1. Collaborative TB/HIV services
Experience from Malawi
Rhehab Chimzizi
TB/HIV Programme Officer
Malawi National TB Control Programme

2. Malawi One of the poorest countries in Africa
Population of 11.5 million
65% of the population poor
Life expectance at birth dropped from 46 years in 1996 to 39 in 2000

3. HIV/AIDS epidemic in Malawi
The first AIDS case was reported in 1985
One million people estimated to be living with HIV/AIDS
HIV sero-prevalence rate in antenatal mothers was 2% in 1985 and rose to 24% in 1999
15% adult HIV prevalence rate
Leading cause of death in most productive age group (15-49)
81,000 deaths annually
About 500, orphans who either lost one or both parents

4. Malawi government response to HIV/AIDS and TB epidemics
High political committement to fight the dual epidemics
Launch of the National Strategic frame work for HIV/AIDS (1999)
Successful application of funds from GFTAM
Restructuring of the National AIDS Control Programme to the AIDS Commission to initiate a truly multi-sectoral response
Country wide DOTS coverage
The development of the 5 year TB Control Plan and linked to this a 3 year joint TB/HIV plan

5. HIV-TB epidemic in Malawi
HIV epidemic has fueled an equally TB epidemic
TB notifications have risen by a factor of 500% between (5000 to TB cases)
In 2000, the HIV sero-prevalence rate in TB patients was 77%
HIV infection has lead to:
Increased number of patients with difficult to diagnose smear negative TB
Increased case fatality
Increased rate of recurrent TB disease

6. ProTEST initiative in Malawi (1999-2002)
A World Health Organisation (WHO) coordinated initiative meaning PROmotion of HIV TESTing as an entry-point into HIV/TB prevention, care and support

7. Rationale for piloting the ProTEST initiative
In 1998 >90% of Malawians had accurate knowledge about HIV transmission and prevention but no impact in HIV infection rates
Few perceived benefits of knowing ones HIV sero status
In 1998 Antiretroviral drugs were too expensive to be considered in this resource limited setting
AIDS was stigmised and feared illness
Little medical support was offered to PLHA
Historically little collaboration between TB and HIV/AIDS Programmes

8. Goal and purpose of the ProTEST initiative
The initiative piloted in one District.
Lilongwe with a population of:
1.3 million
450,000 urban population
Goal:
To reduce the burden of the TB/HIV epidemic
Purpose:
To establish collaboration between TB and HIV
service providers and build capacity within current
initiatives addressing TB/HIV management in
Lilongwe

9. Malawi ProTEST Outputs
1. Increase dialogue, cooperation and
co-ordination between TB/HIV stakeholders
2. Increase capacity of TB/HIV providers
3. Increased use of VCT services
4. A network of service for People Living With HIV/AIDS
5. Increased community involvement in TB/ HIV/AIDS care
6. Economic evaluation

10. ProTEST Project: Promoting VCT for access to TB/HIV prevention and care
 Uptake of VCT
VCT for HIV
Range of interventions for HIV/TB prevention
and care
 TB and other HIV-related diseases
 HIV
Entry point for access to HIV/TB prevention and care
Slide adapted from STOP TB, WHO Geneva

11. Key successes in achieving the outputs
Increased collaboration between the TB and HIV/AIDS programmes
Almost all ProTEST partners registered increase in capacity
Capacity to provide clinical care to TB and HIV/AIDS patients in the community increased
Rapid HIV testing increased the number of people accessing VCT services ( the pilot district >40000 clients/patients accessed VCT services during the period of the initiative)

12. Key successes continued
Evaluation of quality of VCT services regularly performed
New services introduced and promoted for VCT clients, TB patients and PLHA:
CPT for HIV positive TB patients
TB screening for VCT clients
Sputum collection from the stand alone VCT centre
IPT for HIV positive clients without active TB
Condom promotion and distribution
CHBC volunteers able to identify TB suspects and supervise TB patients taking their anti-TB drugs

13. Key challenges Human resources Malawi still donor dependent
Changing environment in the health sector:
SWAP
EHP
Decentralization

14. Phased implementation of joint TB/HIV services
Lessons learnt from the ProTEST initiative
A 3 year ( ) joint TB/HIV services plan developed, the plan linked to the 5 year NTP development plan
Linkage of the two plans in terms of:
Policy
Technical activities
Management
Monitoring and evaluation
Planned endorsed by the MOHP and WHO
Funding secured from WHO/USAID and the basket donors (NORAD/DFID/KNCV)

15. Objectives outlined in the TB-HIV plan
To provide VCT services for TB patients and the general public
To provide CTP TO HIV positive TB patients
To provide IPT to HIV positive persons without active TB
To provide care for HIV positive TB patients
To prevent Recurrent TB
To intensify case finding for TB
To provide nutritional support to TB patients regardless of HIV status
To provide ARV therapy to HIV positive TB patients

16. Setting the pace
Implementation began in January 2003
Country-wide situation analysis was the first activity

17. Specific Objectives of the situation analysis
To assess the state of HIV/AIDS and joint HIV-TB services delivered on the ground
Inform the TB Programme and HIV/AIDS unit how best to move forward

18. Methods The analysis was conducted from Jan-Mar 2003
Data collected in structured proforma
Visits to all NGO, GOM,mission VCT sites
Visits to all TB registration and treatment facilities with an in-depth focus
Discussions with hospital management on findings and how to move forward

19. KEY FINDINGS on Counselling and HIV TESTING

20. HIV Testing sites in 2002 HIV testing sites = 70
Major MOHP and mission hospitals 44
Smaller mission/rural hospitals 13
Health centres/clinics 9
“stand alone sites” 4
Sites providing counselling only 22

21. Number of those tested for HIV in 2002
Total no. persons tested
Blood Donors (39%)
Pregnant women (PMTCT) 5059 (3%)
VCT/patients (58%)
VCT/patients clients
Hospitals/health centres/clinics 35407
“stand alone VCT sites 51,224

22. Counseling services in the 44 major MOHP and Mission hospitals
Some form of VCT services 44 (100%)
Designated VCT rooms 22 (50%)
Some form of VCT register 31 (70%)
Full time counsellors 13 (30%)
QA of counselling services 7 (16%)

23. Trained HIV/AIDS counsellors
Trained counsellors 456
Part time
(67% HCW and 33% lay people)
Full time
(24% HCW and 76% lay people)

24. Factors associated with increased number of HIV tests
Presence of designated VCT rooms
Presence of full time counsellors
Hospitals allowing laboratory staff and counsellors to perform rapid whole blood HIV testing

25. Recommendation
A clear need for scaling HIV-TB services both in quantity and quality particularly in counselling and HIV testing

26. Activities that have already started or about to start
A package of VCT and CPT began on 1st July in 15 hospitals in 11 districts (11/28)
IPT linked to PMTCT services would begin On 1st October
Nutritional support in TB patients supported by WFP in collaboration with other NGO would begin on 1st October in three districts
A proposal to pilot intensified TB cased finding in one district has been submitted to TB Alert for funding
ARV therapy is being offered to eligible patients that include TB patients in 4 sites by other partners

27. Acknowledgements Ministry of Health and Population
National AIDS Commission
NORAD/DFID/KNCV/USAID
World Health Organisation
London School of Hygiene and Tropical Medicine
Liverpool School of Tropical Medicine
All collaborative partners