National Scaling up of ARV therapy in Malawi: the past and the future

1
National Scaling up of ARV therapy in Malawithe
past and the future

• Simon Makombe
• HIV Unit
• Ministry of Health, Malawi

2
Malawi

• 11.5 million people GNP 200 per capita
• 900,000 people infected with HIV
• 170,000 people needing ART
• 4,000 people on ART in January 2004
• 9 sites no standardised systems

3
DURBAN 2000XIII World AIDS Conference

• Countries in sub-Saharan Africa began to think
  about
• antiretroviral therapy (ART)

4
Malawi important steps to ART

• Dec 2000 Vice-president AIDS conference
• Aug 2001 DOTS-system for ART Lancet 2001
• Jul 2002 Global fund submission
• Oct 2003 National ARV Guidelines
• Feb 2004 National ART Scale-up Plan

5
The medicalised model in Malawi

• Doctors to deliver ARV treatment
• Choice of multiple ARV regimens
• Mandatory laboratory monitoring
• LFTs, FBC, CD4-counts
• Computers to track patient follow-up

will preclude rapid and massive scale up
6
The Key is Keep it standardised and simple
7
ART Plan (2004-2005) main elements for the
public sector

• 60 facilities selected for rapid phased scale up
• Free ART to HIV-positive eligible patients
• One first-line ART regimen only Triomune
• Push system of ART supply to facilities
• Standardized system of monitoring/reporting
• Quarterly structured supervision

8
The Process of Scale-Up
Hospitals briefed and asked to submit
applications to be ART sites
Intensive training schedule focused on ART
Guidelines
Hospitals formally accredited for ART
ARV drugs distributed and ART delivered to
patients
9
Drug Procurement

• Site Classification
• Low Burden
• - 25 new pts/month
• Medium Burden
• -50 new pts/month
• High Burden
• -150 new pts/month

• Starter/ Continuation Kits
• Starter Kit first 2 weeks supply
• of drugs for 75 new patients
• (Triomune and Lamivir)
• Continuation Kit 1 month supply
• of drugs for 75 patients for 3
• continuous months (Triomune)

10
ART administration to patients
11
Eligibility for ART

• Positive HIV test
• An understanding of the implications of ART
• WHO Clinical Stage III or Clinical Stage IV
• (CD4 counts lt threshold where applicable)

12
HIV-positive
same day
Staged clinically as eligible for ART with no
contraindications
within one week
Attendance at group counselling session
one week
Attendance for individual counselling and start
of ART
13
Monthly Follow-up of Patients

• Nurse led clinic clinician review 3-monthly
  unless there is an earlier need
• Patients weighed and screened with symptom-based
  enquiry
• Patient master card completed
• ARV drugs dispensed from clinic

14
REGISTRATION AND MONITORING AT FACILITIES
15
Standardised monitoring toolsborrowed from TB
model

• ARV Patient Treatment Master card
• ARV Identity card for the patients
• ARV Patient Register
• ARV Drug Register
• ARV Quarterly Cohort Analysis forms
• ARV Supervision and Monitoring forms

16
National Data Collection and Supervision
Quarterly Site Visits
17
Progress in the Public Sector
18
2006 - 2010 THE VISION

• 5 year ART plan, which includes a 2 year detailed
  rolling budgeted plan (47 million)
• Goal 50 Universal access, ie 45,000 new
  patients on ART per year

19
The Goal
20
CHALLENGES

• Human resources
• Physical infrastructure
• (rooms and pharmacies)
• Drug supplies
• Adequate finances
• Ability to continue with national ME
• Integrity of the First Line regimen
• (drug resistance and long term side effects)

21
The Key will be maintaining simplicity

• ? Simplify the registration / monitoring system
• Reduce patient visits to 2- or 3-monthly
• Decentralise to health centres
• Allow a lower cadre to manage ART delivery
• Maintain quarterly visits