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National Scaling up of ARV therapy in Malawi: the past and the future. Simon Makombe HIV Unit Ministry of Health, Malawi. 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

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national scaling up of arv therapy in malawi the past and the future

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

Simon Makombe

HIV Unit

Ministry of Health, Malawi

slide2
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]

durban 2000 xiii world aids conference
DURBAN 2000XIII World AIDS Conference

Countries in sub-Saharan Africa began to think about

antiretroviral therapy (ART)

malawi important steps to art
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
the medicalised model in malawi
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

art plan 2004 2005 main elements for the public sector
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
slide8
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

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)

Drug Procurement
eligibility for art
Eligibility for ART
  • Positive HIV test
  • An understanding of the implications of ART
  • WHO Clinical Stage III or Clinical Stage IV
  • (CD4 counts < threshold where applicable)
slide12
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

monthly follow up of patients
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
slide15
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
2006 2010 the vision
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
challenges
CHALLENGES
  • Human resources
  • Physical infrastructure

(rooms and pharmacies)

  • Drug supplies
  • Adequate finances
  • Ability to continue with national M&E
  • Integrity of the First Line regimen

(drug resistance and long term side effects)

slide21
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
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