Management Sciences for Health (MSH) works closely with Ministry of Health (MOH) to strengthen family planning (FP) and HIV/AIDS services and is designed to achieve sustainable results. In 2008, Malawi's USAID Mission began funding activities through MSH Community-based Family Planning and HIV/AIDS Services (CFPHS) project to improve access and utilization of family planning and HIV services in rural underserved communities through establishment of fully functional integrated community based FP/HIV services in eight target districts. The population in the eight districts (Karonga, Nkhotakota, Kasungu, Salima, Balaka, Mangochi, Phalombe and Chikwawa) is 3.4 million served by 150 health facilities. USAID's Community-based Family Planning and HIV & AIDS Services (CFPHS) program, implemented by MSH along with its subcontractors, provides a unique opportunity for the GOM/MOH to reposition family planning and improve/increase HIV & AIDS services in communities in the eight target districts.

CFPHS also facilitates policies and guidelines development for social marketing and community distribution of injectable contraceptives. Following policy changes enabling Health Surveillance Assistants (HSAs) to provide injectable contraceptives at community levels, CFPHS has been piloting provision of injectable contraceptives in the target districts over the past year. Through CFPHS, USAID/Malawi also funds a RH Technical Advisor to the Ministry of Health. CFPHS is scheduled to end in September, 2011, and activities funded through this mechanism will play a pivotal role in enabling USAID Malawi to meet its objective of improving the health status of Malawians.

FP/RH and HIV/AIDS services have traditionally been provided at health facility level by professional staff. In order to increase access to community FP/RP and HIV&AIDS services in the context of a severe lack of human resources for health innovations, CFPHS project proposes to invest in training up to 450 CBDAs as volunteer health workers for FP/RP and HIV/AIDS by the end of the project. MSH CFPHS has already trained 75 CBDAs and 15 supervisors (HSAs) to provide door-to-door HIV Counseling and Testing (HTC), referral to FP/HIV services and communication activities to promote positive living,

treatment adherence and increase demand for community FP/RH and HIV/AIDS services. In Year 1 CFPHS trained 21 CBDAs in HTC. By June 2009, these counselors had counseled and tested about 29,000 people. A further 54 CBDAs and 15 HSAs had been trained in HTC by March 2009. Therefore, additional resources will enable the program to train and retain more community-based volunteers through enhanced door-to-door services.

The objective of the CFPHS is to deliver quality, integrated services for Family Planning/ Reproductive Health and HIV/AIDS in 4 of MSH's 8 operational districts namely: Salima, Mangochi, Phalombe, Kasungu. With a population of approximately 2 million people, including about 900,000 adults over age 18, each of the households in the 4 targeted districts could potentially be reached with HTC by an estimated 500 CBDAs if each CBDA visited on average 500 households per year. Given a national adult HIV prevalence of 12%, it is estimated that approximately 90,000 PLHIV live in the four districts, the majority of whom do not know they are infected. These statistics indicate that it would be feasible to scale-up door-to-door testing in these 4 districts and to provide other high yield preventive services (TB screening and nutritional surveillance) in the process of visiting these households.

CFPHS implementing mechanism's strategy relies on an integrated approach to deliver HIV and FP to simulate new activities and meet active demand for HIV Counseling and Testing (HTC) and FP needs by overcoming constraints to accessing services. The activities to be implemented are part of the initiative to be undertaken with Child Survival and Health Population funds and 2008 U.S. President's Emergency Plan for AIDS Relief (PEPFAR) funding.

The key contributions to health systems will be ascertained through the following results: Increased community knowledge and interest in FP and HIV/AIDS services, improved social norms for sexual reproductive health (SRH), FP and HIV/AIDS, increased access and utilization of FP and HIV/AIDS services in communities, improved linkages between point of services, the community and household levels with the existing MOH referral channels and a strengthened enabling social environment for FP, RH, and HIV/AIDS services and behaviors.

CFPHS will enhance collaboration and partnership with district health offices in the four districts. The Community Health Sciences Unit (CHSU), National AIDS Commission (NAC) and MOH's HIV & AIDS Unit have been extremely supportive of this cost-effective initiative and provided necessary guidance regarding Quality Assurance, and logistics management. CFPHS monitors its activities through routine data collection by focusing on 19 core indicators in a reporting system which is integrated in MOH's Health Management Information. M&E tools are being reviewed and adopted for community based recording and reporting.

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

II. Budget Code - HVCT

$250,000 - Year 1 $750,000 - Year 2

Activity 1: Community Based HTC

CFPHS will scale-up community-based HTC services in four targeted districts and scale up operations by expanding coverage, access, and consistent use of FP/RH and HTC services. CFPHS will train 450 CBDAs in HTC/TB screening in PHC Training centers at Mponela, Mwanza and Mzimba. Although MOH HTC guidelines call for all clients tested for HIV to be screened for TB at the same time, this is rarely carried out in practice. HTC training will also include a component on couples counseling per the MOH

approved curricula. CBDAs will also be educated about high-yield HIV prevention topics, especially the importance of discordant couples using condoms and the importance of PLHIV receiving regular CD4 testing per national guidelines and initiating treatment as soon as they become immunologically eligible. The DHMTs will support the program by ensuring quality through supervision of counselors in the provision of door to door HTC services.

In addition to HTC, CFPHS will also provide CBDAs with training to conduct quick nutrition assessment/surveillance, particularly of children under 5 while visiting households, using MUAC or similar easy and inexpensive methods. Malnourished children identified will be referred to appropriate levels of care, either at health facilities, village health clinics, or using community-based approaches to manage malnutrition. Household members will also be provided with focused nutritional education and counseling, including assessment of nutritional risks in young children and PLWA.

In addition to the QA in door-to-door supervision, HSAs will receive a four-day training in HTC and TB screening. The training, to be conducted at CHSU, provides a strong link between the program and the MOH in ensuring quality of services. These HSAs will also be trained in collecting dried blood spots for early infant diagnosis from HIV-exposed infants as per national guidelines (currently 4-6). CFPHS will facilitate referral of TB suspects to community sputum collection centers or health facilities nearest to the community level. HSA supervisors will also be trained in sputum collection, so that patients that are suspected of having TB and referred by the CBDAs can have their sputum collected by the HSAs and delivered to a lab for inspection.

To promote quality in provision of community-based HTC services, CFPHS will facilitate quarterly review meetings to share experiences and lessons, and to address emerging issues in implementation. Trained counselors will have an opportunity to discuss challenges with their supervisors and their respective DHMTs. These meetings will also serve as a forum for updating counselors on new developments in HTC.

In order to secure the investment of trained CBDAs, CFPHS will explore various options that would help retain this valuable human resource in the target districts. It is proposed to provide CBDAs with a monthly honorarium of up to MK3,000 as a form of incentive. Obtaining the full amount of incentive will be dependent on CBDAs attaining a target of HTC at least 85% of adults in their catchment area each year (most door-to-door programs in Malawi achieve >90%) and assuring a high-rate of PLHIV identified through HTC in their given area obtain CD4 testing at least once a year during the annual pre-ART days. Mechanisms will be put in place to ensure that such incentives are sustainable and do not act as a disincentive to other cadres of volunteers within same program. Such mechanisms will also require full commitment and buy-in by the GoM/MoH. There is also need to have mechanisms to ensure that quality

of counseling does not suffer.

As CBDAs provide community-based HIV testing, they will require some essential items to enable them to work. These include: bicycles, stop watches and barcode materials. Other essential requirements include sputum collection kits, lap tables, bags, golf shirts, scissors, aprons, umbrellas, raincoats and lamination of HTC protocols.

Activity 2: Synergy with other projects and services

CFPHS will link CBDA activities to other HIV prevention projects including PSI EBT-Prev, BRIDGE II and PACT, to provide the following: • Family Planning condoms for PLHIV and discordant couples who are identified through the door-to-door HTC activities. The project will collaborate with PSI-EBT project to socially market the new family planning branded condom once it becomes available. • Communication related to prevention-with-positives for discordant couples developed by the MOH, PSI, BRIDGE II, and/or other partners. • Active linkages to PLHIV support groups in communities • CBDAs will also provide referral information about male circumcision to couples once a scale up plan has been developed with national stakeholders.

CFPHS will also collaborate with TB/CAP and Project Hope to implement community-based TB interventions.

Activity 3: Annual pre-ART Saturdays

PLHIV and their partners will be invited to an annual pre-ART Saturday at a nearby health facility or other appropriate location shortly after a given village or set of villages associated with the health center has received door-to-door testing. During this event they will receive education about HIV-prevention, CD4 testing, condoms, cotrimoxazole, and other social support information and referrals. CD4 samples will be taken in the morning and transported to the nearest lab and processed quickly so that results can be phoned to the clinic by the afternoon if possible - if not CBDAs can assist in ensuring patients follow-up to receive their CD4 results at a later time point. This project will liaise with other prevention partners, including Targeted Outreach Communication (TOC) agents funded through the PSI-EBT project, who may be able to provide IEC, films, and other high quality materials to enhance the quality of the information given at the pre-ART Saturdays. The project will seek to link/collaborate with existing PLWH network organizations and other prevention partners to develop sustainable strategies to serve the PLWH and partners in the target districts.

III. Budget Code - OHSS

$125,000 - Year 1 $125,000 - Year 2

Activity 1: Support data collection activities at the district level

Because of the high volume of HIV tests anticipated to be done by the project, , it will be necessary to provide support to the districts to manage the patient data. This will be done in a manner that supports the district systems, rather than creating parallel systems, but will require at least additional staff to support the district M&E officers. These staff will also be responsible for supporting the CBDAs in managing the unique IDs surveillance activity.

CFPHS will strengthen District and Community Provision and management of FP/RH and HIV and AIDS services by supporting the district health management team (DHMT) so that they provide their mandated supervisory and support functions to the health centers. By directing efforts towards the district level, the program can create sustainable supervision and management capacity. CFPHS activities will also focus on strengthening the capacity of the DHMT members to support community based providers, as well as DHMTs capacity in performance monitoring and improvement as related to HIV.

Funding is budgeted for CFPHS to work in collaboration with the MOH and USAID to summarize the results of the door-to-door testing component and disseminate the results in at least one international conference or workshop.

I. Budget Code: HVOP $125,000 - Year 1 $125,000 - Year 2

Activity 1: Dual Protection/condom distribution at household and community level

CFPHS will integrate HIV/AIDS, family planning and sexually transmitted infections (STI's) prevention through promotion of dual protection, encompassing condom promotion and distribution and other behavioral change efforts to reduce STI/HIV risk at household and community level. The program will focus on integrating all HIV community based activities into CBDAs' role. Trained CBDAs, will promote benefits of HIV testing, as well as promote and distribute condoms among the general population and discordant couples to prevent re-infection. HIV positive women, and couples, will be targeted with family planning interventions to reduce the occurrence of unintended pregnancies among them and PMTCT and ART services available.

Activity 2: Behavior Change Communication

Behavior change communication (BCC) will be incorporated into CFPHS activities and shall portray family planning and HIV testing and treatment as mainstream health interventions. BCC messages will target women and men as individual clients or as couples as primary targets.

Secondary target groups will include health providers, village headmen, other community leaders, and opinion leaders whose counseling and supporting role is deeply rooted in Malawian culture as agents of change toward more positive social/cultural norms. BCC at community, family and individual level will be enhanced by the trained CBDAs who will conduct interactive, client-centered interpersonal communication activities with their community networks. The target groups will be engaged in discussions, and create a supportive atmosphere where FP and HIV&AIDS topics will be discussed openly.

Quality communication tools will also be made available for counseling clients, and these will also incorporate key actions around reduction of partners, discordance, and prevention with positives. With PFIP year 2 funds, the program will consolidate efforts started with PFIP year 1 resources and continue to increase coverage of the same activities.

Activity 3: Gender

CFPHS will incorporate a gender approach into HIV/AIDS services by training providers to address gender-related barriers/issues, including identifying signs of gender-based violence that should be addressed as part of HIV/AIDS counseling. Steps will be taken to ensure that protocols address legal and support services in the community to mitigate impact (e.g. partner testing and notification to support disclosure).