1. Monitoring of Antiretroviral therapy (ART)delivery by Regional Tuberculosis Officers (RTO) in Malawi: Rhehab Chimzizi Anthony Harries Edwin Libamba Maxwell Gondwe Felix Salaniponi 4th Global TB-HIV WG Meeting

2. HIV/AIDS in Malawi: 2003 900,000 people infected with HIV
14% of those aged years HIV+ve
>85,000 deaths per annum
170,000 people estimated to need ART
In 2003, only 3,700 patients in 9 sites in the public health sector in Malawi started ART

3. National ARV scale up 2004-2005: main elements
Free ART to be provided in 56 public health facilities
ART offered is first line regimen for adults
ARV drugs to be provided to the health facility if formally assessed as ready
36,000 eligible patients to start on ART during the first 12 months

4. Rationale for National scale up
The moral imperative: AIDS kills >85000 people per year
Geographical equity
Support for WHO “3 by 5” initiative

5. Malawi’s first line ARV regimen
Stavudine/Lamivudine/Nevirapine
d4T/3TC/NVP
Given as fixed dose combination, one tablet twice a day

6. Progress with ART scale up
Date Sites providing ART Number started ART
Jan
Jan
Jul
Sep

7. Tools for monitoring and evaluation of ART delivery
The following tools have been Developed for
use at each health facility:
ARV patient master card
ARV register
ARV identity card
ARV cohort analysis forms

8. Patients standardized monthly outcome
Alive (A)
Dead (D)
Defaulted (DF)
Stopped (STOP)
Transfer out (T)
Each outcome is defined on the master card

13. Problems with national collection of ART data
No HIV/AIDS system for regular quarterly collection of data
HMIS using electronic communication either do not function or data sent after long delays
Therefore
consider using NTP quarterly monitoring and evaluation system

14. NTP monitoring and evaluation system
Malawi has three regions
2-3 regional TB officers per region
RTOs visit all TB treatment facilities once in every quarter
Data collated at regional level from district facilities
Data collated at national level from the regions

15. Piggy-backing HIV/AIDS data on to quarterly collection of TB data
Steps in agreeing how this should be done
NTP agreement about feasibility
Joint TB-HIV agreement on cost sharing
Training of NTP (CU and RTO staff) on ARV delivery system
Development of structured data collection form ( VCT, blood donor, PMTCT, TB-HIV, ARV)

16. First ARV quarterly monitoring activity by NTP: Sites delivering ART Apr-Jun 04
RTOs visited the 11 sites delivering ART between July and August using the structured data collection tool
Data collated, aggregated and analyzed between NTP and HIV unit in September

17. Cumulative analysis of all patients started on ART in 11 sites up to June 30, 2004
Number of patients started on ART up to Jun 2004
Number of patients started on HAART who are:-
Alive
Dead DF
Stopped TO
5558
4191
(75%)
446
(8%)
805
(14%) 46
(1%) 70
(2%)

18. High default rate: reasons
One institution (2114 patients) was charging patients 25US$ per month, patients stopped because of expense. From July 04 ART now free in this institution
Another institution (1693 patients) had missing data, which was recorded as “default”

19. On going monitoring and evaluation
For all sites delivering ART between July-Sept 2004
As of 18th September 2004, the sites number 21 in the public sector
RTOs to visit the sites between October and November, with Data collation and analysis to be done in December

20. Benefits and risks to NTP
Real collaboration between TB and HIV in terms of activities and financial costs
Helps to ensure that HIV-TB patients access ART
Risks
Overburden an already stretched TB service
Shift of interest from TB control to ART
DOTS core activities compromised

21. Acknowledgements Ministry of Health National AIDS Commission
Word Health Organization
GFATM and other donors, particularly DFID, NORAD, KNCV, USAID)