1. A brief overview of ART services at QECH, Malawi Kudzala Aub. MMEDsc. Student Sr. Lead ART Clinician/ HIV Medicine Registrar

2. Outline Current Challenges Genetic Barriers of Regimens Rationale for the clinical decision

3. Challenges Drug shortage problems Especially 3TC, NVP Laboratory back up

4. Challenges Quantity versus Quality Demand versus Supply Shortage of health care personnel Toxicity of the 1st line regime

5. Lancet 2000 - expensive - complicated - logistics - adherence

6. 2000 1 clinician 25 patients Fee-paying

7. Malawi ART clinics 2002

8. TM&IH 2005 - Many lost to follow up - ATN - Poor adherence Personal finance Drug shortage

9. 2004 ART SCALE UP PROGRAMME HIV Unit Ministry of Health Global fund to fight AIDS-TB- Malaria National ART Guidelines Training of > 2000 clinicians and nurses

10. 2004 ART SCALE UP PROGRAMME HIV Unit Ministry of Health Establishments of ART clinics within the existing HCS

11. PUBLIC HEALTH APPROACH TO ART Large number of ART in RLS Standardized than individualized Simplified monitoring of treatment Predominant use of Clinical Officers and Nurses

12. PUBLIC HEALTH APPROACH TO ART ART to be free of charge Follow experiences of the national TB programme Standardised monitoring and reporting

13. PUBLIC HEALTH APPROACH TO ART Quarterly supervision Strong drug logistics Harries et al - BMJ 2004

14. Cost of ARV drugs Netherlands: Truvada® Stocrin® USD 10,000 / year Malawi: Triomune 30® USD 100 / year

15. Malawi ART clinics 2008 2002 2010 5 377

16. 270,000 patients started ART 9% children 60% females 93% on the same first line regimen 5% on alternative first line regimen <1% on second line regimen

19. Major Changes to the National ART Programme in 2011 PMTCT, Paediatric, Adult ART integration Strategic phasing out of Stavudine CD4 threshold increase

20. CHALLENGES Quantity versus Quality Demand versus Supply Shortage of health care personnel Toxicity of the first line regime

21. CHALLENGES Early ART mortality ART failure ART delivery Infrastructure Limited Laboratory Back up

22. DRUG SUPPLY CONTINUES Possible reasons for the Drug Shortage? Increased # of clients on non standard regime. Inadequate financing or under- budgeting. Inefficiencies in supply and distribution chain.

23. SELECTED POINT EXAMPLES OF DRUG SUPPLY Drug shortage is the main problem June 2010 3TC = 0, NVP = 117 August 2010 3TC = 0, NVP = 0 Sept. 2010 3TC = 55, NVP = 100

24. Conclusion

25. Malawi ART Scale up Programme Successful under difficult circumstances using public health approach Large number of patients on ART Favourable outcomes Many challenges Current Challenges

26. Acknowledgements Joep van Oosterhout, M.D., PhD, Associate Professor of Internal Medicine, University of Malawi, College of Medicine

27. Acknowledgements James Blessings Mwambene, Dip.Clin.Med, PGD(Mgt studies), The ART Outreach Coordinator, Queen Elizabeth Central Hospital, Malawi

28. Acknowledgements Cooper Nyirenda, M.D.,MMED, FRCP, Chief Govt. Physician, Queen Elizabeth Central Hospital