Dr Sam Phiri: HIV and AIDS Situation in Malawi

HIV and AIDS Situation in
Malawi: Towards Universal
Access

Dr Sam Phiri
Executive Director
Lighthouse Trust

Global Community Links

Presentation outline

•HIV situation and national
response

•ART program
•The Lighthouse Initiative
•Challenges


HIV and AIDS Situation In Malawi
•Current statistics:
– Population – 13 Million
– 12% HIV prevalence among 15-49 years
– 1.6% HIV Incidence
– 900, 000 people living with HIV/AIDS
•Impact of AIDS:
– About 70,000 adult and child deaths annually
– 700,000 orphans directly related to AIDS
•HIV Prevalence in most at risk populations
– FSW – 70.7% (2006)
– MSM – 21.4% (2009)


HIV Prevalence by Age
19.00%
20.00%
18.00%
17.10% 15.30%
• Content
16.00%
14.00%
13.80%
12.00%
10.00% 12.30%
11.30%
8.00%
6.00% 8.00%
4.00%
2.00%
0.00%

45
Le

15

15

20

25

30

35

40

+
ss

-1

-2

-2

-2

-3

-3

-4
th

9

4

4

9

4

9

4
an
15


HIV Prevalence by Education
20.0%
17.5%
18.0% 15.5%
16.0%
14.9%
• Content
14.0% 16.6%
12.0% 13.9% 14.2%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
-5

-8

-2

-4

ry
e
on

a
1

6

1

3

nd
N

d

d

rm

rm

co
St

St

Fo

Fo

se
st
Po


HIV Prevalence by Marital Status
50.00%
45.00% 42.90%

• Content
40.00%
35.00% 32.60%
30.00%
25.00% 22.60%
20.00% 17.30%
14.80%
13.30%
15.00%
10.00%
5.00%
0.00%
Single Cohabiting Married Divorced Widowed Separated


National HIV Prevalence by
Year
20
18.5
16.9 17
15 15
% Prevalence

13.5

10 Malawi Median

5

0
1998 2001 2003 2005 2007


HIV Prevalence by Locality
30

25 25.3
22.5
20.9 21.1 21.7
20 20.8 20.4
% prevalence

17 17.6 Rural
15 14.5 15 Semi-Urban
13 12.3 Urban
11.2 10.7
10

5

0
1998 2001 2003 2005 2007


Prevalence trends in 15-19 and
15-24 age groups
25

20
19.1
18.3
% Prevalence

15 15.2
14.3 14.3 15 - 19
12.3 15 - 24

10 10.3
9.5

5

0
1998 2003 2005 2007


Malawi National HIV and
AIDS Response
• Prevention and behaviour change
•Treatment, care and support
•Impact mitigation
•Mainstreaming and decentralisation
•Research, monitoring and evaluation
•Resource mobilisation and utilisation
– Main funding from Global Fund and other partners
•Policy and Partnerships


ART Scale Up Plans
(2004-2005) and (2006-2010)
• Phased selection of facilities
•Free ART to HIV-positive eligible patients
•One first-line ART regimen only “Lamivudine +
Stavudine + Nevirapine”
•“Push” system of ART supply to facilities
•Standardized system of monitoring/reporting
•Quarterly structured supervision


Progress in cumulative
patients alive on ART in public and
private sector


National outcomes (cumulative
analysis) March 2011
• Number %
Enrolled to ART 365, 191
Alive on ART 264, 512 72
Dead 42, 549 12
Lost to Follow Up 66, 662 16

Stopped ART 1, 761 <1


Malawi’s response to new WHO
recommendations
•Eligibility
– Stage 3 or 4
– CD4+ cell < 350
– PMTCT Option B+ - All pregnant and lactating HIV
infected women
•Regimen
•Tenofovir + Lamivudine + Efavirenz (TDF – 300 + 3TC 300 + EFV 600)
single FDC
•Challenge
– Round 10 application to Global fund not successful
•Phased approach
– Maintain current regimen except
• New pregnant and lactating women
• New TB/HIV co-infected patients
• First line alternative for severe lipodystrophy


Challenges - Opportunities

•Slow behaviour change response
•Inadequate professional human resource
•Residual social and cultural practices
•Maintaining sustainable financial support
•Balancing HIV agenda with general health
agenda
•Early mortality among patients initiated on
ART


Public Trust Initiative to
complement Government


Lighthouse Strategic Approach
Client-centered care based on 3-prong technical
approach:
•To expand high-quality, integrated HIV and AIDS
prevention, treatment, care and support services
•To promote innovative approaches for HIV
prevention, treatment, care and support through
program development, piloting, evaluation and
dissemination;
•To build and strengthen capacity for HIV and AIDS
treatment, care and support in Malawi.


The Lighthouse Trust
•Centre of Excellence for integrated continuum of
HIV prevention, treatment, care and support
•2 clinics: MPC and Lighthouse
1. HIV Testing and counselling including 31 HC in Lilongwe
2. ART service provision
• 10,000 patient visits/month
• > 15,000 patients alive on ART
• Integrated with TB, FP, STI, and PMTCT
3. Home- and community-based care
4. Capacity building
• National trainers in HTC, ART, palliative care
• Supports MOH in Supervision, mentoring and coaching


HIV Testing and Counseling

(HTC)


HTC Services
Lighthouse urban HTC sites :
– Lighthouse and Martin Preuss Centre clinics
– Kamuzu Central Hospital medical wards, paediatric
wards, antenatal
– STI clinic
– Maula prison
– Chinsapo
Rural health center outreach
 31 rural Lilongwe HTC sites supported for HTC to ANC
mothers
 Increasing links to prevention of mother to child
transmission services


HIV Testing and Counseling


Total HTC client visits
HTC Cummulative Encounters

4500

4000

3500
Clients Tested

3000

2500

2000

1500

1000

500

0
Jan-01

Jul-01

Jan-02

Jul-02

Jan-03

Jul-03

Jan-04

Jul-04

Jan-05

Jul-05

Jan-06

Jul-06

Jan-07

Jul-07

Jan-08

Jul-08

Jan-09

Jul-09

Jan-10

Jul-10

Jan-11

Jul-11
Clients Testing Positive Clients Testing Negative


The Lighthouse Clinic

A Specialist Clinic for
HIV and AIDS


Clinic Registration


Clinical Care
•Free, public HIV/AIDS clinic
– 15,000 on ART by December 2010
– 56% female
– 91% on first line medications
– 9% children under 15 years
•Routine follow-up visits include:
– Regular appointments at intervals of 1, 2, or 3
months
– Diagnosis and treatment of opportunistic infections
– Initiation and maintenance of prophylactic therapy
– Referral to other services especially at KCH


Clinical case review


Lighthouse Trust cumulative
outcomes: Q4, 2010
Number % of ever
enrolled
Ever enrolled in ART 24,590
Alive on ART 14,293 59%
Dead 1,771 7%
Defaulted 3,310 13%
Stopped ART 440 2%
Transferred-out 4,766 19%


Total Clinic Reviews
14,000

New Patients
12,000
Follow-ups

10,000 MPC Opened
Clinic Client Visits

8,000
Limits
Imposed
6,000 Free
Lighthouse Centre ARVs
Opens
4,000

2,000

0
May-05
Nov-01

Nov-08
Apr-01

Aug-03
Jun-02

Jan-03

Mar-04

Sep-07

Apr-08

Aug-10
Dec-05

Jul-06

Jun-09

Jan-10

Mar-11
Feb-07
Oct-04


Electronic Data Management
•Lighthouse and MPC implemented a real-time electronic
data system (EDS) in 2005
•Collection of patient level information on all ART patients
– Registration, vitals, nurse visits, clinical care, and
dispensing records
•Uses touch screen technology
•Label scanners and printers facilitate easier monitoring
and supervision for blood samples and drug dispensing.
•Near completeness of patient level data from 2006
onward.
•All patient EDS data is accessed through an Access
database for effective monitoring and evaluation


The Lighthouse
Community Home Based Care

Quality Care at Home
for the Chronically Sick
in Lilongwe City


Home based care (HBC) program
•Leader in promotion of Palliative Care
– End of life care for terminal and dying patients
•Works through existing community groups to encourage ownership
and sustainability
•Patients identified through:
– Lighthouse or MPC referral
– Community volunteers
– Local hospitals
•Dedicated, well-trained community nurses provide quality care
– 150 patients, on average, per month
– Patients receive 2 nurse visits/week for medication and follow-up
– Patients receive visits from community volunteers for psycho-social
support


Community Home Based Care


Clients Registered

1000
2000
3000
4000
5000
6000
7000

0
Nov-05

Feb-06

May-06

Aug-06

Nov-06

Feb-07

HBC
May-07

CV
Aug-07

LH
Nov-07

Feb-08

May-08

Aug-08
LHMPC (Bottom)
HC

Nov-08
uptake
Ndife Amodzi

Feb-09
Other

May-09

Aug-09

Nov-09

Feb-10

May-10

Aug-10

Nov-10

Feb-11

May-11
Total Ndife Amodzi client

Capacity Building Role
•MoH certified Training Courses:
– ART, HTC, and palliative care
– Over 1,000 clinicians and nurses trained in
ART provision
•Provides clinical attachment for ART & HTC
•National supervision teams for HTC and ART
•Mentoring for new ART/HTC sites
•Leader in national policy development and
piloting


Challenges…


Space challenges in clinic reception


Lighthouse challenges
•Balancing service quality with overwhelming demand

•Balancing service delivery with capacity building

•Balancing service delivery with operational research

•Maintaining high community volunteer retention

•Financial support for human resource


A cross section of the Lighthouse Team


•


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