The program is designed to accomplish the highest standard of health and well-being in Malawi by pursuing 3 objectives:

a. Reducing new HIV infections; b. Improving treatment, care and support for people with HIV/AIDS; and, c. strengthening health systems.

Implementation will be in the South-East Health Zone districts of Balaka, Machinga, Mangochi, Mulanje, Phalombe and Zomba; combined population of greater than 3.1 million people.

Beneficiaries fall into 3 categories:

a. Front-line healthcare workers

b. Health systems supervisors and managers

c. The population of the South-East Health Zone

The program is designed to build sustainable, locally owned capacity and increased autonomy during a finite time-span. Services are delivered through the existing system, rather than building a parallel system. The program has been planned through consultation with MOH officials at all levels. This has made it possible for partners to incorporate innovations, while remaining consistent with goals/implementation plans developed under the Malawi National Action Framework.

Dignitas will conduct routine, integrated M&E to assess program impact on health outcomes and cost-effectiveness. The capacity of the ZHO, DHOs and health facilities will be bolstered in data collection and analysis for decision making. There will be evaluations at key points in the intervention cycle: baseline assessment including health-service gaps and training needs assessment of District Health Supervisors; mid-term audit of Supervisor support program; annual audits of clinical programs; and, an end-of-term evaluation compiling lessons learned and intervention outcomes.

B. Budget Code: HBHC: Adult care and Support

Activity One: Adult Care and Treatment at Tisungane Clinic & HRH: Dignitas will continue to manage Tisungane ART Clinic at ZCH (with targets of 33,900 Pre-ART patients by end of FY 2012/39,900 by end 2013, and 23,500 ART patients by end of FY 2012/29,500 by end of 2013). Activities include the management of a Healthcare Worker Clinic and the training and management of Expert Patients (in-service training and mentorship of 28 by end of FY 2012). Outreach for new clients is done by training staff to conduct education and community sensitizations. Patient retention is supported by defaulter tracing. Referrals between sites, including specialist HIV consultation services, are managed by the development of a district wide referral system (see Budget Code -OHSS). Program M&E includes quality improvement initiatives in addition to collection and analysis of routine programmatic data. These activities also support research studies that will help to answer important clinical and programmatic knowledge gaps, such as optimal timing of ART in TB-HIV co-infection and the incidence of ART toxicity and side effects.

Activity Two: Building Healthcare Worker Capacity Through Innovative Clinical Tools and Training: Scaling-Up of STAT-PALM+ to the Zone In Zomba District, with support from the Canadian International Development Agency (CIDA), Dignitas is presently undertaking a project to facilitate the integration of HIV/AIDS and TB care with primary care through activities that build sustainable capacity in the district health system. The project is an innovative in-service training curriculum for healthcare workers that focuses on a set of integrated symptom- and sign-based primary care guidelines. In South Africa, this combination has been shown to promote higher-quality evidence-based practice, expand access to care, reduce misdiagnoses/inappropriate treatments, and enhance staff satisfaction/confidence. The scale-up is not anticipated to commence until the final quarter of FY 2012. Therefore, deliverables during the period FY 2012 are coordination meetings with DHOs and DHMTs (3 by end of FY 2012), reproduction of training materials, and training of 12 Trainers.

D. Budget Code: HVTB care: TB/HIV

Activity One: Integration of TB/HIV Dignitas will facilitate the integration of TB/HIV screening and care at each district hospital, and will continue to staff and manage an integrated TB/HIV clinic at Zomba Central Hospital. TB/HIV integration will also be incorporated into other trainings and meetings. These activities support the MoH and partner organizations in achieving the goals of the national TB strategy, and the integration focus supports sustainability of the program over time. TB/HIV clinical outcomes will be integrated in the electronic database to facilitate high quality data for review, reporting and tracking progress. Integration of TB/HIV at each district hospital in the zone will also include a contribution to site refurbishment (3 by end of FY 2012 and 1 by mid-2013).

Key Issues include Health-Related activities (Child Survival Activities; Safe Motherhood; TB); Gender (increasing womens legal rights and protection; increasing gender equity in HIV/AIDS activities and services; addressing male norms and behaviors; increasing womens access to income and productive resources); and Workplace Programs.

G. Budget Code: PDCS Care: Pediatric care and Support

Activity One: Early Diagnosis and Treatment of Pediatric HIV Infection: Pediatric ART and Supporting HIV+ Adolescents Due to its rapid progression, it is imperative to follow-up on HIV exposed infants, promptly diagnose HIV infection, and quickly initiate appropriate treatment. Dignitas will support the MOH Early Infant Diagnosis (EID) and Pediatric ART programs through supportive supervision and mentorship activities. The EID programs main focus is to strengthen laboratory support/diagnostics for pediatric clients. This will include development of logistics plans to transport DBS samples for DNA PCR testing, assessment of HC and hospital needs, and development /implementation support of the zonal scale-up of PCR testing.

A Teen Club for HIV+ adolescents will empower them to build positive relationships, improve their self-esteem and acquire life skills through peer mentorship, adult role-modeling and structured activities (to reach 360 adolescents by end of FY 2012 and 500 by end 2013). In ZCH, adolescents will be provided Pre-ART and ART services along with peer education and support for transition to adult HIV care.

Provision of ongoing mentorship in pediatric ART at decentralized ART sites in the zone (15 by end of FY 2012 and 20 by end of 2013) will strengthen available services.

Activity Two: Child Care and Treatment at Tisungane Clinic & HRH Refer to Budget Code HBHC: Adult Care and Support and Budget Code HTXS Treatment: Adult Treatment for an overview of the activity and deliverables.

Clinical care for HIV+ child patients not yet qualifying for ART will be provided (5,800 by end of FY 2012; 6,790 by end 2013), as well as care of ART patients (4,000 by end of FY 2012; 5,015 by end of 2013). By end of FY 2012 900 patients will receive registration, counseling and initiation of beginning ART, and another 900 by end of 2013.

Activity Three: Support for ART Decentralization- Refer to Budget Code HTXS Treatment: Adult Treatment for an overview of the activity and deliverables, which focus on training, supervision, improving quality of care and strengthening health services.

Budget Code: HLAB Laboratory Services

Activity One: Lab Capacity At ZCH, a Dignitas Lab Technician will continue to provide lab services, mentorship for quality assurance, and training in CD4 testing. A senior Dignitas Lab Technician will serve as Lab Services Coordinator, and will provide mentorship and training to lab staff in other facilities across the zone. The team will work to establish efficient and effective workflows governing daily and weekly laboratory procedures, managing incoming orders, managing incoming and outgoing data. Stock management, including record-keeping and forecasting, procurement of supplies, and timely communication with colleagues regarding stock-outs, will be improved. Protocols for on-site and decentralized testing, especially CD4, DNA PCR, and hemoglobin, will be established and followed. CD4 testing for Pre-ART patients, HIV-exposed infants over 12 months, and monitoring of patients on ART cohort will be scaled up. Other efforts will focus on improving quality and efficiency of laboratory services in general.

Activity Two: Access To and Uptake of Lab Services In addition to PMTCT clients, increased availability and uptake of CD4 testing will facilitate monitoring of the pre-ART cohort to ensure timely initiation of ART, and may enable earlier diagnosis of treatment failure among the ART cohort. In order to ensure sustainable, accredited laboratory services, the program prioritizes technical assistance to optimize the quality and throughput of service in existing MOH facilities.

I. Budget Code: HVSI Strategic Information

Activity One: Strengthening Supervision and M&E Capacity Health systems M&E in the South-East Zone is rudimentary and hampered by gaps and overlaps in reporting. This is an urgent action area, given the rapid decentralization of ART care to rural health centers and the need to monitor clinical outcomes. Dignitas will support national capacity building to collect, manage, analyze and use data, and support broader M&E initiatives. A key start to these activities will be the collaborative development of functional district and zonal supervisory structures and processes with regard to supervision of service delivery, the referral system, and M&E. This will include assessments to determine the needs of supervisors, and a subsequent assessment and revision of supervisory tools, curriculum and training. Specific training of HSA supervisors through outreach training mechanisms and the development of appropriate structures and tools will also be a focus. Supportive supervision/quality assurance will include : on-the-job training for Supervisors; monthly and quarterly reviews of ART, TB/HIV, HTC, and PMTCT data collected at health centers; quarterly mentorship of District ART, TB, HTC, PMTCT, and HBC Supervisors to promote appropriate supervision of service delivery, and collection of M&E data; routine supervisors meetings to exchange lessons learned, best practices, and challenges, and to share /interpret data; and a collaborative mentorship project that will conduct program quality control audits, discuss results at dissemination meetings and incorporate lessons learned into district and zonal implementation planning process.

Activity Two: Health Management Information Systems (HMIS) Specific activities include the adoption of unique patient identifiers, the incorporation of patient-level TB, HTC and PMTCT data in the Tisungane database, and the implementation of an electronic medical records system, facilitating integration of non-ART and ART data (i.e. Activity One above). Baobab electronic medical records system will be adopted at Tisungane Clinic and 2 additional site in Zomba, with planned roll-out to district hospitals across the zone.

J. Budget Code: OHSS Health Systems Strengthening

Activity One: Strengthening Systems for Referral, Patient Tracking, and Follow-up With other stake holders, Dignitas initiated the development of a referral system for Zomba District. A series of tools and processes was developed to strengthen links between communities and health facilities, to empower healthcare providers to make appropriate referrals, to close incomplete referral feedback loops, and to rapidly identify and trace ART defaulters/pre-ART patients/HIV-exposed infants lost to follow-up. Key activities include quarterly task force meetings, the roll-out of the referral system in Zomba district, an analysis of patient tracking in Zomba with development of the tracking system , engagement with Community Health Centre Committees, and quality assurance. These activities will be disseminated to the remaining 5 districts in SEZ, and followed up with an audit to quantify and qualify the performance of the system.

Activity Two: Improved Pharmacy Management Dignitas Pharmacy Coordinator will provide mentorship to district and health center pharmacies. Involvement in the districts will improve existing deficiencies in supply management and utilization of stocks. The key activity of supportive supervision will include: management of supplies of ARVs, drugs for the treatment of opportunistic infections, and HIV test kits; establishment of effective protocols and tools to facilitate communication; ART sites accurate projection of stock needs, timely procurement, and adherence to MOH safeguarding protocols.

Activity Three: Strengthening Coordination In all districts, Dignitas will seek to improve coordination among stakeholders in the short-term, and build the capacity of health systems managers to accomplish this goal in the future. The key activity is supportive supervision to ZHO and DHOs, including development of the HIV-related program components for the yearly District Implementation Plans (DIPs). Semi-annual meetings with ZHO and DHOs will review implementation progress and support planning for the coming months, and quarterly reviews of progress and challenges with ZHO and DHMT staff on a quarterly basis will complement these meetings.

E. Budget Code: HVCT Care: Counseling and Testing

Activity One: Counseling and Testing Basic HTC services are well developed in Zomba District. In the five other districts in the Zone, Dignitas will assist DHOs in completing the scale-up of basic HTC services (20 sites by end of FY 2012 and 15 sites by mid FY 2013). The national quality assurance program will be included in these efforts. Additional activities include training, assessment, provision of non-medical supplies, sensitization to reach target population and the establishment of protocols. HTC services use the national algorithms and include client-initiated and provider-initiated testing, as well as couples testing, pediatric testing, and involvement in local and national Know Your Status campaigns. Initial training of HTC counselors will reach 50 by end of FY 2012. Refresher training of counselors will reach 30 by end of FY 2012 and 70 by mid 2013, the latter of whom will receive training in pediatric HTC and/ or couples counseling. Care providers will be sensitized to the need for PITC, and provided with the knowledge necessary to implement it and to make appropriate referrals. 1,000 IEC materials will be provided for 8 HTC sites running youth friendly health services. Protocols to identify and track infants in need of HIV testing will be established. Non-medical supplies will be provided.

Regular M&E is conducted to national standards, and annual operational audits are planned. Assessment to determine the need for additional mentorship and/or supportive supervision in coordination and clinical practice will be included in this. HTC supervisors meetings for 72 supervisors will be held quarterly. Linkages to care, treatment and prevention services will be supported through development of a referral system (see Budget Code -OHSS).

A. Budget Code: MTCT Prevention: PMTCT

Activity One: Improved Early Uptake of ANC and HTC Services In order to provide the most effective PMTCT care, women need to be tested for HIV prior to 14 weeks gestation, requiring early access to services. Facilities will offer a male friendly environment facilitating couples counseling and testing. Mother-baby pair follow-up and support mechanisms will be facilitated using Mother to Mother support groups. Expert patient programs will facilitate the retention of HIV positive pregnant women and their new born babies. Deliverables will include: scaling-Up HTC services in the Zone (20 sites by end of FY 2012 and 15 sites by mid FY 2013); mobilization of HTC, PMTCT and ART providers to promote HTC/ Early ANC to their clients and to test them directly (580 by end of FY 2012); community sensitization sessions (15 by end of FY 2012 and 15 by end 2013); production and dissemination of service maps and directories (6 by end of FY 2012); and, establishment of quality assurance processes to track whether ANC attendees have been tested for HIV, and to follow-up with those not tested.

Activity Two: Improved Access to PMTCT care & Perinatal HTC PMTCT providers will be supported and trained to prescribe and manage Option B-plus with the new single dose regimen for HIV positive pregnant women and their HIV exposed infants.

Deliverables will include: provision of clinical care and support for HIV positive pregnant women on ART (3,000 by end of FY 2012 and 3,145 by end 2013); clinical care and support for ART patients (33,900 by end of FY 2012 and 39,900 by end 2013); initial training for PMTCT providers (20 by end of FY 2012 and 20 by 2013) and refresher trainings (60 by end of FY 2012 and 30 by end of 2013); CD4 Testing (20 facilities by end of FY 2012 and 15 by end 2013); mobilization of PMTCT providers to practice PITC in the perinatal period (240 by end of FY 2012 and 180 by end 2013); targeted support/integrated supervision/intensive mentorship visits to PMTCT providers (240 by end of FY 2012 and 180 by end 2013); implementation of semi-annual meetings of PMTCT providers (2 by end of FY 2012 and 2 by end 2013); and, provision of ongoing quarterly mentorship and support.

C. Budget Code: HXTS Treatment: Adult treatment

Activity One: Adult Care and Treatment at Tisungane Clinic: Refer to Budget Code HBHC: Adult care and Support for an overview of the activity: Activities include PEP (100 by end of FY 2012; 150 by end 2013); registration, counseling and initiation of patients (6,000 by end of FY 2012; 6,000 by end 2013); and procurement of non-medical supplies. Clinical outcomes are tracked and evaluated monthly through an electronic data base. Adherence to ART is monitored through self-report at each clinic visit and adherence counseling is a component of each clinical interaction. Loss to follow-up patients will be traced by HSAs. Along with supportive supervision and intensive mentorship schedules, HCW will be provided in-service/refresher trainings to develop their skills and knowledge.

Activity Two: Support for ART Decentralization: To expand equitable access to care, it is vital to enable local health centers to provide basic ART-related services. Through training, mentorship, community sensitization and supportive supervision, Dignitas will support the DHOs to provide these services. Quarterly meetings of ART providers in Zomba District will provide a forum for information exchange. All Health Centres will receive supportive supervision for HIV-related services during quarterly visits, including ART/OI clinical management, PMTCT, HTC, data management (including use of the pre-ART register), management of drugs and supplies, and TB/HIV integration.

Activity Three: Increased Access to Early Maternal HAART Women testing HIV+ can radically reduce the chances of passing on HIV to their babies by using Option B-Plus. For further follow up of pregnant women, activities will ensure access to CD4 testing (13 sites by end of FY 2012; 20 sites by end of 2013). District laboratory staff will be mentored, as well as designated lab supervisors from the DHO, to ensure the quality of CD4 testing (including semi-annual supervision visits to test sites).

Activity Four: Building Healthcare Worker Capacity through Innovative Clinical Tools and Training: Scaling-Up of STAT-PALM+ to the Zone: refer to Budget Code: MTCT prevention: PMTCT for an overview of the activity and deliverables.

F. Budget Code: PDTX Treatment: Pediatric Treatment

Activity One: Child care and treatment at Tisungane Clinic- Refer to Budget Code HBHC: Adult care and support and Budget Code HTXS Treatment: Adult Treatment for an overview of the activity and deliverables, with focus on the provision of PEP and the procurement of non-medical supplies. Dignitas will contribute to the scale-up and increasing enrollment of HIV positive children into ART care with provision of treatment and prevention of OIs and HIV/AIDS related complications. Health care providers will be trained and mentored to be well-equipped in managing HIV positive children. Monitoring and evaluation of pediatric programs will be conducted to improve quality of service provided at health facilities with pediatric ART service provision. In ZCH, adolescents will be provided Pre-ART and ART services along with peer education and facilitation of adolescents transitioning into adult HIV care. The capacity of health facilities to provide Early Infant Diagnosis will be improved through scaling up of Provider initiated HIV testing and counseling. Provision of DBS transportation to laboratory sites that perform DBS and facilitation of transportation of CD4 samples for pre-ART and ART children will improve care. In order to improve the long-term outcome of children on ART, continuous counseling on adherence to treatment will be provided along with defaulter tracing using HSAs in the health facilities. A nutritional assessment tool will be utilized in order to link children who need nutritional support using routine anthropometric measurements and referral to Nutrition Supplementation Unit. Procurement of pediatric drugs and nutritional support are provided through national mechanisms.

Activity Two: Support for ART Decentralization- Refer to Budget Code HTXS Treatment: Adult Treatment for an overview of the activity and deliverables, which focus on training, supervision, improving quality of care and strengthening health services. Decentralization of ART services promotes integration with routine pediatric care and maternal health services.