PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Subdivisions of Program Areas, these track general higher level sub-classifications of expenditure.
Subdivisions of Major categories, these are the most detailed expenditure data.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008
New/Continuing Activity: New Activity
JHPIEGO will assist the Ministry of Health (MoH) to complete the roll out of the performance and quality
improvement initiative in infection prevention to all districts in an effort to reduce HIV and possible Hepatitis
B transmission among health providers in health facilities. This will be achieved through facilitating
sensitization meetings, training quality improvement and assurance support teams in infection prevention
(IP), conducting baseline assessments at the facilities, conducting monitoring and supervision at facilities,
addressing identified IP gaps with available resources, and working with District Health Management Teams
(DHMT's) to ensure they budget sufficient funds to guarantee the availability of adequate and consistent
supply of IP commodities. Target population for the program is the general population. These activities wrap
around performance and quality improvement work to be undertaken by JHPIEGO with family planning and
maternal and child health funding.
Since 2002, JHPIEGO Malawi has worked with MoH Nursing Division and the National Quality Assurance
Steering Committee (NQASC) to improve IP practices in hospitals throughout Malawi. As the JHPIEGO
bilateral agreement comes to an end in September 2007, the follow-on activities in this area will be
undertaken through a central agreement with JHPIEGO. Among the critical activities to be completed is the
roll out of the national IP guidelines and standards to all health facilities.
To date, the PQI/IP process has been introduced in 35 hospitals. Improvements have been documented in
all hospitals and nine have achieved recognition by MoH. JHPIEGO will continue to roll out this initiative to
other facilities and support the existing facilities to achieve recognition status.
Activity 1: Development of National Guidelines
JHPIEGO will build on the assistance provided through the previous JHPIEGO bilateral project to help the
MoH in developing national guidelines and standards for IP. The infection prevention standards cover 14
departments of the hospital that includes the operating theater, labor/maternity wards, medical wards,
surgical wards, casualty department, laboratory, dental, and family planning clinics; and these are being
implemented in 35 health facilities covering all central and district hospitals. Two thousand and twelve
health workers in Malawi have been trained in injection safety with technical support from JHPIEGO and
other USG partners MSH and Save the Children. With FY 2008 funding, JHPIEGO will provide support in
increasing the capacity of health care institution workers to prevent occupational exposure to HIV, Hepatitis
B and other infections including hospital-based nosocomial infections. The first activity is to provide
supportive supervision to the existing 35 hospitals throughout Malawi that have already been introduced to
the national IP standards so that a maximum number of sites receive certification as meeting MoH infection
prevention standards and guidelines. These activities will be coordinated with activities carried out by USG
partner Pact Malawi (ID#17396)
Activity 2: Technical Assistance
JHPIEGO will expand the provision of technical assistance to the MoH to adapt the standards to be
applicable at the Health Center levels so that correct IP practices can be extended. As part of this process,
JHPIEGO will also assist the Reproductive Health Unit (RHU) and the Nursing Directorate to create a
method of recognition and certification for Health Centers which achieve IP standards.
Activity 3: IP Standards
JHPIEGO will work with stakeholders at the district level to roll out IP standards to the Health Center level.
JHPIEGO will demonstrate this process in 15 Health Centers and encourage MoH, DHMTs, and other
partners to take up this initiative.
Activity 4: Training in Injection Safety
JHPIEGO will train 180 health care workers in safe injection practices and universal precautions as well as
introduce health care workers to procedures for using post exposure prophylaxis (PEP). Four training
sessions will be held at these 15 sites, and three members at each facility will be trained. JHPIEGO will
continue to work with the existing 35 hospitals to address multiple underlying factors affecting facilities'
ability to meet their IP goals. Pact Malawi will extend this training and disseminate PEP information to
greater numbers of health care workers (see Pact Injection safety narrative).
This funding will go specifically to support hospital staff training in providing injection safety and hospital
supervisory staff training in ensuring a minimum quality standard for services.
New/Continuing Activity: Continuing Activity
Continuing Activity: 17131
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
17131 5924.08 U.S. Agency for JHPIEGO 7665 5630.08 JHPIEGO CSH $100,000
11127 5924.07 U.S. Agency for JHPIEGO 5630 5630.07 JHPIEGO CSH $0
5924 5924.06 U.S. Agency for JHPIEGO 3884 3884.06 $163,958
Program Budget Code: 06 - IDUP Biomedical Prevention: Injecting and non-Injecting Drug Use
Total Planned Funding for Program Budget Code: $0
Program Budget Code: 07 - CIRC Biomedical Prevention: Male Circumcision
Program Budget Code: 08 - HBHC Care: Adult Care and Support
Total Planned Funding for Program Budget Code: $3,174,764
Program Area Narrative:
Malawi is making progress towards achieving its target of enrolling 250,000 individuals on antiretroviral therapy (ART) by 2010. By
June 2008 there were 207 public and private health facilities delivering ART in all districts, with 184,405 patients ever started on
ART and 121,707 patients alive on ART, the vast majority of whom were initiated based on clinical staging.
With little to no pre-ART care available in country, there is a need to both expand care and treatment services to include pre-ART
care, as well as focus on quality of care and treatment for those already initiated on ART. Linking HIV counseling and testing
(HCT) services to HIV care services is important to reduce the number of HIV-infected individuals lost to follow-up once tested.
Malawi almost exclusively initiates people on ART based on clinical staging. The use of immunological staging and availability of
laboratory services can help move more people in need of treatment on to ART, and improve the quality of care and treatment.
Management of existing patients is anticipated to become increasingly complex as the Malawi program transitions from acute to
chronic care. Care and treatment challenges which USG will address in FY09 and beyond include a severe lack of human
resources at all levels and an M&E system which needs strengthening.
Increased focus on care and support services nationally is required in communities, as community care and support has not
developed as quickly or as systematically as ART services. The limited national, GFATM and PEPFAR resources which exist for
care and support are directed primarily at supporting community home-based care programs (CHBC) for chronically ill bedridden
patients (not limited to PLWHA) through CBOs and NGOs, even though approximately 90% of ART patients are ambulant. Other
challenges include limited national coordination of care and support; poor procurement and supply chain management of
cotrimoxazole, other OI drugs, and supplies for home-based kits; and a limited focus on prevention (including prevention with
positives). Malawi currently provides HTC for more than 1 million people a year. However, many individuals who have tested HIV-
positive and were not eligible for ART, have been lost to follow-up, and have therefore not benefited from cotrimoxazole
prophylaxis (CPT) and other care interventions that reduce disease progression and prevent opportunistic diseases.
Previous USG Support
Recognizing GFATM support, and in a strategic effort to fill critical gaps, USG funding for facility-based adult care and treatment
has been in human capacity development, training, laboratory services, M&E and program evaluation, while support for
community-based services has focused primarily on CHBC programs through international "umbrella" organizations such as Pact
Malawi, to provide technical and program management support to indigenous CBOs and NGOs. In FY08, Pact Malawi supported
10 partners including the Palliative Care Ass. of Malawi (PACAM) in partnership with Africa Palliative Care Ass. (APCA), National
Association of Persons Living with HIV/AIDS in Malawi (NAPHAM), Lighthouse Trust, and some CHAM health facilities. This
support was to provide clinical, prevention, social, psychological, and spiritual services for people living and affected by HIV and
AIDS in facility, community and home-based care settings. PACAM/APCA provided technical support to the Government of
Malawi (GOM) to scale up palliative care services in Malawi, develop palliative care guidelines and training manuals, train HBC
master trainers, advocate for increased access to opioids; and improve capacity of health workers to assess and manage pain.
Additionally, USG has supported long-term HIV/AIDS Technical Assistant (TA) in MOH, and Lighthouse, a Malawian NGO which
serves as a center of excellence for HIV/AIDS care and treatment, including CHBC.
FY09 USG Support
i. Human Capacity Building
USG will continue support to the national care and treatment effort by funding a medical officer and a laboratory officer as part of
the USG team. These personnel will provide technical oversight for the expansion and improved quality of care and treatment
services. Through ITECH, USG will fund a new clinical support team to assist MOH's Department of HIV/AIDS with the expansion
of HIV/AIDS treatment services throughout Malawi. The team will be comprised of a Senior TA and two Malawian Staff Fellows as
counterparts. The Staff Fellowship program is intended to attract Malawians into a mentorship program to help address MOH
concerns on human capacity development and sustainability of the HIV/AIDS treatment program. USG will continue to support
Lighthouse through funding senior staff, building organizational capacity, and supporting cross-cutting activities such as task
shifting. PACAM/APCA will train palliative care service providers, and sensitize medical training institutions to include palliative
care in pre-service training for health professionals. Pact/Malawi partners will also train home-based care providers.
ii. Laboratory Capacity Building
In partnership with Howard, USG will continue supporting the expansion and sustainability of MOH in laboratory capacity building,
human capacity building and training, uninterrupted flow of laboratory supplies and reagents, quality assurance/quality control
systems, and service contracts for essential laboratory equipment. Laboratory training will include CD4 and CD4% enumeration,
chemistries, hematology, and diagnosis of common infections including opportunistic infections. The training will aim at building
the capacity of lab staff to provide support for HIV services while maintaining quality standards.
iii. Early Referral and Retention in Care and Support
FY09 funding activities will strengthen referral, feedback and patient tracking systems which will facilitate access to a continuum of
HIV/AIDS prevention, care and treatment services, and reduce loss to follow-up. Proposed activities include mapping existing
services: HCT, PMTCT, ART, food and nutrition, livelihoods, malaria, TB, FP services; developing referral directories, simple
referral, feedback and patient tracking tools to improve clinical care and tracking of HIV-infected persons; and providing
psychosocial and adherence support to pre-ART and ART patients. USG will work with MOH, Lighthouse, Pact, and other
stakeholders to adapt successful referral and patient tracking models in Malawi for phased national scale up, and address
program barriers to retention in care such as transport. PLWHA support groups will play a key role in community patient tracking
efforts, and with support from health care workers they will continue to lead interactive individual and group sessions with PLWHA
on positive prevention, disclosure, nutrition, alcohol, safer sex, FP, and positive living.
iv. Cotrimoxazole Prophylaxis and HBC kits
According to the national policy on the use of CPT, the main indications for CPT for any adult living with HIV include symptomatic
HIV disease [Stages 2, 3 and 4] or a CD4 count of 500/mm3 or less, regardless of symptoms. Thus, all patients eligible for ART
are also eligible for CPT. However regular access to CPT remains a serious challenge, as does stocking and replenishing of HBC
kits. USG support will focus on supply chain management through PEPFAR-funded Deliver and Strengthening Pharmaceutical
Services projects to increase access and coverage of CPT and other commodities, and working with MOH to advocate for
increased awareness of CPT in routine HIV care. USG will also explore revising home-based care kits to a manageable number of
v. Expanded Community Support for HIV Services
USG will partner closely with the National AIDS Commission and MOH to pilot an "expanded community support model" which
complements facility-based HIV services, as well as gender-sensitive community home-based care for bedridden chronically ill
patients with increased adherence and gender sensitive psychosocial support for ambulant ART and pre-ART patients in a few
districts. The key components (5Rs) of the model are to improve Readiness of patients for early and timely initiation to treatment
(ART and cotrimoxazole), support ART and pre-ART patients in adherence and Retention; improve Responsibility of patients
through prevention with positives and positive living; early Referral for ART patients with drug related problems; and Reporting
through simple tools. PEPFAR will support "centers of excellence" such as Lighthouse to mentor other facilities and community
partners and pilot the model in PEPFAR supported programs.
v. Palliative Care
Access to analgesics, especially opioids is a major challenge because of restrictions on opioid prescription by nurses, poor clinical
training in opioid pain management and lack of pain management guidelines. USG will support PACAM/APCA advocacy efforts to
improve access to morphine, and revise current opioid prescription practice to allow nurses prescribe morphine. USG in
collaboration with MOH and PACAM/APCA will also develop opioid guidelines, national M&E guidelines for care and support, and
integrate palliative care into HBC programs.
vi. Basic Care Package
USG will work with MOH to explore developing and standardizing an essential care package for facility and community-based
care. The package is likely to include CD4 counts, cotrimoxazole, TB screening and management, insecticide-treated bed nets
(ITNs), livelihoods, food and nutrition assessment, positive prevention (HCT for family members and other contacts, status
disclosure, FP), pain and symptom management, safe drinking water, personal hygiene and succession planning for children and
families. PEPFAR and PMI will strengthen linkages to the proposed GOM universal access for ITNs that will allow non-pregnant
PLWHA to receive ITNs.
vii. Food and Nutrition
FY09 focus is to strengthen nutrition in care and support interventions through technical assistance from the PEPFAR Nutritionist.
PEPFAR-funded partners will conduct nutrition assessments for PLWHA through facilities and HBC programs to identify and refer
malnourished patients to MOH "food by prescription" programs available at most ART sites. PLWHA support groups and HBC
volunteers will also provide nutrition counseling (and food support from wraparound programs where available), and support
PLWHA and their families to maintain home gardens for improved nutrition. Using FY08 "plus-up" funding, public private
partnerships will be implemented in FY09 with Project Peanut Butter to increase local production of ready-to-use therapeutic foods
to manage malnutrition in PLWHA, and with Land-O-Lakes to provide milk and HIV prevention services to households with
chronically ill patients and vulnerable children.
viii. Monitoring and Reporting for PEPFAR
In Malawi, a person may be counted as a care and support client if HIV-infected (diagnosed or presumed), or HIV-affected, and
provided with at least one clinical and one non-clinical care and support service directly supported by PEPFAR funds at any
service delivery level. This definition strengthens the provision and referral to key clinical care services for HIV-infected individuals
in both facility and community-based settings. These numbers are calculated from routine data accompanied by quarterly
supervision visits and verified in the annual situational analyses. All services are provided through public and private facilities, and
double-counting only pertains to clients who transfer to a different treatment site. The scale-up of the electronic data system with
FY09 funds will better capture this information.
ix. Quality of Care and Support Services
PEPFAR quality activities will focus on improved supportive supervision and feedback to program volunteers, and improved
outcomes for PLWHA through improved retention in care and treatment. PEPFAR will also collaborate with MOH and other
partners to standardize program monitoring indicators and data collection and reporting tools on care and support.
x. Support to the Malawi Defense Force (MDF)
FY09 funding would be used to expand the reach of MDF's HBHC program by procuring motor bikes and motor ambulances for
use by MDF's caregivers; and expand the current program to include home-based testing and other services. PEPFAR funds will
also enhance the clinical skills of military personnel using the training programs at the Infectious Disease Institute in Uganda. In
particular, the Training of Trainers course will be used to allow attendees at IDI to bring their newly gained knowledge back to
other personnel at their military hospitals.
Compact Funding Program Plans
GOM and PEPFAR have discussed a framework under which a new partnership agreement will be developed using FY08 and
FY09 Compact funds. In September 2008, a Concept note was submitted to OGAC, and the country team was given approval to
begin developing a partnership compact with the GOM. Adult Care and Treatment is a priority area under consideration.
Additional USG compact funding would improve access to, and quality of, HIV care and treatment services. In collaboration with
the MOH and other partners, USG will support national efforts to create and improve the quality of services to pre-ART and ART
patients. Specifically, USG and partners will assist in rolling-out a basic palliative care package including quality-assured
immunological staging to identify PLWHA in need of earlier initiation of ART, improve pain management and access to opioids,
strengthening of longitudinal follow-up and referrals, optimizing linkages and integration between PMTCT, TB, and HIV care and
treatment services, and delivering quality laboratory services for patient monitoring. This support will increase the survival of
adults and children as Malawi moves towards reaching the goal of 250,000 people on ART by the end of 2010.
USG proposes a new care and support RFA to expand clinical, prevention, social, spiritual and psychological services for persons
living with and affected by HIV/AIDS, including a pilot of cervical cancer screening and treatment, thus filling an enormous gap in
the care for pre-ART and ART patients. The program will also strengthen national M&E systems and provide opportunities for
operations research on care and support.
USG will support the GOM Community Nutrition and HIV/AIDS Worker Initiative. This is a plan to pilot a new cadre of lower-level
community health workers who will assist in providing care for PLWHA and conducting activities at the community level to improve
nutrition. This activity will require careful application of USG Malawi's sustainability strategy, and may require a cooperative
agreement with the GOM.