1. Every day. In times of crisis. For our future. Dr. Kechi Achebe, Senior Director HIV/AIDS & TB Integrated Community Case Management - One Opportunity for Integrating HIV/TB: The Malawi Experience

2. Outline CCM Elements, Main Sub Strategies, Program Requirements and Benefits Adaptation considerations Lessons learned from pilot of iCCM for TB/HIV in Malawi 2

3. 3 CCM – What is it?

4. 4 CCM: Elements Priority Elements: Treatment of childhood malaria, pneumonia, and diarrhea by CHW at community level Other Elements: – Malnutrition – Neonatal sepsis – Preventive/promotive: newborn care, PMTCT, etc. according to local need/epidemiology

5. 5 CCM: Main sub strategies Equip and train Ministry of Health staff at clinics to: – Provide standard case management – Support, supply and supervise community health workers. Equip and train community health workers to: – Treat and sometimes refer common, serious, infections. – Manage small drug boxes or “kits”. Train families to: – Recognize and promptly seek treatment for danger signs. – Complete the treatment or accept referral.

6. Benefits of iCCM Increases geographic access for parents and caregivers seeking treatment for sick children Encourages timely care seeking for the diagnosis, treatment and care for three common childhood illnesses (pneumonia, diarrhea and malaria) Reduces inappropriate use of artemisinin combination therapies and antibiotics which maximizes resources and lowers potential for drug resistance Promotes resilient and sustainable community health systems 6

7. 7 Adaptation of iCCM for TB/HIV

8. Adaptation of iCCM September 2013 - Geneva consultation to review draft WHO/UNICEF materials to use by CHWs for newborns and children and the HIV/TB adapted materials became available in 2014 8 CHWs are a vital channel for increasing the access of mothers, children, and women who are pregnant or lactating to HIV- and TB-related interventions Contacts with mothers, pregnant and lactating women, and caregivers of sick children provide the opportunity to provide information and advice on HIV and TB prevention, testing and care

9. Adaptation Considerations Capacity of CHWs Maintaining quality Asking one very clear question: eg. Yes or No: Q. Lives in a household with someone who is on TB treatment? Thus the adaptions does not include: – Community-based counselling or testing – Dispensing HIV care such as cotrimoxazole prophylaxis – Personal counselling on ARV uptake and adherence – Clinical assessments for ARV-related side effects – Dispensing TB prophylaxis 9

10. The Mwayi wa Moyo Project, Blantyre, Malawi: Background Save the Children went into partnership with MOH National consultation workshop with key MOH, DHO, other partners held in February 2015 CCM-HIV/TB integration pilot endorsed Adaptation of Malawi CCM manual conducted based on WHO-UNICEF package Caring for the newborn and child in the community/Sick child Save the Children started implementing pilot in Blantyre District in partnership with DHO in April 2015 10

11. WHO/UNICEF manual: Caring for the Sick Child in the Community Caring for the sick child in the community (2 to 59 months): “The CHW identifies and refers children with danger signs to a health facility; treats pneumonia, diarrhea and fever; identifies and refers children with severe malnutrition, HIV and TB or at risk of HIV & TB; refers children with other problems; advises on home care and prevention of illness.” 11

12. Steps taken ….. 1.Oriented trainers to the adapted manual – March 2015 2.Conducted a pre-test of the manual – March 2015 3.Identification of district facilities to implement this intervention – March 2015 4.Randomized selected facilities into intervention and control arms. (9 control and intervention) – April 2015 5.Trained 51 HSAs in the 2 arms – May 2015 6.Distributed of registers and drugs - June 2015 12

13. Other activities… 1.Trained Senior HSAs in CCM 2.Trained Mentors 3.Trained HSAs and SHSAs in C-Stock 4.Trained AEHOs in supervision 5.Trained Senior HSAs in supervision 6.Conducted Endline assessment to evaluate differences in uptake of HIV/TB services between intervention and control arms after one year 7.MOH evaluated pilot experience for uptake and scale up 13

14. Lessons Learned from Malawi 14 Substantial number of Children at risk for HIV identified Lack of privacy in village clinics prevent disclosure of HIV/TB status Referral between the community and health facilities still remains a challenge (less than 10% identified were referred to the health facilities) HIV/TB indicators are not included in the children’s health passport, so difficult to capture, identify and support children exposed and visa versa