also go further to incorporate the module into the TB clinic and the newly built Bwaila Maternity unit which is close to MPC. This will offer an opportunity to link up directly the PMTCT mothers into Care and method for follow up of those who have be lost to follow up. It is envisaged that new features for the national roll out will be tested and piloted at the Lighthouse before they are deployed. We plan to do an evaluation of the functionality of the EDS at the Lighthouse. This will include its function as care delivery tool such as accuracy in setting appointments and prescriptions; and its functionality as an M&E tool such as conducting a cohort analysis which is still a challenge now. We plan to do this with year 2 funds.

Activity 2: Evaluation of Task-Shifting Project and other activities

PEPFAR funds a broad SI budget line which covers costs of recruiting external enumerators, data entry staff, and others to support many small program evaluations. This enables Lighthouse to be flexible and responsive to emerging issues. As an ongoing task shifting plan, Lighthouse would like examine whether nurses can monitor stable children and identify children with complications who need re-assessment and management by clinical officers

Lighthouse plan to conduct regular monitoring and evaluation of the roll-out of HIV testing and counseling (HTC) to health center ANCs, and revised Ndife Amodzi ART community program M&E tools. Currently, HIV/TB co-infected patients who are eligible for ART are managed within the TB clinic. Lighthouse also plans to evaluate the effectiveness of providing ART services within the TB clinic. If the program is successful, Lighthouse intends to rollout the program in other health centers.

The details of these investigations will be developed through Year 1, and timing will largely depend on the capacity and priorities of our M&E department.

Activity 3: Roll-out of the ART EDS

This activity directly supports treatment services and because of the ever growing burden of managing large number of patients at treatment sites, the paper-based system of registering and tracking patients is becoming inadequate to meet the program needs. The will support MOH the transition from a paper- based tracking system to an electronic system for high burden sites. With another PEPFAR supported partner, Baobab Health Trust, we will continue piloting and improve innovations in the software and hardware for the new electronic data system (EDS).

Lighthouse replaced the old touch screen system at Lighthouse with the EDS currently working at the Martin Preuss Center. Lighthouse will continue to help designing algorithms for the next level version of the EDS, including options for more pediatric functionality and more integration of CD4 testing. Lighthouse will offer their facilities as beta testing sites for Baobab as they develop new modules for TB treatment, and for referral between ANC, PMTCT, and ART services.

Budget Code: HVOP ($100,000) As mentioned in the HBHC narrative, HVOP activities at Lighthouse are closely interlinked with HVOP activities and so the narrative describes the broader activities within which these two budget codes are implemented.

In Year 1 we will pilot management interventions for Pre-ART patients, linking them from facility-based HTC, community-based HTC and the clinic for comprehensive care and support. This will involve treatment for opportunistic infections, screening for TB, screening for STIs, screening for pregnancy, family planning services among patients at every visit. We use Lighthouse services to define a model intervention for Pre-ART service delivery.

Lighthouse comprehensive care center houses one of the busiest ART clinics in Malawi registering over 8, 000 contacts with HIV positive patients on ART each month. This clinic presents an opportunity where HIV preventive interventions will be delivered routinely to ART patients at each visit. Lighthouse has an existing patient education and counseling program into which prevention messages for positives will be

incorporated. The Training unit will work with HBC and clinic staff to develop focused messages targeting individuals with HIV. This will also be a model intervention for Prevention with Positives (PwP) which aims at reducing HIV transmission.

Some activities lined up for Year 2 as a scale up from Year 1 are described below. Lighthouse provides facility based HIV Care services at the Lighthouse center, Martin Preuss Center, Maula Prison, two Lilongwe rural health centers and community-based HIV services with Lilongwe city strategic areas. We use a family-centered approach for a continuum of care to HIV positive persons including adolescents. This care is aimed at improving quality of life and prevention for positives. Methods of program and monitoring and evaluation are described in technical budget area HVSI.

Activity 1: Lighthouse establishes a model for pre- ART service delivery in Malawi

Patients frequently come to our ART clinic or are referred from HTC in advanced stages of HIV-infection. Therefore, early mortality among patients starting on ART remains high and their response to ART is less than if had started in less advanced immunological stages. However, regular follow-up of patients including WHO-staging, immunological monitoring, and provision of Cotrimoxazole prophylaxis would add an additional workload to our already overstretched ART-clinic staff. Current national guidelines focus on scaling-up ART-initiation of eligible patients through decentralization, task-shifting and extended supplies of ART up to 3 months, and there is no clear guidance on where and how pre-ART patients should be managed. These guidelines are currently under finalization at the Ministry of Health (MOH), and Lighthouse is playing a key role in working with MOH to conceptualize and demonstrate the new national pre-ART program.

With the view to universal access, and the goals of reduction of early mortality among patients on ART, durability of the 1st line regimen, and intensified Prevention-with-Positives (PwP), there is need to develop a model to deliver pre-ART services to patients not yet eligible for ART. Every month, Lighthouse registers HIV-infected patients, who are not yet eligible to start ART (pre-ART patients). They usually receive CPT and are asked to come back in regular intervals. The needs for this large group of pre-ART patients are not yet addressed. In collaboration with MOH, we plan to develop a comprehensive service package for this underserved group, including provision of CPT, TB screening, STI screening, nutritional screening and counseling and provision of therapeutic feeding and food supplements if eligible, regular CD4 monitoring in order to improve their clinical condition, to delay their disease progression, and to identify ART eligibility timely to reduce early mortality related to late ART initiation. In addition, we will set up a robust M&E system for pre-ART services and link with the MOH, which plans to recommend standard procedures and M&E tools for pre-ART services. With MOH, we will explore options to develop, implement and evaluate these procedures together in order to inform national policy on the feasibility of

this new area.

At ANC in Bwaila hospital, the PMTCT program traces HIV infected pregnant women with CD4 count below 250/µl, which do not pick their results. However, those women, who picked their result but did not register at the ART clinic at MPC, are not yet actively followed-up. With funding available, we will close this gap and give these women a continuum of quality care at MPC and at the same time make PMTCT much more effective.

The package will: a. Link with the HIV and AIDS Department of the MOH and consult on possible plans and developments, e.g. introduction of specific M&E tools for the pre-ART clinic (e.g. pre-ART register), which can be piloted b. Establish a cohort of HIV positive patients not yet on ART and monitor their outcomes for a period of three years. c. Monitor regularly WHO stage and six-monthly CD4 counts in pre-ART patients and refer to ART if eligible d. Examine knowledge, attitudes and perceptions of pre-ART patients e. Develop and deliver IEC-messages focusing on CPT, nutrition, positive living and "positive prevention", taking results of the previous activity into account f. Organize involvement of the community in the care of pre-ART patients: Encourage pre- ART patients to join support groups formed with the support of our community home based care program. g. Give all pre-ART patients who attend support group meetings a monthly professional talk within their catchment's area focusing on disease progression h. Document this process, evaluate and disseminate findings to inform MOH about feasibility and outcomes

Activity 2: Prevention with Positives (PwP)

Lighthouse comprehensive care clinic houses one of the busiest ART clinics in Malawi registering over 8,000 contacts with HIV-positive patients on ART each month. This clinic presents an opportunity where HIV preventive interventions will be delivered routinely to ART patients at each visit. Lighthouse has an existing patient education and counseling program into which PwP messages will be incorporated. The Training unit will work with HBC and clinic staff to develop focused messages targeting individuals with HIV. The messages will be delivered through group education sessions, one-on-one counseling, and IEC materials. The primary focus will be on assisting HIV infected individuals to disclose their HIV status to partners, reduce their risk of transmitting HIV, and reduce the risk of primary STI infection or HIV re- infection. This package aims at reducing HIV transmission (prevention with positives) and will rely on support and involvement of the community through linkage with our existing Ndife Amodzi program.

Activity 3: Promotion of Water Guard Technology for safe water

Health interventions at community level to prevent opportunistic infections are very crucial especially for PLHIV. Lighthouse in collaboration with Population Services International (PSI) piloted Water Guard water purification technology in one CBO (Chimoka) in FY08, which reported high incidences of cholera previously. This targeted HBC patients' households to improve access to safe water thereby reduce incidences of diarrhea disease in immuno-compromised patients in home based care program. The initiative started with one day training of 40 volunteers from the pilot sites in water guard technology usage, which in turn transferred skills gained to primary care givers so as to effectively prevent water borne diseases in the households. To ensure that the trained volunteers have really transferred the skills, a survey was done by Lighthouse staff, which proved that all households involved in the pilot accepted the concept and were adhering to the procedures. A follow up was done to establish incidence of water borne diseases in that community and proved that there was none. Further enquiries at Area 18 Health Center confirmed it, as there was no cholera case reported from the pilot during the FY 07 rain season period. However with limited funding this activity did not progress in FY 2008 and during the next rainy season a major cholera outbreak occurred. Because of this experience, and because of anticipated on- going exposure to cholera in some of the higher-density residential areas, Lighthouse plans to comprehensively continue providing Water Guard to HIV-infected individuals and their families. In Year 2, Lighthouse will purchase and distribute 1,800 bottles of water guard which will benefit 150 patients targeted for care at any particular time.

Activity 4: Strengthen linkage between community and Lighthouse facilities

There is a need to further strengthen LH links and contributions to the community in order to enhance HIV prevention through behavioral change, improved knowledge of volunteers and community care supporters, and economic empowerment. Health interventions at community level to prevent opportunistic infections through use of clean water, insecticide bed-nets for malaria and nutritional support as well as distribution of prophylaxis for common opportunistic infections by CPT will reduce the disease burden and progression of HIV infection among our patients, indirectly reducing transmission of the virus to HIV-negative individuals. Our linkages with the community and the active pool of the volunteers will assist in the establishment of outreach points for pre-ART clients which will be recruited through the Ndife Amodzi program.

Budget Code - PMTCT ($150,000.00)

Since 2007, Lighthouse with its partners at Bwaila hospital works to strengthen the linkage between ANC/pMTCT and ART services so that HIV-infected pregnant women, eligible for ART have more effective pMTCT and better quality of life. However, in 2007 and 2008, less than 40% of women referred from ANC started ART while pregnant. Despite improvement to 67% in 2009, the proportion is still low. However, of those who registered at MPC, 78% started on ART while pregnant. In FY08 we developed protocols to facilitate documentation and referral of eligible pregnant mothers for ART initiation from PMTCT program to the Lighthouse ART. With Year 1 funding we are setting up and reinforcing strategies of referral of PMTCT mothers into ART at Bwaila Hospital. This will involve setting up linkage of our EDS and tracing mechanism using our Back-to-Care Program operations to trace the referred mothers who do not turn up at MPC ART Clinic. In 2010, the new maternity at Bwaila hospital next to MPC is fully operational and the new maternity at KCH next to Lighthouse will open. Both facilities will offer PITC at ANC and HTC in the labor ward, as well as CD4 testing for HIV-infected pregnant women. The electronic data system (EDS) will expand with several workstations at Bwaila maternity, including the registrations of newborns, which will allow us to better monitor effectiveness of referral at patient level. PF year 2 funds will be used to strengthen the referral and follow-up systems for PMTCT mothers between ANC and ART. In 2010, additional funding will allow Lighthouse to manage effective services with the increased demand and this will give an opportunity to improve the situation:

Activity 1: Implement identification of exposed and infected infants and provide pre and ART Care at MPC - Increasingly, HIV DNA PCR positive infants are identified or referred to MPC, with their HV-infected mothers, who choose MPC as their ART site. We are able to offer HIV-exposed infants with uncertain HIV status HIV DNA PCR and Cotrimoxazole preventive therapy (CPT) directly at MPC without further referral. If infants are presumed HIV infected with severe HIV disease or are PCR positive they start ART at MPC when ready.

Activity 2: Pilot a systematic continuum of pre and ART care model for mother-infant pairs - The proposed additional funding will push the momentum provided by MoH's decision to place the continuum of care for mother-infant-pairs (MIPs) within the context of systematic pre-ART care- a model, which is already one focus of Lighthouse activities within this agreement. We will be able to pilot pre-ART tools and systems developed by the MoH, improve M&E of MIP-follow up, and inform future direction.

Activity 3: Implement active tracing for eligible pregnant mothers from PMTCT to ART - Gaps which will be addressed in Year 2 include identifying missing ANC attendees who are eligible for ART, and have

been referred from ANC but have not reached the ART clinic. We will reinforce our Back-to-Care Program team to follow up on all referred cases that do not reach the clinic and establish their outcomes. Consent for follow-up as part of routine care will be obtained at ANC during their initial visit. This funding will support one additional field tracer. We rely on all our diagnostics on Kamuzu Central Hospital including CD4 count for pregnant women. KCH as a tertiary care center for the central region and they are under pressure to deliver laboratory services to many providers. We will therefore continue to request backup CD4 services from the University of North Carolina (UNC) laboratory at KCH.

Activity 4: Restructure ART Clinic at Lighthouse to Ensure Prompt Initiation of HAART for Eligible HIV- Positive Antenatal Mothers -

The Lighthouse ART clinic is one of the largest ART sites in Malawi and already operates at full capacity. Lighthouse faces challenges in its service delivery capacity to address the urgent ART needs of eligible HIV-positive mothers identified at nearby PMTCT sites close to their homes. FY10 funds will be used to continue reorganizing operations at the ART clinic to ensure that all eligible antenatal mothers are initiated on HAART promptly, and followed up in a schedule that is synchronized with their PMTCT visits.

Activity 5: Integration of family planning services into the ART- and pre-ART clinic - Lighthouse is a family centered clinic and recent plans include the integration of ANC and family planning activities into the ART clinic at both Lighthouse and MPC. With the opening of the new Bwaila Maternity Wing close to MPC has reduced the gap between ANC and MPC ART therefore we will now implement the family planning integration at Lighthouse. All patient receiving care at the Lighthouse will access counseling and provision of contraceptive methods.

Budget Code HVTB ($35,000) With Year 1 funds, Lighthouse will continue to implement protocols for routine provider-initiated testing and counselling (PITC) of both the general population in all its sites and TB patients at Bwaila hospital. The scale-up of HIV Testing and Counselling (HTC) in Malawi will be informed by the Lighthouse experience at Bwaila Hospital, (TB and HIV integration) and we have already set in place clear mechanisms to transfer this knowledge through TB quarterly meetings in all the three regions of the country. We will maintain our HIV screening among TB patients at above 90%. We are also planning to extend this to TB suspects. We will also consolidate our initiative of starting and managing TB patients on ART in the TB unit at MPC instead of referring them to the ART clinic which we have observed to have a

risk of losing some. The pilot of early start of ART among TB patients will also be finalised in 2009 and lessons learnt will be taken into consideration for the FY10 implementation of this activity.

In Year 2, Lighthouse plans to additionally:

Activity 1: Support National roll out of New TB/HIV Collaborative activities

As a member of the National TB/HIV technical subgroup, Lighthouse was part of the task force developing a new 5-year National TB/HIV Operational Framework for Malawi that was completed at the end of 2007 covering 2008 to 2011. The plan emphasizes integrating HIV information in the National TB register and incorporating TB information in the ART register. With PEPFAR support, Lighthouse piloted a program which integrates HTC as a standard package of care for all TB patients and captures HIV information on each TB patient in one register. The National TB/HIV subgroup planned to work with Lighthouse to roll out this new register nationally. However, this plan was not achieved due to other factors beyond Lighthouse control. In the meanwhile all logistics to implement this are in place. Lighthouse will utilize National TB existing quarterly meetings in all the three regions of the country. TB officers will be reoriented on the use of new register and to monitor their ongoing recording and reporting practices. This would be supported by a comprehensive follow up system to the sites.

Activity 2: Support TB Officers on collaborative TB/HIV activities

Lighthouse will continue to provide input and support to the development process of TB/HIV Collaborative activities sharing experience from the MPC. As appropriate, support the implementation of the National Plan, specifically in terms of the development and planning of guidelines and training. As part of the process of implementing a model pilot program integrating TB and HIV activities, Lighthouse adapted the WHO/CDC generic DTC training guidelines to the Malawian context, and used it to provide a two-day training to TB officers. Collectively, the trained TB officers (TBOs) have done well in the field and increased HIV testing rate for TB patients to over 93% within their clinics. About 40% of people reaching the TB registry actually had tested positive prior to arrival at the Lighthouse, but that was not being systematically captured in the registers.

Working in collaboration with the National TB/HIV coordinating body, Lighthouse with 2010 funds plans to focus on supporting new Monitoring and Evaluation (M&E) system tools; integration of HTC, especially in Referral hospital (50% of registrations); and co-management of TB treatment and ART combined from 2 months.

Activity 3: Counseling and Testing for TB Patients and Suspects

With Year 2 funds, Lighthouse will continue to implement protocols for routine counselling and testing of both the general population in all its sites and TB patients at Bwaila hospital. The scale-up of HIV Testing and Counselling in Malawi will be informed by the Lighthouse experience at Bwaila Hospital, (TB and HIV integration) and we have already set in place clear mechanisms to transfer this knowledge through TB quarterly meetings in all the three regions of the country. We will maintain our HIV ascertainment among TB patients at above 90%. Studies in Malawi have shown that HIV prevalence in TB suspects submitting sputum for AFB microscopy is about 60% and compares closely with the rate in TB patients (70%). HIV screening of TB suspects therefore offers an opportunity for early identification of HIV as an underlying cause of symptoms in TB suspects. We plan to provide a similar routine HIV testing and counselling among TB suspects who come to MPC (chronic coughers). We will advocate that this HIV ascertainment among TB suspects and patients should be a routine service in TB clinics nationally.

The planned activities will result in improved TB/HIV services for hopefully over 4000 people. We are happy to report that Lighthouse persuaded the National TB program (NTP) to decentralize registration. And sputum microscopy is taking shape in most of the health within and outside Lilongwe. Only about 35% of the TB patients registered at the MPC are actually managed there. However if registration is decentralized, a significant proportion of MPC registrations will be lost and Lighthouse will have to consider how to support its health centers in Lilongwe and other referring sites and how to get TB patients onto ART.