Established in July 2001 as a public trust under the Office of President and Cabinet (OPC), the National AIDS Commission (NAC) provides overall leadership and coordination of the national response to HIV and AIDS. Governed by a Board of Commissioners, NAC facilitates development of policies, frameworks and guidelines; provides technical assistance and financial support to implementing agencies; mobilizes resources to support HIV/AIDS interventions; and monitors and evaluates progress and impact of the various initiatives and programs of the national response.

Under the leadership of the NAC, the three year extended National Action Framework, a strategic document that guides the planning of HIV and AIDS programs, was developed in 2009. NAC, as the national coordinating body for HIV and AIDS, champions the implementation of the National Action Framework to guide various HIV and AIDS interventions by all stakeholders including the public and private sectors, non-governmental organizations, community-based and faith-based organizations and communities nationwide involved in the national response. The Integrated Annual Work Plan (IAWP) is

the principal tool that operationalizes the National HIV and AIDS Action Framework (NAF). As a planning and budgeting instrument, it ensures effective allocation and utilization of resources to achieve the short to medium-term objectives and programmatic targets of the NAF.

The NAC employs the National Monitoring and Evaluation Plan which was created to track and evaluate progress in the implementation of the National HIV and AIDS Action Framework. The NAF is aligned to the Malawi Growth Development Strategy (MGDS), and it aims at achieving priority goals and medium- term expected outcomes outlined under the social development theme of the MGDS. The National HIV and AIDS M&E plan therefore plays a critical role in tracking changes in the HIV epidemic and bringing about policy and programmatic improvements with the aim of effectively contributing towards the achievement of MGDS targets and goals.

The PEPFAR Partnership Framework was developed is collaboration with NAC, the Government of Malawi and other key partners and reflects the national priorities for mitigating the HIV epidemic in Malawi. The NAC will play a critical role in harmonizing and synthesizing the PEPFAR Partnership Framework reporting into the National M&E plan as well as coordinating the evaluation of the national response and providing data to guide policy, program and resource allocation decisions.

Since 2007, NAC has been funded through a cooperative agreement with CDC Malawi with the following primary objectives:

1. Coordination and implementation of national strategic information activities: NAC has the primary responsibility for coordinating and reporting on the national Monitoring and Evaluation plan. With PEPFAR funding, NAC takes a leading role in developing and surveillance strategies, implementing HIV surveillance activities in the general population and as well as high-risk groups, drug resistance monitoring, and carrying out important data dissemination and use activities including data triangulation, epidemic modeling, incorporating data into national policies, developing a research database, and national and sub-national data analysis. 2. Supporting policy development, implementation and capacity building for key national interventions: NAC has been instrumental in providing coordination and capacity building support for innovative new programs including National HIV Counseling and Testing Week. In addition, NAC is a focal partner in providing evidence and leadership to policy development and program implementation for the development and roll-out of male circumcision services.

NAC will implement PEPFAR activities under the National Action Framework and Partnership Framework with direct support to national-level capacity building in the Government of Malawi and other local partners and increasing program scope, scale and quality through the collection and use of strategic

information. NAC does not support any cross-cutting activities.

Budget Summary PFIP Year 1 Funding - $800,000 PFIP Year 2 Funding - $900,000

Budget Code - HVCT $100,000

Activity 1: Support for Full-time CT Technical Assistant at the MOH: This is an ongoing activity from 2009. USG will continue to support the salary for a full-time CT Technical Assistant in 2010 at the HIV/AIDS Unit of the MOH. The Technical Assistant will work within the Government of Malawi (GoM) structure providing both technical and programmatic guidance for CT scale up while building local capacity for coordination of CT activities at National level.

Key responsibilities of the Technical Assistant will include: • Provision of technical guidance to MOH on CT policy guidelines, CT sites development, and CT training; provision of support to MOH in planning, co-ordination and implementation of CT in a variety of

settings, including health care facilities, NGOs, CBOs and private sector; development of national system for CT standardized generic training, Training of Trainers (TOT), and training of CT Supervisors to ensure sustainability of CT service provision; provision of technical guidance in setting quality standards for CT; provision of assistance to MOH in developing and implementing a national system for CT supervision, M&E, and reporting; and conceptualization and implementation of innovative interventions for increasing uptake of CT by underserved communities. Indicators: Same as above

Activity 2: Support for Malawi's National HIV Testing Initiatives:

The HIV Testing and Counseling event has been a high profile national campaign involving accelerated community education on benefits of CT coupled with creation of opportunities for all Malawians to access HIV testing and counseling. The bulk of services during the weeklong campaign were provided in temporary sites as outreach to underserved communities. Resources for the exercise including HIV test Kits are provided largely through Global fund monies programmed for CT. The campaigns increased visibility of CT services and give every segment of the population an opportunity to be tested for HIV where they live.

With FY 2009 funding, NAC is supporting activities that strengthen the quality of the National Counseling and Testing Week, and with FY 2010 funding NAC will continue these activities. Indicators: P11.2.N

Budget Code - HVSI $200,000.00

Activity 1: Support the Research and Surveillance Technical Working Group and implementation of the National HIV Surveillance Strategy

The Research and Surveillance Technical Working Group is tasked with the responsibility for developing and overseeing the implementation of the National HIV Research Strategy and the National HIV Surveillance Strategy. It is comprised of members from NAC, the Malawian government, local and international research institutions, NGOs and international donors.

In PF Year 1 and 2, NAC will support quarterly Research and Surveillance TWG meetings. A primary purpose of the TWG will be to develop and disseminate the National HIV Surveillance Strategy in 2010 and support key activities in its implementation in the following year.

Activity 2: Support the HIV Drug Resistance (HIVDR) Surveillance Task Force and implementation of the National HIVDR Surveillance Strategy

By March 2009, the Malawi Ministry of Health had initiated approximately 200,000 people on ART. The national ART program centers around one standardized first-line therapy, and there is very limited use of one standard second line treatment. It is critical, therefore, to monitor the emergence of HIV drug resistance (HIVDR) so that the MOH can respond accordingly. Malawi has adopted a three prong approach to monitoring HIVDR: Threshold Surveys to look at transmission of drug resistance, Monitoring Surveys to understand the development of drug resistance under treatment pressure, and Early Warning Indicators reporting to assess programmatic factors that contribute to the development of drug resistance.

With PF Year 1 funding, NAC is supporting quarterly HIVDR Task Force Meetings. The purpose of the Task Force is to ensure that drug resistance monitoring activities are being conducted on an timely basis and that the results are interpreted, disseminated, and when appropriate, that the MOH is responding by making necessary changes to the national ART program. The HIVDR task force includes more than 15 members from different divisions of the Ministry of Health, development partners, and representatives of the survey sites. In PFIP Year 2, NAC will continue to support the HIVDR Task Force to achieve the above objectives as well as to develop and implement the National HIV Drug Resistance Strategy.

Activity 3: Monitoring HIV among High Risk Populations

With FY 2009 funding, NAC organized regular meetings to review and revise the methodology for monitoring HIV prevalence and risk-taking behaviors in high risk populations. It has been agreed that the next BSS of high risk groups will not take place until after January 2010 so it does not overlap with DHS activities. With FY 2010 funding NAC will continue to support the coordination of BSS activities within the National HIV Surveillance Strategy. These will include revision of the methodology for the survey, data analysis and dissemination of the findings of the survey.

Activity 4: Monitoring HIV among the General Population

With Year 1 funds, NAC will support data collection and analysis for the Demographic and Health Survey

which includes HIV biomarkers. NAC has been highly active in the development and coordination of this activity and will continue to play a key technical and financial role in the implementation of the HIV biological component of this survey including the HIV counseling and testing component, laboratory supervision and quality assurance and analysis activities. With Year 2 funds NAC will support regional/district level data analysis and use of the DHS results.

Activity 5: HIV Incidence Estimation

NAC plays a focal role in using available HIV data to conduct mathematical modeling of the number of people estimated to be infected with HIV and projected to acquire HIV in the future. Incidence estimation currently relies on the UNAIDS/WHO EPP/Spectrum model to conduct these calculations. This information had proven to be invaluable to coordinating and financing the national response, however it has been recognized that additional laboratory estimation methods would provide necessary data for better understanding the incidence of HIV among the general population as well as high risk groups and geographic areas. NAC will continue supporting the process. NAC will also support the coordination and modeling and laboratory-based assay methodologies to estimate incidence, in particular data analysis, dissemination and use of findings as part of the National HIV Surveillance Strategy.

Activity 6: Data Triangulation

With previous funding, NAC supported the triangulation exercise including data collection, analysis and interpretation. With new funds NAC will support dissemination of the findings to all stakeholders for consideration in various HIV and AIDS programme developement.

Indicators: H7.2.N H7.5.N H7.6.N H7.7.N H7.8.N P11.1.D (DHS)

Budget Code - OHSS $100,000

Activity 1: Support for Full-time CT Technical Assistant at the MOH:

This is an ongoing activity from 2009. USG will continue to support the salary for a full-time CT Technical Assistant in 2010 at the HIV/AIDS Unit of the MOH. The Technical Assistant will work within the Government of Malawi (GoM) structure providing both technical and programmatic guidance for CT scale up while building local capacity for coordination of CT activities at National level.

Key responsibilities of the Technical Assistant will include: • Provision of technical guidance to MOH on CT policy guidelines, CT sites development, and CT training; provision of support to MOH in planning, co-ordination and implementation of CT in a variety of settings, including health care facilities, NGOs, CBOs and private sector; development of national system for CT standardized generic training, Training of Trainers (TOT), and training of CT Supervisors to ensure sustainability of CT service provision; provision of technical guidance in setting quality standards for CT; provision of assistance to MOH in developing and implementing a national system for CT supervision, M&E, and reporting; and conceptualization and implementation of innovative interventions for increasing uptake of CT by underserved communities.

Indicators: H2.3.N H6.1.D

Activity 2: Strengthening Capacity for District- Level Monitoring and Evaluation ($200,000 PF09 Funds) Malawi has instituted a wide-scale decentralization of health services including responsibility for planning, implementation, financial management and monitoring and evaluation of HIV programs now resting at the district-level with Local Assemblies (LA). Districts require capacity building in order to implement and monitor quality programs and feed their results to the national level. Through a cooperative agreement between NAC and the Ministry of Local Government and Rural Development, USG will support the GOM to build the capacity of LA's to strengthen district-level monitoring and evaluation systems. Through this support at the central level, the Ministry of Local Government can create a sense of ownership and foster leadership in the district and community response. This is a new activity in FY11.

Budget Code - CIRC $300,000 - Year 1 funds

Activity 1: Dissemination of and sensitization on the male circumcision policy

With FY 2009 funding, NAC will provide national leadership in the development of the Male Circumcision Policy, in collaboration with other local and international partners. This policy will guide the implementation of interventions in the country, and wider dissemination of the policy as well as sensitization of communities and local leaders will take place in FY2010.

Activity 2: Critical Operations Research

In FY10, a rapid assessment of male circumcision is being undertaken in Malawi, and it is anticipated that this will raise some questions with regard to gaps in the current knowledge and practice of male circumcision in the country. PF Year 2 funds will be used in conjunction with other partners to support time-limited operations research that will help answer some of those questions. For example, efforts will be made to better understand confounding factors that may drive the high prevalence of HIV infections among communities with the highest proportion of male circumcision, the Yao, and the Lomwe ethnic groups.

Activity 3: Male Circumcision initiatives

NAC will work with the Male Circumcision sub-group of the National HIV Prevention Task Force, which is led by the Ministry of Health, to identify and fund priority male circumcision initiatives and campaigns to pilot and/or scale-up. This activity will begin in PF Year 1 and be expanded in FY 2010 Indicators: P5.1.N H6.1.D