IMPACT: (A) Scale-up high quality HIV treatment and PMTCT through Malawis Christian hospitals and (B) and support access to HIV services through training new health workers. The Christian Health Association of Malawi (CHAM) is an ecumenical, non-profit umbrella organization for church-owned health facilities providing health care to 40% of all Malawians. It has 41 hospitals and 132 health centers across Malawi, 90% located in rural hard-to-reach areas. CHAM also has 12 training colleges producing 77% of all new nurses in Malawi.

CHAM's national response against HIV was limited by weak staffing and funding historically. Under PEPFAR it set-up comprehensive HIV services in four key hospitals in FY09, and scaled up to six more (ten total) the next year. Hospitals were selected based on disease burden and gap needs for HIV/TB services, in districts with high burden. Coordination, scale-up and monitoring for services in the faith-based sector is strengthened in this partnership, which also develops management capacity in CHAM for further scale-up in its network. Another core objective is to support the training of front-line health workers for Malawi's health system and national HIV response. PEPFAR now supports 550 students to become nurses, clinicians, pharmacy and lab professionals through CHAM colleges, linked to strengthening the nurse colleges through other programs including I-TECH, GAIA and ICAP. In COP 12 and 13 CHAM will scale-up the HIV service program to another 20 sites, focusing on highest burden communities, and support an intake of an additional 250-300 health professional students (most nurses), to assist in closing Malawi's large deficit in frontline health workers delivering HIV and essential health services in the public sector nationally.

Impact: Deliver a comprehensive family-centered HIV care package according to MOH guidelines, including pre-ART and primary care services, in all target facilities and community settings.

A standard package of integrated care components are specified under the new national HIV program guidance under the umbrella HIV Care Clinic (HCC) concept. This model promotes integration of services to facilitate access for clinical monitoring, preventive services and ART for family members affected by HIV. In this family-centered approach, clinic services are offered at the same time and in the same clinic for ART, follow-up of HIV-exposed infants, and pre-ART follow-up for children and adults. Pre-ART, in particular, is critical to establish an effective continuum of care for HIV-affected patients and families and to assure that individuals are transitioned to HIV treatment early and without being lost to follow-up.

Reorganizing clinic operations to support an integrated HCC service delivery, promoting male involvement, and scaling up pre-ART services under this new national guidance are among the key approaches for supporting effective HIV care at the PEPFAR supported CHAM hospital sites. Supporting high quality treatment and care for HIV-exposed and infected children, including Early Infant Diagnosis (EID) services and follow-up for exposed infants, facilitated by efficient specimen transportation networks, is another. Integral in this service model are the preventive services (see below) such as PHDP, family planning, and STI services, which are at the core of primary health services delivered under this approach. Effective TB screening and treatment is also supported by the Pre-ART and HCC programs.

CHAM will lead its facilities under PEPFAR support to adopt these more effective, integrated care models consistent with MOH guidelines, through facility improvements, program funding and support, technical assistance, trainings, and supportive supervision. In some hospitals with very remote, rural catchments, the program funding will also support community outreach with clinical treatment and care as well as prevention services.

Impact: Provide effective TB and HIV services consistent with national guidelines to co-infected patients, through promoting TB and HIV service integration and delivering stronger services in the three Is model, including intensified case finding (ICF), isoniazid preventive therapy (IPT), and infection control (IC).

Integrated TB and HIV prevention, diagnosis, and management services will be provided in all targeted facilities with higher TB and HIV case burdens, according to national program guidance. Particular attention will focus on reducing delays in ART treatment initiation for TB-HIV co-infected patients and promoting simultaneous enrollment in TB and HIV chemotherapy, with strong clinical and program support. HTC counselors will conduct routine TB screening using a standardized checklist. Routine PITC will be provided for all TB patients and referral systems will be established to facilitate access to ART services, in locations where they are not fully integrated. CPT and IPT shall be provided to eligible TB-HIV patients in addition to other components of the HCC care model. In facilities, CHAM will support the establishment and implementation of effective IC guidelines and practices, in cooperation with the MOH. At district-level, CHAM will support the decentralization of TB registration sites and other initiatives in order to fill gaps and expand access under the National TB Program (NTP) strategic plan. At community level, peer education and edu-tainment will be conducted to raise awareness, increase community-based case finding and emphasize TB infection control principles. CHAM will collaborate with local organizations and DHO initiatives to establish and strengthen sputum collection sites at community level, to operationalize community-based case finding. Finally, key CHAM facilities will engage, through cooperative support of other PEPFAR partners, to strengthen laboratory-based diagnostic services for TB case finding, including optimization of fluorescent LED microscopy or other novel diagnostic approaches.

Impact: Support the intake of an additional 250-300 new nursing and other health professions students in CHAM training colleges and build stronger capacity for human resources for health (HRH) to support Malawis HIV response and broader health sector needs.

Malawis substantial deficit of health professionals to staff its public sector (MOH and CHAM) facilities is recognized as one of the nations greatest challenges in health. Ten CHAM colleges train health workers for Malawi, and a total of 450 new health care workers graduate each year. CHAM nursing colleges train more than 70% of Nursing Midwife Technicians (NMTs) and graduates fill critical staffing needs in 8090% of MOH and CHAM rural health facilities. In 2006, the MOH asked CHAM to rapidly scale up their training programs, and to double their intake of new students within one year. To support the national human resource for health (HRH) plan to increase output of critical health workers and alleviate the HRH crisis resulting from a chronic shortage of health professionals, 550 students in CHAM colleges are being provided with bursaries through PEPFAR funding currently, and will serve in the rural areas upon graduation, as part of their bonding agreement. Bursaries support 300 NMTs, 50 clinical officers, 50 laboratory technicians, 20 pharmacy technicians, 100 medical assistants, 30 pharmacy assistants. In addition, bursary support is being provided for the training of 21 nurse-tutors at Masters level, to ensure appropriate tutor- student ratios are maintained through the rapid scale-up of training institutions outputs. This also supports the delivery of health services defined in Malawis Essential Health Package (EHP), including the reduction of maternal mortality. Starting with COP FY12, additional intakes of NMT students will be supported by PEPFAR on an annual basis. This support may be expanded to other priority health worker cadres. Between 250 and 300 students will be funded for one year of study with this budget amount in COP12 (prior student intakes will continue to be funded by PEPFAR budget sources from prior years, for their 2nd and 3rd years of study). Support for bursaries complements a strategic mix of technical assistance in collaboration with other partners supported by PEPFAR-Malawi (I-TECH, GAIA, NEPI ICAP, etc.) to increase training institution outputs and improve the quality of pre-service education of health care workers.

Impact: Identify and enroll HIV+ children in services, through aggressive PITC among children in medical and nutrition clinics and wards, and expand access to HIV services for vulnerable populations through improved HTC and prevention services.

Under-diagnosis of HIV in children in Malawi is well documented and is a priority focus for PEPFAR under COP 12. PITC will be aggressively for children presenting in both clinical and nutrition units, and identified HIV+ children will be immediately linked in to pre-ART and staging for ART under the national family-care model. Uptake will be supported by program mentors supported by PEPFAR. PITC will also be integrated in STI and TB clinics in all facilities, following successful program models implemented in Malawi and consistent with national program guidelines. HTC services are provided free of charge at CHAM facilities and given the rural location of most facilities, this will support national efforts to attain universal access to HIV testing in hard to reach areas. Access to HIV services will be further enhanced as CHAM will continue to conduct sensitization campaigns and provide door to door counseling and testing in rural communities. In addition, CHAM will support programs to address testing and counseling needs of special groups including health service providers in line with HIV work place policy, and at risk populations, such as prisoners and seasonal fishermen. HIV testing services for the youth and couple counseling will also be implemented. In order to support those tested, post test clubs and PLWHs support groups will be established to support individuals living positively with HIV.

Impact: Contribute to national scale-up of integrated treatment and PMTCT through increased coverage and effectiveness of PMTCT services in CHAM health facilities, supporting the elimination of MTCT of HIV in Malawi.

CHAM facilities form part of the public sector HIV strategic plan and response, alongside MOH facilities. In line with the new national HIV integrated guidelines, CHAM has implemented test and treat for all HIV-positive pregnant and lactating women (Option B+) since September 2011. All antenatal clinics (ANC) in CHAM offer PMTCT and have become ART expansion sites. Integration of HIV services with ANC, maternity, postpartum, under-5 and family planning will be fostered in this program and scaled up, consistent with the MOH integrated program guidance and a family-centered model based on covering the entire continuum of care. This is consistent with the HIV program model which was implemented in ten CHAM hospitals during the first two years of the PEPFAR cooperation, and which was designed specifically to anticipate the integration and program expansion underway currently in Malawi. In COP FY 2012 and 2013, the programmatic gains implemented and proven in those first ten sites will be scaled out to twenty additional CHAM facilities across Malawi. Additional clinical program support will be added through mentoring, aligned with and supporting Malawis national HIV mentoring program, to increase the quality and uptake of PMTCT, treatment and care objectives, including pediatrics.

While the new program offers promise and a better approach for comprehensively reaching HIV-positive pregnant women with effective means of both prevention and treatment, the outcomes leading up to this period suggest that many women have been missing crucial PMTCT interventions. Loss to follow-up occurs associated with poor access to health services (distance) and stigma. Access will be facilitated through expanded implementation of community outreach clinics providing integrated ANC and ART services in some remote and rural catchments, and following-up patients actively using cell phones. Community based approaches and linkages to health facilities will be achieved scaling up peer support interventions to new sites. This will include sensitization and psychosocial peer support for eligible women to support adherence to ART, strategies to reduce stigma and the active promotion of male involvement. Couple counseling will be implemented through community support groups with the use of Couple to Couple mentors.

The program approach will also support the mother-infant-pair (MIP) to assure that essential clinical program elements of the PMTCT are delivered. This will include tracking patients to prevent loss to follow up and support adherence to therapy, and assuring that timely EID testing is completed with result returned for patient management. It will also include provision of associated essential services (or linked community referrals) for core components of primary care services for HIV+ women and their infants, including family planning, PLWHD, nutrition, and malaria prevention.

Impact: CHAM hospitals serving communities with poor access to HIV services will increase the reach, uptake and quality of HIV treatment through strongly-performing programs delivering integrated HIV services under the MOH family-centered model.

PEPFAR has supported CHAM to implement and scale-out more effective HIV treatment, care and PMTCT services at its priority, higher-burden hospitals across Malawi, by support the development of holistic and integrated services under the family-centered HIV care model now being rolled out nationally in Malawi. With the implementation of Malawis new guidelines and B+ approach for PMTCT in September 2011, there is strong opportunity to build on capacity developed over the past 2 years with PEPFAR support, and maximize the reach of HIV treatment and care within their catchments. CHAM hospitals are developing effective models of outreach and rural-based program scale up, to expand access to high-quality clinical programs to people in the most remote regions of Malawi. Treatment support will be expanded from ten key CHAM facilities (in FY11) to twenty additional rural CHAM hospitals under COP12 and 13. PEPFAR support will help CHAM to share experiences and best practices across facilities and regions, and consolidate guidance for most effective approaches. CHAM will also add clinical and program mentoring to the capacity building support provided to sites with PEPFAR support, as part of the national MOH mentoring program which is accompanying and supporting the uptake of integrated HIV services nationally. CHAM and facility staff will participate with MOH in conducting the national quarterly site supervision (M&E) exercise, and will leverage that experience back into program improvement at their home facilities.

Other aspects of quality and access will be emphasized in the CHAM program approach to adult treatment and care. Importantly, increased access to CD4 testing will be assured at all CHAM supported sites, which linked to pre-ART services, will assure that effective staging and timely initiation of ART is completed. As viral load (VL) capacity is also developed in Malawi, through PEPFAR support, in FY12 and 13, patients being followed in the CHAM sites will also be linked in to higher quality treatment monitoring.

CHAM will strengthen its capacity in program M&E by establishing a standardized monitoring system for member health units to ensure accurate data collection, analysis and utilization for information driven decision making. An electronic data system (EDS) will be established across the participating facilities in collaboration with Baobab, strengthening patient management and program M&E alike. Tools and modules will be piloted and adopted for routine programs and databases will be developed at the CHAM Secretariat. Capacity building will be conducted for all program staff in data recording, analysis, and the appropriate utilization of program data at both facility and CHAM Secretariat-levels.

Impact: CHAM hospitals serving communities with poor access to HIV services will increase the reach, uptake and quality of HIV treatment for infants and children, through effective programs delivering integrated HIV services under the MOH family-centered model.

Pediatric treatment and care in Malawi is characterized by poor access and quality outside of urban centers, contributing to under-representation of children in programs nationally and a very low percent coverage of ART (30%) compared to need for children. Clearly part of the weak performance is due to failure to test and identify HIV+ children. PEPFAR will support CHAM to take an aggressive approach to PITC for children presenting to clinic and nutrition centers, and support strong program gains for EID in CHAM facilities, in order to better identify infants and children requiring enrollment in pre-ART and ART programs. Community outreach will also be used to increase the reach of HIV testing to children. The availability of HIV test kits for diagnosis, and of CD4 tests for staging of HIV+ children, will be prioritized. If necessary, PEPFAR funds will be used to ensure that test kit supplies are maintained and prioritized for key strategic needs, such as testing in ANC and PITC for children.

Capacity building for treatment of infants and children will be supported through training of clinical providers, backed up by program and clinical mentoring. PEPFAR will support the addition of a clinical mentor to the CHAM team, who will participate in the MOHs coordinated national HIV mentoring program, working to support building capacity for program quality and effectiveness both at the level of zonal and district mentoring teams, and through those teams, with the CHAM facilities and providers themselves. Capacity to deliver high quality pediatric treatment and care, consistent with the national guidelines and program model, will be developed through this approach over time. Mentoring will be coordinated with the MOH quarterly site supervision process, to complete a real time evaluation and feedback loop leading to improved performance. Pediatric ART enrollment and pre-ART are expected to be bolstered through this approach and the technical support of the PEPFAR team.