The primary goal of Baylor College of Medicine-Childrens Foundation Malawi (BCM-CFM) is to expand the scope and reach of its Tingathe outreach program, which provides comprehensive PMTCT and Early Infant Diagnosis (EID) services to mothers and infants at participating facilities and facilitates prompt entry of infected infants and mothers into a continuum of care for optimal treatment outcomes. Tingathe strengthens systems to improve the quality and utilization of PMTCT, EID, and pediatric HIV care services thereby contributing to the reduction of maternal, neonatal and child mortality and morbidity and, ultimately, the reduction of new HIV infections. These targeted interventions are priority areas of USG support under the Malawi Partnership Framework and the Global Health Initiative (GHI) Strategy.

Currently, Tingathe operates in four sites in Lilongwe district, with plans to expand to four new sites in FY 2012. Additional activities under Tingathe include conducting operational research to identify service-delivery barriers and to develop strategies to overcome them. Addressing such obstacles will strengthen coordination and linkages between services to help ensure provision of comprehensive medical care and improve the quality of existing services and their capacity to absorb increased patient load via training, mentorship, and supervision of Ministry of Health (MOH) staff.

Through its robust monitoring and evaluation system Tingathe will improve adherence supervision and defaulter tracking activities (patient retention in care). BCM-CFM plans to procure one vehicle to assist program expansion outside of Lilongwe.

In COP13, Baylor Tingathe project will implement priority TB/HIV interventions in six high burden sites with a primary focus on HIV exposed/infected children and HIV positive pregnant women. The six sites include two urban health centres, one rural and four District hospitals in the Central region of Malawi. As part of its TB/HIV interventions, the project will strengthen intensified case finding, provision of IPT, and infection control practices. To improve TB case finding the project will adopt two main strategies. The first, called primary case finding, will integrate TB case finding into the projects existing HIV testing, PMTCT, pre-ART and ART interventions. The second strategy, called secondary case finding, will focus on secondary household contact tracing/case finding investigations in all cases identified through primary screening. Tingathe will provide training and clinical mentorship to strengthen the clinical competency of service providers on the diagnosis and management of TB/HIV and establish good infection control practices that minimize TB transmission in health facilities.

In Malawi, provision of IPT is still in its early stages. The first (large scale) distribution of isoniazid and pyridoxine for the HIV programs reached ART sites during July 2012. In the last quarter of FY12, 27% of pre-ART patients were on IPT. A further increase in IPT implementation is expected in the coming months and year. Tingathe will support health facilities and providers in the roll out of the IPT program. Tingathes support will include training, mentorship, supportive supervision and provision of job aids.

At community level, community Health Workers (counselors) will incorporate a TB symptom and history-based screening tool into all HIV testing. Patients who screen positive (for TB) will be referred for formal evaluation at the nearest health centre. The project Counselors will follow these cases through the entire process of diagnostic evaluation and treatment (if indicated). At Health facility level, counselors and clinical mentors will collaborate with MOH staff to routinely and formally integrate TB screening into patient encounters for HIV-infected and exposed patients enrolled in the Tingathe program. At high burden sites, a Counselor will administer a TB screening questionnaire while the patient is waiting to see the clinician. This screening process will help identify patients eligible for Isoniazid Preventive Therapy (IPT) versus those who need a full TB treatment.

Depending on need (e.g. staff turnover, programmatic changes), Tingathe will train/re-train additional health facility and community staff to make sure service providers have the knowledge and clinical competence they need to fully implement TB/HIV services.

Tingathe will implement a monitoring and evaluation plan that is harmonized with the national M&E framework. In COP13, the project will begin tracking and reporting on key indicators including coverage of TB screening, initiation of TB treatment among pre-ART and ART patients and provision of IPT.

All Tingathe interventions are in line with the national TB program strategy and MOHs HIV/AIDS guideline. The project will coordinate with the national TB program and other key partners including the USG funded TBCARE II project.

In partnership with the Ministry of Health (MOH), BCM-CFM aims to scale up the provision of comprehensive pediatric HIV care at antiretroviral therapy (ART) clinics across the country through the pediatric HIV outreach and training program. BCM-CFM has developed a systematic approach and comprehensive training package for on-site training and clinical mentorship of MOH providers in PMTCT, EID, and pediatric HIV care and treatment. BCM-CFM clinicians and nurses work with hospital and health center systems to ensure better linkage between departments, identification of high-risk patients, and help the health facilities set up PITC systems. These activities have contributed to the improved capacity of ART clinics and providers to offer quality care and increase the enrollment of HIV-infected and exposed children. To ensure the quality of care remains consistent, MOH providers will be trained and supervised so all sites participating in the program will be able to offer this minimum package of services.

BCMs Tingathe program focuses on using community health workers (CHWs) to bridge clinical services, improve linkages between programs and providers, ensure proper follow-up, and increase access to services for HIV+ children and their families. The goal is to create a decentralized, complete continuum of care for mother-infant pairs between ANC, PMTCT, ART, EID, and pediatric HIV care and treatment. CHWs follow clients to their homes and health center, from initial diagnosis until final negative diagnosis, or successful enrollment of HIV+ infants into care. HIV+ infants are followed to ensure they are receiving appropriate services.

Tingathe continues to make major contributions to scaling-up PMTCT programs in Malawi through the expansion of geographic coverage from the current four sites in Lilongwe, which has 1,946 active and enrolled clients, to 10 sites in four districts in the central region by end of FY12. By end of FY13, the target is to reach 3,900 mother-infant pairs. Tingathe will continue to track progress toward targets through patient registers, database, and monthly reports from the sites.

Tingathe is involved in community sensitization and education through daily health talks at health centers, regular meetings with teachers and village leaders, and large-scale sensitization events. Tingathe works with Feed the Children to provide Vitameal to all pregnant mothers and infants, and links clients with acute malnutrition to outpatient therapeutic programs.

Tingathe estimates $200 per patient/unit receiving PMTCT. To help decrease cost and increase efficiency, the program is planning to utilize patient groups as piloted by MSF in Mozambique and fostering more involvement of Ministry of Health (MOH) staff in the program.

Currently, children make up only 9% of PLHIV that are alive and on treatment. In COP13, pediatric ART will be one of the major areas of support to the national HIV/AIDS program. The current national guideline stipulates universal ART for HIV-positive children less than 2 years, and HIV-exposed infants with Presumed Severe HIV Disease. The project will use clinical mentorship, supportive supervision, and in-service training to build the skills of health providers in Pediatric ART, including timely initiation, provision of appropriate regimen and dosage, clinical and lab monitoring of ART, and caregiver counseling.

In addition to improving the quality of pediatric ART services, the project will focus on optimizing the identification of HIV-infected children, and facilitate their enrollment and retention in care/treatment. Tingathe has a team of community health workers that facilitate the smooth progression of clients (HIV positive women, HIV exposed infants, HIV positive children) through the PMTCT Pediatric Care/Treatment continuum. The Community Health Workers play a key role in making sure HIV-exposed infants are enrolled into the EID program (immediately after birth), HIV positive infants are enrolled in care/treatment, and liaising with HSAs for the tracing of exposed infants who miss their EID schedules or HIV positive children who miss their ART schedules.

Tingathe will train/mentor health workers in the proper application and use of the national monitoring and evaluation tools. Project staff will particularly emphasize the need to capture complete maternal and infant information on the heath passport and master cards.