IMPACT: This investment is designed to result in the quality scale up of HIV treatment, PMTCT and medical male circumcision services throughout Malawi through providing information for programmatic decisions and supporting districts to use this information for effective decision making about how to spend scarce resources. In response to the HIV and AIDS epidemic and in the spirit of embracing a multi-sectoral approach, the Government of Malawi established the National AIDS Commission (NAC) in 2001, under a trust deed to provide leadership and coordinate the national response to HIV and AIDS in Malawi. NAC is responsible for coordinating all HIV and AIDS responses in the country and works closely with the HIV/AIDS Unit in the Ministry of Health (MoH) to develop policies and promote compliance with operational guidelines for all biomedical HIV prevention and care activities. The role of the Commission is to: 1) Guide development and implementation of the National Strategic Plan (NSP); 2) Facilitate policy and strategic planning at all level; 3) Advocate and conduct social mobilization in all sectors at all levels; 4) Mobilize, allocate and track health resources; 5) Build partnerships among all stakeholders in country, regionally and internationally; 6) Assure knowledge management through documentation, dissemination and promotion of best practices; 7) Map interventions; 8) Facilitate and support capacity building; 9) Lead monitoring and evaluation of the national response; and 10) Facilitate HIV and AIDS research. With PEPFAR funding, NAC takes a leading role in developing surveillance strategies, implementing HIV surveillance activities in the general population as well as high-risk groups, drug resistance monitoring, and carrying out important data dissemination.

Ia) Zonal HIV and AIDS Research and Best Practices Dissemination Meetings

The National AIDS Commission organizes national research and best practices dissemination meetings every year. The aim of such meetings is to enable stakeholders to share findings of various studies and surveys as well as best practices to inform programming. These meetings do not accommodate all important stakeholders especially those from the districts. Zonal dissemination meetings are therefore held to allow district staff access to data that would be important for planning various activities including interventions in HIV and AIDS.

b) Regional HIV and AIDS M and E refresher training and working sessions on Local Authority HIV reporting system

The National AIDS Commission (NAC) as a coordinator of the national response is responsible for capacity building of HIV/AIDS implementing agencies in the area of M and E among others. A nationwide comprehensive training on HIV and AIDS M and E for stakeholders was conducted in 2008. Due to high staff turnover, a refresher will be vital to ensure that HIV and AIDS data management is done by trained personnel consequently resulting in improved data quality. With the development of the new national HIV and AIDS Monitoring and Evaluation Plan-2011-2016, the data collection tool is one of the elements that has undergone some changes and therefore Local Authority officials responsible for reporting will have to be re oriented on the operation of the HIV and AIDS data base by conducting working sessions.

The benefit of male circumcision in Sub-Saharan Africa in reducing men from acquiring the HIV virus is compelling, as determined by randomized clinical trials conducted in South Africa, Kenya and Uganda all of which concluded that medical male circumcision (MMC) significantly reduces female-to-male transmission of HIV: South Africa (60%), Kenya (53%), and Uganda (48%). Current evidence also suggests that male circumcision is beneficial in risk reduction for sexually transmitted infections which are known to exacerbate both transmission and acquisition of the HIV virus. In Malawi, the male circumcision rate is low with little improvement noted from 2004 to 2010 (21% to 22%, respectively). HIV prevalence for circumcised men compared to uncircumcised men has not been in the anticipated direction [13.2 and 9.5, respectively (2004 DHS), 10.3% and 7.6%, respectively (2010 DHS).

Malawi has formally adopted VMMC as a key prevention strategy for HIV and delivery of MC services is currently being piloted in a number of districts. No doubt, the pilot will identify gaps in the current knowledge and practice of MC. To enable scale up of MC to other districts, NAC will conduct operations research to better understand confounding factors for uptake of MC in some settings, and to identify facilitating factors for uptake of MC in other settings. Results from such research will be used to ensure improved MC service delivery through adoption of strategies that focus on increased public awareness and improved service delivery through facility preparedness. NAC will support community and social mobilization (through trainings, production and distribution of IEC resources) and improved service delivery (through support for provider trainings to build MC capacity, and facility supportive supervision.

NAC will support and ensure: 1) technical support for supervision services to male circumcision and that providers report accurate MC data through onsite supportive supervision visits; 2) operational research on male circumcision; and, improved public awareness.

The uptake of HIV counseling and testing by Malawians is one of the countrys success stories. Scale up of voluntary counseling and testing (VCT) activities in Malawi is evident from the initial two testing sites established in 1992 to 118 in 2004 to currently over 772 sites in the public and private sectors throughout Malawi. According to the 2010 DHS, almost 100% of women and men reported knowledge of where they could get an HIV test. However a smaller percentage (75% of women and 50% of men) had ever been tested and received their results. Couples testing is also considerabley low and requires scale up. Currently approximately 1.7 million tests are administered annually, achieved through multiple HCT entry points (PITC, FP, PMTCT, etc.). This number could increase significantly if inventory and stocklouts of test kits were appropriately managed, The decision to be tested for HIV serves as the first step and entry point into high impact HIV/AIDS interventions (e.g, ART, PMTCT, TB etc.); knowledge on ones HIV status has also been associated with safe sex practices and protection of ones HIV negative partner from infection. Having an understanding of HIV testings confounders and facilitators among missed and hidden or hard to reach populations throughout Malawi will help facilitate scale up of HCT services to individuals who are potentially at high risk for HIV infection. Implementation of Option B+ will address the currently low uptake of HCT among the pediatric population.

Under this mechanism, NAC will support impact evaluation studies for HTC programs being scaled up in Malawi to assess program effectiveness and efficiency, with a special focus on couple counselling and testing and low uptake, hidden and hard-to-reach populations.

Initiatives to improve prevention of mother-to-child transmission (PMTCT) of HIV during pregnancy, childbirth and breast feeding have been scaled up in Malawi overtime and have played an important role in reducing HIV prevalence. Option B+, a modified version of WHO Option B, is being implemented in Malawi and will provide ART to all pregnant women accessing PMTCT services for life, regardless of CD4 count. Implementation of Option B+ has resulted in an increase in ART sites from 450 sites in June 2011 to 650 in January 2012 and is expected to substantially increase the number of patients on ART. It is estimated that by 2015 the overall number of HIV infected people on ART will reach 550,000 and ART coverage for the pediatric population will have doubled to 60%.

NAC will support: 1) implementation and monitoring of Malawi's new Option B+ program to improve PMTCT service delivery and health care integration; 2) trainings, supportive supervision, and capacity building activities that ensure a high standard of service delivery provided by physician care providers, health surveillance assistants, lay counselors, community volunteers, and community based organizations; 3) expected increase in uptake of HTC (test and treat) through the purchase of HIV test kits; 4), PMTCT surveillance and assessment of the impact of the national PMTCT program and Option B+ to improve effectiveness and efficiency, and to identify new priority activities to reduce the rate of MTCT; 5) outcome evaluation of the number of children born HIV negative from HIV positive mothers and assessment of impact of Option B+ on population transmission, 6) drug resistant monitoring of both mothers and infants, 7) ANC sentinel surveillance.

The scale up of care and treatment in support of Malawi's new national ART guidelines to initiate ART at CD4 < 350 instead of 250, and implemention of Option B+ are estimated to significantly increase treatment coverage. As of June 2011, the GoM was providing ART to 277,000 person; it is expected that coverage will almost double by 2015 to 550,000. The proposed integrated, continuum of care service delivery model will require interventions that address system strengthening, capacity building, and supportive supervision.

Under this mechanism NAC will 1) support SI activities that aid in facilitating service delivery and understanding of the impact treatment and care services, 2) support the MoH in strengthening data capturing systems (e.g., HIV registries, etc.)

Malawi has a high burden of pediatric HIV disease. Of the approximate 1,000,000 PLWHA in Malawi, 20% are children under age 15, the majority of which were infected via MTCT. It is expected that continued scale up of the national ART program and implementation of PMTCT Option B+ program in Malawi will lead to an increase of ART patients to 550,000 by 2015 with coverage of children increasing from 30% to 60% in the next 2-3 years. Pediatric prospective HIV drug resistant monitoring is important in assessing performance of ART and will continue to be supported by NAC to ensure timely and appropriate treatment regiments. Additionally, as proposed by a US-based interagency team of seven consultants from the PEPFAR Adult Treatment and Pediatrics/PMTCT Technical Workgroup (OGAC, CDC, and USAID), a comprehensive, in-depth evaluation of Malawi pediatric program will be conducted to inform scale up of the past year's activities. NAC will provide TA and support for the evaluation.