Partners in Hope (PIH) Medical Center, a local faith-based non-governmental organization, continues to improve the quality of HIV care in Malawi by increasing the capacity of Christian Health Association of Malawi (CHAM) and MOH facilities to deliver quality HIV services in the Central West Zone and Northern Region. These interventions include strengthening linkages within the continuum of care and treatment, greater integration of services, and conducting operational research to promote better programming.

The project objectives, which are aligned with the PFIP goals, are to: reduce new HIV Infections by improving the quality and uptake of PMTCT and ART services; improve the quality of treatment and care for Malawians living with HIV; and support systems strengthening and linkages between services and health facilities. PIH achieves these objectives by building the capacity of health care workers through training, follow-up mentoring and supportive supervision of sites, and implementing the integrated ART/PMTCT program (Option B+ test and treat approach and decentralization of ART). Additionally, PIH provides laboratory support and strategic information support to health facilities to improve their diagnostic and data management capacities.

Capacity building of health workers and health facilities is at the core of PIHs program approach to ensure sustained improvement in quality of services. In order to foster efficiency and effectiveness in its program design and implementation, PIH processes enable regular review of its work. All programmatic shifts at a health facility are done in close consultations with district health officials.

In FY13, EQUIP will continue its support to four hospitals and eight health centers in the central and northern region to improve quality of pre-ART care and effective linkage to ART and other health services. Its expected that 12,316 individuals will receive at least one care service.

EQUIP will conduct regular in-service training and clinical mentorship visits to these health facilities and aims to build the skills of health providers on the diagnosis and management of opportunistic infections (OI), staging of patients, provision of CPT, nutritional assessment, etc. Malawis new guidelines for the clinical management of HIV promote the concept of HIV Care Clinic (HCC) an integrated and family-centered approach to providing HIV services. EQUIP will assist health facilities in the implementation of the HCC model including provider-initiated counseling and testing (PITC) for family members of HIV positive clients.

PIH will continue implementing the full package of Prevention with Positives (PwP) and refine tools and systems to make the delivery (and documentation) of these services more effective and efficient. The inclusion of PwP outputs in the Baobab electronic data system (due to be implemented in early 20112) will improve the delivery and monitoring and evaluation of this service. In FY13, EQUIP will support 7,600 PLHIV with a minimum package of PwP.

EQUIP will help all sites integrate the basic package of reproductive health services and family planning outlined by the Ministry of Health. In-service training in family planning, as well as STI diagnosis and treatment, is a part of the curriculum for training at EQUIP-targeted CHAM sites. EQUIP will work with health facilities and district health offices to strengthen linkages with community-based care programs and ensure effective referral to and from health facilities. In collaboration with the health facilities and other NGOs operating in the area, EQUIP will update service directories that would facilitate referral.

Once a month EQUIP will facilitate a stakeholders meeting at the facility level to review monthly performance and identify actions that need to be taken to improve HIV services on a continuous basis.

In FY11, 86% of PLHIV were screened for TB in EQUIP-supported health facilities (HFs) and 7% were started on TB treatment. PIH clinical mentors provided regular support to healthcare providers on TB/HIV integration, including intensified case finding in ART and pre-ART clinics and timely initiation of ART treatment.

In FY13, EQUIP will emphasize implementation of clinical protocols for improved diagnosis of TB in HIV patients. This will be accomplished by training health providers in TB diagnosis and treatment. Each CHAM site will be equipped with improved screening tools such as standardized questions and laboratory services to support TB diagnosis and monitoring during treatment. Laboratory personnel will be trained by PIH technical experts. PIH will implement polymerase chain reaction (PCR) for TB diagnosis. EQUIP will also support health centers to adhere to the new national guidelines to initiate newly diagnosed patients with both HIV and TB on ART as early as possible (within two weeks of starting TB treatment). This will be accomplished through EQUIPs participation in the national training program on the new guidelines and ongoing supervision and mentoring at sites. PIHs TB/HIV mentorship will be in line with the new guidelines for clinical management of HIV and the National TB Program (NTP) strategies.

EQUIP has a robust monitoring and evaluation system, and regularly tracks standard PEPFAR indicators (including TB/HIV indicators) in addition to its own custom indicators.

In FY12, EQUIPs partner, Baylor College of Medicine Childrens Foundation Malawi (BCM-CFM), will continue to strengthen Mother-Infant Pair (MIP) follow up including Early Infant Diagnosis (EID). BCM-CFM staff will work alongside Christian Health Association of Malawi (CHAM) hospital staff to improve services within 5 target hospitals and to pilot new mechanisms to improve referral and retention of HIV-exposed infants in care within their catchment area. EQUIPs pediatric program includes training of staff on pediatric HIV care and treatment and regular mentorship. Moreover, the program deploys community workers which are entrusted with facilitating patient flow within health facilities, following up with clients in communities, and tracking those who miss their appointments. In health facilities where there is no CD4 capacity, EQUIP transports samples for processing to the Partners in Hope Medical Center and results will be brought back.

Through its clinical mentorship, EQUIP aims to expand provision of ART and CPT to 85% of HIV-infected infants and eligible children and implementation of regular clinical and CD4 monitoring of all HIV+ children. Its expected that 85% of infants born to HIV positive women are started on cotrimoxazole prophylaxis within two months of birth.

Targeted facilities will also be assisted to increase capacity growth monitoring and assessment of nutritional status of HIV infected children. Children that need nutritional supplementation or therapy will be linked with nutritional rehabilitation units within health facilities. Another emphasis of EQUIP/Baylor activities will be to improve integration or effective linkage of pediatric HIV services with MCH, under five clinics, TB, and nutrition programs.

In FY12, EQUIPs interventions will include the purchase and installation of laboratory equipment for onsite measurements of CD4, monitoring of ART side effects (especially Hb, Lactate and Creatinine), and OI testing at each CHAM facility. EQUIP will purchase and supervise installation of CD4 equipment at St. Johns Hospital and renovate the laboratory at Nkhoma Hospital.

EQUIP will continue to support training and technical support for laboratory staff at four CHAM hospitals through the laboratory at PIH. Training includes accurate diagnosis of OIs, CD4 testing, laboratory monitoring of ART side effects, lab management and quality assurance. Additionally, EQUIP will work with other USG lab partners on DBS collection and sample transport for EID.

In FY12, EQUIP will deploy site-level Electronic Data Systems (EDS) in five targeted CHAM clusters. EDS will be instrumental in the routine collection of service data, as well as a patient management tool (i.e., clinical decision support system). The EDS has multiple modules including ART, PMTCT, ANC, and Lab. Once the patient unique identification system -currently in pilot - is implemented, these modules will facilitate referral and linkage of patients across multiple service units.

The EDS modules are developed through other USG funds. EQUIP will leverage the existing system and work with Baobab, EDS developer, to do relevant customizations that meet the need of the facilities. Baobabs EDS is becoming the de facto standard electronic data system in Malawi; therefore, by adopting this system, EQUIP is adhering to the national trend. Prior to deployment, health facility staff will be trained on use of EDS for routine data collection and patient management.

As part of their regular clinical mentorship, EQUIP staff will assist health facility staff in the appropriate implementation of the national HIV M&E system, regular review of service data, and its use for quality improvement.

In FY12, EQUIP will support the northern region in the planning and conducting regular supportive supervisions for key HIV services. EQUIPs supportive supervisions will also assist these health teams in using the information collected for timely decision-making.

EQUIP has taken a lead role in working with the Ministry of Health (MOH) to implement the new national HIV/ART guidelines and the national mentoring strategy. In order to achieve the rapid and successful rollout of major changes in HIV care, in FY12, EQUIP will assume responsibility for clinical mentoring at 2 hospitals and 8 health centers in the northern region. Clinical mentoring will be a critical bridge for the training gap that exists between traditional didactic training and practice in the clinical setting. Mentoring will include an emphasis on systems mentoring, which is expected to mitigate challenges faced by the health facility, including stock outs, complex data entry and tracking, retrieval and feedback of laboratory results, and linkages between HIV services in the continuum of care particularly those related to maternal-child health.

EQUIP will play a key role in the rollout of the new national ART guidelines that focus on test and treat, the maternal child health continuum, and TB diagnosis, treatment, and linkage to HCC/ART. EQUIP will support the development of the national model for mentoring, training materials, train-the-trainer courses, monitoring tools, and planning of trainings.

EQUIP will collaborate with other health and HIV programs in the target districts for better coordination of activities to build effective linkages. At the national level, EQUIP will participate in MOH technical working groups and contribute to discussions and sharing of best practices.

In FY11, 21,189 individuals were tested for HIV in EQUIP-supported health facilities. This figure represents client-initiated and provider-initiated tests. Through its clinical mentorship, EQUIP emphasized testing family members and effective linkage of those who test positive to pre-ART clinics. A shortage of HIV test kits was a major challenge during the fiscal year leading to tremendous lost opportunities.

In FY13, EQUIP aims to enable 13 health facilities to be more strategic in their use of HTC resources, targeting those at highest risk and maximizing the number of people identified for treatment. Its expected that 22,000 individuals will be tested for HIV and receive their results in FY13. EQUIP will work with partner hospitals and health centers to increase HTC among TB patients, in the in-patient adult and pediatric settings, malnutrition programs (Nutritional Rehabilitation Units, Outpatient Therapeutic Program), and antenatal clinics. In coordination with Baylor, EQUIP will continue to support the expansion of HTC in infants and children (in addition to EID). Training will focus on boosting provider-initiated HCT at the base CHAM hospital and satellite clinics. EQUIP personnel will work within each CHAM cluster to increase the number of centers providing HCT services and work to improve the integration of HCT sites with STI and family planning programs such that HIV prevention messages can be combined with other important prevention programs and interventions.

EQUIP will support laboratories in the target health facilities with training for lab technicians and facilitating external quality assurance (EQA). EQUIP uses the national HIV monitoring and evaluation (M&E) system that tracks number of tests done, test results, and tests done among couples. EQUIP exceeded its FY11 target for the PEPFAR HTC indicator (P11.1.D). EQUIPs M&E system doesnt currently allow further breakdown of the HTC indicator into various variables of interest. The program will work with facilities and MOH to explore opportunities of collecting this data without burdening healthcare workers.

In FY11, EQUIP was one of the key partners in the Ministry of Healths (MOH) effort to implement the new Option B+ integrated ART/PMTCT guidelines. EQUIP coordinated a zonal-wide planning meeting with representatives from all seven districts in the northern region. Three EQUIP staff participated in the training of trainers program, and led ten weeks of trainings in Mzuzu an initiative that was fully financed by the EQUIP project. EQUIP also provided logistical and financial support for additional trainings led by MOH in Karonga and Rumphi districts.

Similarly, EQUIP played a leading role in assisting the MOH developing a national mentoring strategy for continuous on-the-job training of staff on the new guidelines. EQUIP led the team in drafting the mentoring model and contributed to the development of the national mentoring monitoring and evaluation plan and training curriculum.

In addition to supporting the aforementioned national efforts, EQUIP continued its regular clinical mentorship, as well as lab and strategic information support at its target health facilities (HF). In FY11, the HIV status of 7,043 pregnant mothers was ascertained, while 475 HIV positive pregnant mothers received ARV prophylaxis in EQUIP supported HFs. In FY13, EQUIP aims to test 14,220 pregnant women for HIV infection and to initiate 554 HIV+ pregnant women on ART.

In FY13, EQUIP will continue to support MOH efforts through intensified mentorship to its target facilities in the northern and central zones. The trainings and regular mentorship will focus on building the knowledge and skills of health workers on providing quality PMTCT services including PITC, couples counseling and testing, as well as effective implementation of Option B+ with timely initiation of ART and follow up to ensure adherence. EQUIP will also assist HFs to develop and implement systems that would enhance MIP follow up including EID and management of exposed infants. As part of an effort to strengthen HF M&E systems, EQUIP will support deployment of Electronic Data Systems (EDS) that would facilitate clinical data collection. Through its clinical decision support system, EDS will also improve patient care.

In FY 11, EQUIP-supported health facilities (HFs) initiated 1,472 HIV positive people on ART. By the end of the fiscal year, 5,455 PLHIV were receiving their ART at these sites. A cohort analysis of program data showed that 94% of all PLHIV that started treatment 12 months ago are still alive and on treatment. EQUIP supported these sites (4 hospitals and 8 health centers) through in-service training, clinical mentorship and building their lab and strategic information capacities. The project uses the Ministry of Healths ART monitoring and evaluation (M&E) system and assists HFs in the appropriate application of the M&E tools, and the use of data including analysis of ART cohort data.

In FY13, EQUIP will continue to support the Ministry of Health (MOH) in its effort to expand ART services to additional sites, as well as to enhance continuous quality improvement in existing ART sites. Through its clinical mentorship (at least once a month), EQUIP will work to strengthen the clinical skills of service providers in management of OIs, clinical staging, ART initiation, managing common ART side effects, and assessment and management (or referral when appropriate) of treatment failure. In order to improve adherence to ART and other HIV care services, EQUIP-trained PLHIV and HCT counselors will offer adherence counseling at supported CHAM hospitals and affiliated sites.

Capacity building of health workers and HFs is at the core of EQUIPs program approach to ensure sustained improvement in quality of services. In order to foster efficiency and effectiveness in its program design and implementation, PIH has established processes that enable regular review of its work. As part of its management structure, PIH has a steering committee which has prominent local and international health experts as its members. The Steering Committee serves as an advisory group. Additionally, prior to initiating any programmatic intervention at a health facility, PIH consults with district and zonal health officials and does capacity assessments to better understand existing needs.

In FY12, in collaboration with Baylor, EQUIP will continue to train CHAM personnel and oversee the implementation and integration of EID and pediatric ART programs at all five supported CHAM hospitals and eight health centers within their catchment area. Clinical training includes basic pediatric ART curriculum (in-service) for sites not currently providing pediatric ART. All sites will eventually have personnel who have received training in pediatric HIV/AIDS management including clinical staging, management of OIs, ART initiation, managing ART side effects, and assessment and management (or referral when appropriate) of ART treatment failure in children.

The program deploys community workers who are entrusted with facilitating patient flow within health facilities, following up clients in communities, and tracking those who miss their appointments. Through its ongoing clinical mentorship, EQUIP will promote integration of pediatric HIV treatment services into MCH platforms of service delivery and linkages with nutrition support programs, and linkages with community based activities. EQUIP will collaborate with other USG lab partners to strengthen collection of Dried Blood Sport (DBS) and sample transport mechanisms for EID.

EQUIP will support deployment of Electronic Data System (EDS) in its target health facilities. EDS will be instrumental in facilitating data collection, and ready availability of service data. Additionally, this project will work with health facility staff to regularly review data collected through the M&E system and use the data to make decisions that would enable continuous quality improvement. The EDS has a clinical decisions support system that assists service providers in patient management through automatic feedback and reminders.

Key achievements will include five hospitals providing basic pediatric ART according to national and international standards; 15 health care providers mentored in providing basic pediatric ART according to national and international standards; 319 and 358 HIV positive children are expected to be enrolled on ART at EQUIP-supported sites in FY12 and FY13, respectively; and 2,420 and 2992 are currently on ART in FY12 and FY13, respectively.