IMPACT: This PEPFAR investment is critical to the national PMTCT (including EID) and HIV treatment program, and also lays the foundation for the national VMMC program; without this mechanism, Malawi would not have scaled up ART and PMTCT, developing and disseminating guidelines, training health workers, performing quarterly supervision at all health facilities, producing quarterly HIV reports, supporting ongoing mentoring of health workers and the ground level logistics of operationalizing Option B+.

This mechanism also supports evaluations which are critical to understand and improve the national HIV PMTCT and ART program. Implementation and coordination sits in the Planning Department with different operating units within the Ministry conducting specific activities. The overall purpose of this mechanism is to increase access to quality and comprehensive services in areas of: HTC; Care, treatment and support; PMTCT; pre-Antiretroviral Treatment; Antiretroviral Treatment; HIV related laboratory services, palliative care, HIV and Tuberculosis integrated services and strengthening national HIV Monitoring and Evaluation systems.

The specific objectives are: 1)strengthen delivery of HIV services through a continuum of care from prevention to care and support at all levels of health service delivery, 2)expand the scope and quality of PMTCT services through effective implementation of newly adopted WHO recommended guidelines for PMTCT and ART, including strengthening Early Infant Diagnosis (EID), 4)scale up delivery of quality HIV related laboratory services, 5)to support critical surveillance activities pertaining to HIV incidence and drug resistance, 6)support effective implementation of male circumcision, and 7) strengthen HIV monitoring and evaluation systems.

Provision of Home Based Care (HBC) remains a critical component of the HIV and AIDS response in Malawi. The Ministry of Health has recently developed the Community Home Based Care (CHBC) guidelines in collaboration with partners to ensure effective and efficient implementation of standardized CHBC. These new guidelines recognize the shift of CHBC from primarily a palliative service to a broader community support mechanism for all HIV-positive individuals and those with other chronic diseases. MOH will scale up CHBC service delivery to increase access to community services. MOH will also increase demand and acceptability of CHBC services through social mobilisation activities. Activities to promote CHBC adherence to guidelines will also be implemented through conducting supportive supervision visits and providing training for providers.

The challenge of TB and HIV comobirdity remains a significant public health concern, highlighting the need for stronger integration and linkages between HIV and TB service delivery. PEPFAR has supported MOH's efforts to integrate TB and HIV for several years, and significant results are emerging such as increased access to ART for patients accessing TB services. Ministry of Health now plans to roll out TB/HIV integrated services nationwide. The intention is to improve HIV service uptake among eligible TB patients and vice versa. While over 80% of TB patients are testing for HIV, and comorbidity is approximately 70%, less than 50% of HIV-positive TB patients initiate ART. Likewise, TB screening in HIV clinics is inconsistently implemented, and this funding will increase intensive TB case identification among pre-ART and ART clients in order to reduce TB mortality among HIV patients. Joint TB/HIV quarterly supportive supervision will also be provided.

A functioning laboratory system is essential for effective delivery and quality assurance of multiple health and HIV-related needs including HIV rapid testing, CD4 cell count, viral load monitoring, and diagnosis of opportunistic infections. MOH will strive to expand access and improve quality of HIV related laboratory services. This mechanism will strengthen the capacity of the central reference laboratory to provide essential diagnostic services for disease monitoring and surveillance, and will support adherence to quality standards in laboratory settings.

Through this support the Ministry of Health will continue disease surveillance and drug resistance surveillance studies. The drug resistance study settings will include existing ones and new sites. This funding will also involve strengthening the Health Management Information System (HMIS) at all levels of service delivery to ensure quality data for decision making. Strategies to achieve this will include review of data standards, institutionalising technical structures for health information and consistent performance reviews of HMIS.

While all of the activities funded under this mechanism have a systems strengthening component, this proportion of the funding for this mechanism approximates the systems strengthening impact. Through this mechanism, MOH will be supported to strengthen organizational and human capacity, to develop new policies and guidelines for the health sector, and to provide supervision and quality assurance.

Current evidence suggests male circumcision is beneficial in risk reduction for Sexually Transmitted Infections including HIV. Because of this, Malawi has formally adopted male circumcision as a key preventive strategy for HIV. To this end, in this COP, specific strategies for establishing medical male circumcision services will be implemented. Considering the early stages of strategy adoption, the focus will continue to be on public awareness, facility preparedness and systems aspects. These address both the demand and supply side of the medical male circumcision program. In this mechanism there will be activities such as: community mobilisation for male circumcision, social mobilisation for male circumcision through trainings and public forums in various social institutions including schools, consistent supportive supervisions to ensure safe and effective implementation of male circumcision services, and trainings for service providers to build capacity in male circumcision service delivery.

HIV Testing and Counseling remain an integral part of the HIV response. It provides an entry point into various high impact interventions for HIV and AIDS such as ART, PMTCT and other facility and community-based programs. This mechanism will place significant emphasis on improving the quality of HTC in order to increase the proportion of people who receive accurate test results, and provide those who test HIV-positive with referrals to prevention, care and treatment. This mechanism will: Scale-up and strengthen Provider-Initiated Testing and Counselling (PITC) particularly in ANC settings; improve linkages with both prevention and treatment settings such as PMTCT and ART to promote effective referral of positive clients; strengthen the couples testing initiative including identification of discordant couples in order to provide targeted prevention interventions; strengthen capacity through provision of trainings, and improve quality of services provided through improving the external quality assurance (EQA) process and conducting supportive supervision to HTC sites.

At present in Malawi, approximately 60% of HIV-infected pregnant women access PMTCT services, reflecting wide gaps in this aspect of the HIV response. Prevention of Mother to Child Transmission of HIV (PMTCT) will continue to be the focus of this mechanism, with the aim of supporting the implementation of the 2011 Malawi Integrated Guidelines for HIV Clinical Care, and improving access to quality PMTCT services so that universal access to PMTCT and progress towards the Elimination of MTCT (EMTCT) can be realised. Among the critical steps to pursue this, this mechanism will adopt a strategy to initiate and strengthen integration between PMTCT and other health services including family planning, ART, and under-5 clinics. This mechanism also intends to support evaluation of PMTCT through a prospective 3.5 year evaluation. Capacity development initiatives for PMTCT service delivery points to effectively deliver services will also be supported in various ways, key among them being: support for the HIV Department management processes, quarterly supportive supervision, training of health workers in emerging information and guidelines and sharing best practices in PMTCT service delivery.

MOH will utilize CDC funding to engage in national coordination activities including TWG support and annual dissemination meetings. Additionally, quarterly supervision of all sites and clinical mentoring will be supported. The latter is a very intense and extensive activity, where each health facility providing ART is reviewed for data quality, adherence to guidelines, stock of supplies, and other criteria. This activity is at the core of the functioning of the national HIV treatment system.

MOH will utilize CDC funding to engage in national coordination activities including TWG support and annual dissemination meetings. Additionally, quarterly supervision of all sites and clinical mentoring will be supported. MOH will include a pediatric-focused team member on all supportive supervision visits. This support will ensure contined scale-up in pediatric treatment access nationally, and will link to the clinical mentoring program for followup of sites which are underperforming in pediatric ART.