Malawi ProTEST Lessons Learned Presented by Rhehab Chimzizi TB/HIV Programme Officer Malawi National TB Control Programme

Main aim of the Malawi ProTEST Project To reduce the burden of dual TB/HIV epidemic in Lilongwe, Malawi

Malawi ProTEST project outputs Increased dialogue,co-operation and coordination between the NTP, NACC and non governmental partners addressing TB/HIV care Increased capacity in key HIV and TB service providers Increased use of VCT services A network of services for people living with HIV/AIDS Increased community involvement in TB and HIV/AIDS care Cost and cost –effectiveness analyses of the interventions

Increased Dialogue and Coordination (output 1) Need for better coordination of TB/HIV activities at district level Regular district TB/HIV coordinating meetings catalyses collaboration Regular TB/HIV meetings require funding for transport, stationery, and preparation and circulation of minutes To achieve better collaboration a coordinating body/person needs to be identified at district level The DHMT should be the entry point for future collaborative TB/HIV activities

What succeeded? Increased collaboration between TB and HIV/AIDS control programme more evident Full-time coordinating personnel Focal coordinating body Key TB/HIV stakeholders keen to participate in district coordinating meetings Regular TB/HIV coordinating monthly meetings with minutes

What were some of problems encountered Restructuring of the NACP No full involvement of the DHMT due to the absence/weak District AIDS Coordinator Three parallel AIDS Coordinating Committee in one district Collaboration doesn’t always come naturally…..

Increased capacity in key HIV and TB service providers (output 2) New organisations established to care for TB and HIV/AIDS require capacity building input Building capacity in these organisations does not necessarily require huge financial input, however considerable investments of time, particularly for strategic planning and supervision is critical

Output 2 continued The district TB/HIV coordinating body is required to recognise the potential of new organisations that need capacity building in- puts Recording and reporting system allows new organisations to monitor their progress Future plans for district TB/HIV activities should consider ways of training district staff in capacity-building of organisations

What succeeded? Flexibility in allocating immediate funds for capacity building (donors and implementers) Capacity developed in the following organisations: LCH HBC group, Lighthouse clinic and NAPHAM As a result of increased capacity technical partners became interested to fund activities in these organisations

Increased use of VCT services (output 3) There is unmet demand for VCT services The provision of “while you wait” HIV test-results using whole blood rapid HIV test kits is attractive to the clients It is feasible for non-laboratory medical/nursing staff to perform HIV testing using whole blood HIV testing kits Whole blood HIV test kits have the potential to facilitate rapid scaling-up of VCT services both in urban and rural areas

Output 3 continued Integrated and stand alone VCT services attract different types of clients, therefore complimentary Regular evaluation of the quality of VCT services results in improvements in the quality of VCT services Evaluation of VCT services can be performed simply using UNAIDS quality evaluation tools, adapted to the local situation VCT counsellors need system of support to deal with the stress of service provision Countries need to established new cadre of VCT counsellors instead of depending on medical and nursing personnel who are already busy with other activities

What succeeded (Output 3) Clients accessing VCT services increased due to: Use of rapid HIV kits Radio advert about VCT services on site clinical care at stand alone VCT centre CPT in TB patients

What succeeded (output 3) Simple quality evaluation improved VCT services Quality evaluation tools used in supervision of VCT services Quality evaluation tools for VCT services helped to facilitate support for counsellors

What failed? Adequate access to VCT services for people living in rural areas Development of VCT IEC materials Sustainable quality control of rapid HIV test kits Sustainable VCT services in mission hospitals and health centres

A network of services for people living with HIV/AIDS (output 4) Referral Networks District service providers keen to collaborate Facilitated by duplicate referral books Involvement of HBC providers encouraged two-way referral of clients between hospital and community Enhanced by data feedback

Output 4 Continued Clinical care of clients accessing VCT services Clients welcome on-site provision of clinical services at a stand alone VCT centre PLWHA welcome access to care at a specialised HIV clinic, and existence of these services may help to de-stigmatise HIV Clinical services for PLWHA at government facilities limited by poor availability of essentials drugs for OIs and palliative care The quality of HBC services can be improved through collaboration with medical services

Output 4 continued Cotrimoxazole preventive therapy (CPT) TB patients are willing to access VCT and CPT, but access to VCT limits CPT in rural areas Side-effects from CPT are rare if TB patients are asked about the allergy to sulpher drugs prior to commencing CPT Significant proportion of TB patients continue take CPT after completing TB treatment

Output 4 continued Isoniazid Preventive therapy (IPT) HIV-positive VCT clients appear to be keen to start IPT after ruling out active TB The proportion clients that complete six months of IPT is low (32%)

Network of services: What failed? No VCT services in the rural for TB patients to access CPT TB/HIV care by traditional Healers not successfully monitored Development of IPT brief pack for individual HIV positive clients

Increased involvement in TB and HIV/AIDS care (output 5) Improving quality of HBC services Frequent meetings and dialogue between different HBC providers are vital to ensure better collaboration Medical support given to HBC patients can be improved by linking community volunteers to community nurses, health centres and HIV/AIDS/palliative care clinics

Output 5 continued Involving the community in TB/HIV/AIDS case-finding, care and prevention HBC volunteers have great potential to increase case-finding for active TB HBC community volunteers may not be acceptable as DOT supporters for many TB patients unless the volunteer has been involved in the diagnosis of active for particular patients

Output 5 continued HBC providers need training to promote VCT Traditional healers and private practitioners have the interest and potential to become involved in TB/HIV diagnosis and care Religious leaders are keen to engage with NTP, and NACP Religious leaders and traditional healers have expressed reservations to promote condom use

Data we would have liked to have collected Condoms distributed for all partners TB treatment outcome for clients screened for TB Contra-indication to CPT identified by VCT counsellors Impact of IEC strategies (leaflets, peer education) Patient concordance with CPT

Key recommendations for scaling-up collaborative TB/HIV activities Both TB and HIV/AIDS programmes to be equally involved in the planning process Entry into the district should be through the DHMT Training, capacity building and supervision should be allocated adequate funds Select districts that have both strong HIV and TB services in the initial stage Activities should be introduced in a phased manner both in scope and time Don’t lose emphasis on prevention (esp ARVs)

Key requirements for national scale-up of TB/HIV activities Government/political commitment Adequate financial and technical assistance Equal involvement of TB and HIV/AIDS programmes in planning TB/HIV activities Establish a TB/HIV working group at national level Establish district TB/HIV coordinating committee Establish a new position of a National TB/HIV Officer/coordinator Involve the DHMT in the planning process Conduct situation of TB/HIV services at district level

Engagement of Directors for NTP and NACC in national scale-up Establishment of National TB/HIV steering committee Establishment of national TB/HIV working group An officer in NTP responsible for HIV and an officer in NACC responsible for TB activities

Acknowledgement All ProTEST Partners in Lilongwe, Malawi The Ministry of Health and Population The Royal Norwegian Government The World Health Organisation (WHO) The London School of Hygiene and Tropical Medicine (LSHTM) The Liverpool School of Tropical Medicine