IMPACT: This mechanism is designed to directly scale up high quality and innovative HIV treatment services at Lighthouse, and through demonstrating new service delivery and integration models, is also designed to improve the quality and efficiency of HIV treatment services nationally. The Lighthouse is the largest indigenous trust providing integrated HIV services provider in Malawi, supporting over 22,000 PLHIV of which over 17,000 are on ART. It provides referral level services to ART sites in the Central region. Two Lighthouse clinic sites at KCH and Martin Preuss Centre at Bwaila hospital were established in collaboration with the Ministry of Health. MPC integrates ART with TB service delivery at the largest TB treatment site in Malawi and is supporting the pilot of integrated ART- PMTCT services and the Bwaila maternity unit, which has the highest volume nationally of ANC visits and deliveries. It has been designated a national training center by the MOH and certifies providers in HIV testing and counseling (HTC), palliative care and ART. Lighthouse program models inform the national policy and support operational guidance to improve the quality and efficiency of integrated treatment, care and support for HIV service delivery and facility and community level. The partner collaboratively pioneered the development of patient electronic data (EDS) approaches, which are now being rolled out at higher-burden sites nationally. It has also launched an innovative program aimed at reducing defaulters and improving long-term retention in ART treatment through active follow-up. Lighthouse plans to procure one vehicle for outreach clinics and mentoring of facilities for ART scaleup.

Models for integrating reproductive health services, including family planning, STI and cervical cancer screening, into the pre-ART and ART clinic at the partners high burden sites will be piloted and results disseminated to other stakeholders. This includes implementation of appropriate cervical cancer screening interventions for resource limited settings, such as visual inspection using acetic acid (VIA). Insecticide treated nets (ITNs) and Water Guard Technology distribution will be incorporated in the service package at facility and community level, targeting pregnant and lactating women and children <15 years. This will be a joint effort of the clinic team and the home-based care programs, and will strengthen the linkage with Bwaila ANC and ART adolescent clubs.

The national ART guidelines recommend quarterly pre-ART follow-up which will improve patient follow-up and initiation on ART. Notification strategies using SMS and phone calls will be piloted to communicate with eligible pre-ART patients once the results of CD4 testing have been obtained at the ART clinic. This will assist patient tracking and reduce the time to ART initiation. This will entail data collection through the development, piloting and revision of tools and integration of data sets in the EDS. Proven approaches to involve the community in the support of ART patients through Community Volunteers will be employed to promote psychosocial support, treatment adherence, early referral, and positive living. These will include the partners existing strong network linking facility and community based services through community volunteers, and a trained cadre of volunteers and nurses engaged in home-based care. In 2012-2013, the use of volunteers in the partners Back to Care (B2C) program will be piloted and evaluated to assess impact on tracing defaulters. It is expected that the volunteers at community level will be more effective and cost-efficient in encouraging patients not to not miss appointments or default from treatment.

The partners TB and HIV services are integrated from screening and diagnosis through treatment initiation and follow up. All ART and pre-ART patients are screened for TB at each visit, supported by prompts in the EDS at the point of clinical care. If a patient is suspected of TB, an in-house referral to the chronic cough unit is made. If TB diagnosis is confirmed, the patient is initiated on TB treatment concurrent with ART in the HIV clinic setting at KCH, and at MPC where Malawis highest volume TB clinic is co-located with ART, HIV treatment is routinely initiated in the TB clinic setting. Pre-ART patients diagnosed with TB start TB and HIV treatment simultaneously. In 2012-2013 TB diagnosis will be strengthened through use of novel diagnostics (Gene Xpert) as well as improved fluorescent smear microscopy, consistent with WHO guidance. Intensified case finding (ICF) will be realized through these innovations.

Eligibility for TB- HIV co-infected patients to initiate ART immediately will reduce loss to follow-up. Active patient follow-up needs to be strengthened to reduce delays in ART initiation and improve treatment outcomes. Only 65% of TB-HIV co-infected patients at MPC start ART within the first few weeks of TB therapy, largely because some TB treatment initiators quickly decentralize out to community sites for follow up and miss the integrated ART initiation. The partner will pilot approaches to integrate service delivery and support early initiation such as data collection of locator information from all TB-HIV co-infected patients at registration, tracking of patients to B2C program, through the use of appropriate technology (SMS-text and phone call) with patient consent (see HBHC narrative).

Treatment Scale-up: USD 150,000

The partner will provide HTC services as a component of a facility based HIV prevention strategy at its two high-burden facility sites (KCH and Bwaila MPC), as well as HTC and PITC at KCHs STI clinic and medical wards and at Bwaila Maternitys ANC. Beyond these hospitals and clinics, the partner will continue to provide HTC services at Maula Prison and at the community level throughout urban Lilongwe. Program innovation in this area has resulted in PITC for STI clients increasing from 43% to 99% after the partner led service integration in this area. The partner will continue to improve the HTC program through intensified STI and TB screening and referrals delivered in an integrated package with routine HTC counseling. In FY 2010 integrating PITC in STI and TB services resulted in over 95% of STI clients at KCH and Bwaila and over 65% of TB suspects at MPC knowing their HIV status. PITC will also be initiated in the short stay ward at KCH as an entry point for medical patients to access ART. Routine supportive supervision will be conducted in collaboration with the District Health Office (DHO) using the national HTC supervision check list to support quality assurance through data quality checks. Capacity building will be conducted through standardized on-the-job training and mentoring for counselors. Best practices will be documented and disseminated to stakeholders.

Positive Health Dignity and Prevention (PHDP) interventions will include capacity building of health workers and community members and implementation of behavioral change interventions to reinforce the key messages at facility and community level. Information, education and communication (IEC) materials will be piloted and revised using a participatory approach with PLWHA. Innovative methods for low literacy audiences such as songs and skits will be adapted to enable PLWHA trained in PHDP interventions to conduct community based IEC. A model will be developed for community based PHDP training methods (training of facilitators and community volunteers) and evaluation of knowledge transfer.

In the facility setting and in MOH sites supported by the partner with mentoring, PHDP interventions will be integrated consistent with MOH guidelines in the family-centered HIV integrated care package, encompassing services focused on pre-ART patients, mother-infant-pairs and others in standard ART. Delivering PHDP services particularly in the setting of discordant couples will be part of a standard and uniform care approach.

The partner at MPC will support Bwaila Hospital with the largest maternity service in Malawi - to strengthen ART provision and retention for women who start ART while pregnant or lactating. Bwaila recently implemented the national Option B+ program in cooperation with MPC, initiating all pregnant and lactating HIV+ women on lifelong ART. Bwaila ANC operates as an ART outreach clinic under MPC. The partner will take an active role in mentoring, supervision and monitoring to help Bwaila implement high quality services, and support ART initiation, retention, transfer and tracing, assuring that the continuum of care for these women is as strong as possible. It will work cooperatively with fellow PEPFAR partner Lilongwe Medical Relief Trust Fund (LRMTF), Mothers to Mothers (M2M) and the District Health Office (DHO) to reduce defaults among women who start ART through active tracing using SMS, phone, and home visits.

Currently, HIV-positive infants are identified at either Bwaila Maternity or at MPC through EID testing. Under new Malawi guidelines, exposed infants receive CPT from 6 weeks and remain closely followed in care for two years. With Bwailas constrained health staff, the partner will take a proactive role to follow up exposed infants from both Bwaila and MPC, facilitated by an expanded electronic patient data system (EDS) which will link patients and mother-infant-pairs (MIPs) across HIV, ANC, maternity and under-5 clinics. The EDS will facilitate substantially enhanced EID tracking. The partner will support Bwaila maternity staff to effectively use its new EDS system completely and consistently, in its move from paper to electronic patient records beginning in 2012. It will also train and mentor its Bwaila ANC partners to better follow-up with infants during the postnatal period through 12 months, and will actively provide HIV treatment and care for women and infants who formally transfer in to MPC. It will also collaborate to trace patients lost to follow-up (LTFU); in partnership with M2M and DHO, the partner will reach and return 80% of LTFU infants within its Lilongwe urban catchment back to care.

Implementation of new national ART guidelines, with active pre-ART, test-and-treat for pregnant and breastfeeding women, and early treatment initiation otherwise (CD4<350 cells/mm3), will result in a significant increase in case loads in ART clinics and HIV related services. The partner operates two super-high burden treatment sites (more than 15,000 patients actively on treatment) and serves as a center of excellence and referral site for Malawis Central Region. Its service model encourages decentralization of stable patients on treatment out to community level MOH facilities for long-term follow up. PEPFAR funding will continue to support the partners core service delivery as a leading ART provider in Malawi.

Service delivery models promoting integration and continuum of HIV care in resource limited settings will be supported by the partner with capacity building interventions, including clinical and health systems mentoring and supervision, in the Lilongwe urban area. To support the scale up of ART sites and the success of Malawis new integrated HIV program approach, with high quality outcomes, experienced ART clinicians will provide out-reach services and mentorship at MOH facilities to enable the attainment of certification as independent ART sites. In addition, referral systems will be piloted to strengthen PMTCT and TB service linkages with MOH health centers, and establish a continuum of care. The partner will collaborate with other PEPFAR-supported programs operating in Lilongwe district in order to provide coordinated support under MOH and DHO management. The partner will support Baobab and MOH in the national scale-up of an electronic data system (EDS) aimed at improving data quality and patient management. New modules to support integrated HIV service delivery will be piloted, monitored and evaluated by the partner. This innovation will allow the routine collection of complete patient information on ART and TB, to enable optimal patient monitoring, integrated program monitoring and evaluation, and to minimize LTFU of co-infected patients. Lessons learned during implementation will be documented to strengthen EDS systems and integrated program management. Best practices will be disseminated through publications and presentations at the national and international level forums.

The partner will also be supported to continue and expand didactic, on-the-job, and skills-based trainings for MOH and partner organizations to certify providers of HIV testing and counseling (HTC), palliative care and ART throughout Malawi. In 2012-2013, trainings will be expanded to include PITC, couples and child testing and counseling and electronic learning modules on HIV treatment and care.

Treatment Scale-up: USD 450,000

Treatment Scale-up: USD 100,000