1. 100,000 people started on ART with very limited human resources. - Experiences from Malawi 14 June 2007 Dr Kelita Kamoto Dr Erik Schouten HIV/AIDS Unit Ministry of Health Malawi

2. HIV & AIDS Unit MOH Malawi Human Resources crisis Principles of ART programme Task shifting Outcomes of ART programme Some issues around ART scale up

3. HIV & AIDS Unit MOH Malawi Malawi 12 million inhabitants GDP US$ 200 930,000 people infected (14% of adult population) 90,000 HIV/AIDS deaths annually Severe HRH crisis Main health care providers:  Ministry of Health and Christian Health Association of Malawi (CHAM)  Small private for profit health sector  International NGOs and research institutions involved in ART

4. HIV & AIDS Unit MOH Malawi Vacancies in MOH and CHAM Posts EHPPosts filled% vacancies Medical Doctors43316263% Clinical Officers1,4051,03326% Nurses8,4403,41660% Medical Assistants1500 49167% Pharmacy technician26913450% Med Lab technician50718264% Health Surv. Assist.11,0004,66458% June 2006

5. HIV & AIDS Unit MOH Malawi Human Resources GoM declared a crisis of human resources; the health sector ‘has collapsed’ (Secretary for Health) Chakrabarti / Piot (February 2004); the health sector human capacity crisis in Malawi is an emergency ‘requiring exceptional measures that might otherwise be dismissed as unsustainable’ HIV is an advocate for Health systems strengthening This lead to 6-year Human Resources Emergency Relief Plan (US$ 273 million)

6. HIV & AIDS Unit MOH Malawi Principles of ART Programme Based on realities (a public health approach): Simple (1 st Line regimen only, one regimen for all, no laboratory monitoring or CD4 count needed, drug supply, short training, intensive quarterly supervision) Standardised (case finding, treatment regimen, reporting and monitoring). All providers following national protocol. Inclusive (all providers involved: mission hospitals, profit and not-for profit private sector) Lower cadres of staff involved (task shifting)

7. HIV & AIDS Unit MOH Malawi Task shifting in Malawi Clinical officers and medical assistants for a long time work as medical doctors. Have specialised in orthopaedic, anaesthesia, psychiatry, dermatology, ophthalmology, etc Nurses run health centres as clinicians apart from normal nursing duties HSAs are microscopists for malaria and TB sputum apart from preventive activities, vaccination and health promotion HSAs involved in HIV testing and counselling Non medical health workers involved in HTC, nutrition clinics, Community Home Based care and follow up patients (incl. adherence)

8. HIV & AIDS Unit MOH Malawi ART health care provider model Medical officers, clinical officers, nurses and medical assistants can prescribe ART Decision to allow nurses to initiate treatment made in June 2007. (Support through Act of parliament, NMCM) In day-to-day practice some tasks are carried out by e.g. clerks (follow up on ART) Research into identification of patients and follow up of ART in stable patients by HSAs Community workers targeting PLWHA to follow up ART to stable patients

9. HIV & AIDS Unit MOH Malawi ART health care provider model (2) All health workers in ART clinics have been trained (one week intensive training, followed by 2 week attachment in well established clinic), passed an exam, certified and registered with the Medical Council The national ART guidelines describe the scope of practice Intensive quarterly supervision of all ART sites

10. HIV & AIDS Unit MOH Malawi National laws or policies that facilitates task shifting Policies and laws exists allowing nurses to prescribe. Regulatory bodies made a positive decision on nurses to initiate ART. We are waiting for approval of volunteers and HSAs to follow up (including re-supply) ART to patients? The laws are silent on ART moving to health centres. In general health centres do not provide complicated interventions (ART seen as such). The law is silent on volunteers handling drugs such as anti- malarials and pain-killers The government at all levels including regulatory bodies have accepted task shifting with the aim of:  Increasing access to health services  To utilise available human resource at nearest community/facility

11. HIV & AIDS Unit MOH Malawi Outcomes ART programme 140 sites (government, mission, private sector) 100,000 people ever started (over 70,000 alive and on treatment) 2006 - 2010 Scale up plans to start treatment for 45,000 people per year (50% of people becoming eligible for ART) Number of people alive on treatment % of adult population on treatment 2006 60,0001% 2010160,0002.5% 2015210,0003.5%

12. HIV & AIDS Unit MOH Malawi Antiretroviral Therapy # Sites# people started # people ever started # Alive and on ART Proportion children starting ART 200231,202 200393,7036,4144,000 2004246,76913,18310,7616% 20058924,67837,84029,0826% 200614146,35185,16859,9809%

13. HIV & AIDS Unit MOH Malawi

15. Equity. Who has access to ART? Research to socio-economic, geographic and demographic determinants of access. Example: Proportion of HIV infected population accessing ART by 31 st December 2006 6 districts had a relative low uptake of ART services: Dedza Mangochi Phalombe Ntcheu Mulanje Machinga

16. HIV & AIDS Unit MOH Malawi HTC - PMTCT - ART

17. HIV & AIDS Unit MOH Malawi Do ART services take away staff from other essential health services? In June 2006:  with 43,390 people alive and on ART (59,851 people ever started)  916 health worker days per week required to run the ART clinics  257 HCW lives saved is equivalent to 1,139 extra staff days in the health sector (presentation on the study in the Implementers Meeting and will be published in Bulleting of WHO)

18. HIV & AIDS Unit MOH Malawi Mortality in 8 private sector companies and Malawi Defence Forces MBCA ART sites. 7/10 provided data Most companies provide data on employees and spouses, one on employees, spouses and other dependents No point in time of start of ART (often senior management first, followed by other staff Number of staff “stable”

19. HIV & AIDS Unit MOH Malawi Mortality in 8 private sector companies 20022003200420052006 ESCOMES4748573334 PortlandESD105202 SOBO/ Carlsberg ES151422166 ADMARCES5664554448 Shire Bus linesES472725 20 UnileverES117724 Water boardES1113999 DwangwaES24814015111799 Total 445318328246222 E = employee; S = spouse; D = dependents

20. HIV & AIDS Unit MOH Malawi Mortality (adjusted) in 8 Companies in Malawi

21. HIV & AIDS Unit MOH Malawi

22. Costs of the ART programme By 2015 costs of ART only will be US$ 40 – 50 million per year. This would increase the health budget by approximately 30%

23. HIV & AIDS Unit MOH Malawi Costs of the ART programme Average costs of ART per person per year Costs of ARVs pppy (see next slide)US$ 148.09 CTX for CPT10.37 Drugs for HIV related diseases10.00 Therapeutic feeding21.35 Costs for training, IEC, M&E, supervision, OR, health education, infrastructure, etc. 24.35 Staff costs per person per year on ART4.80 Other service delivery costs (running costs clinic, laboratory support) 10.00 Average costsUS$ 228.96

24. HIV & AIDS Unit MOH Malawi Average costs of ARVs per person per year Monthly Costs of ARVs (FOB) Costs per year (US$) inclusive of all costs Proportion of people on each regimen 1st line regime (d4T,3TC,NVP) 7.76 130.0895.0% alt 1st line regime I (ZDV,3TC,NVP) 16.43 275.533.0% alt 1st line regime II (d4T,3TC,EFV) 26.50 444.411.0% 2nd line regime (ZDV,3TC,Tenofovir, Lopinavir/Ritonavir) 70.351,179.771.0% Average costs for ARVs per person per year148.09 Average costs of ARVs per person per year Costs of ARVs per person yearCosts of ARVs per person year Costs of CTX for CPT per yearCosts of CTX for CPT per year Costs for drugs for other HIV related diseasesCosts for drugs for other HIV related diseases Costs for Therapeutic Feeding for patients on ART per person on ART per year Costs for Therapeutic Feeding for patients on ART per person on ART per year Costs for training, IEC, M&E, supervision, OR, Health education, infrastructure,etc.Costs for training, IEC, M&E, supervision, OR, Health education, infrastructure,etc. Staff costs per person per year on ARTStaff costs per person per year on ART Other service delivery costs (running costs clinic, laboratory support)Other service delivery costs (running costs clinic, laboratory support) Average costs of ART programme US$ Average costs of ART programme US$

25. HIV & AIDS Unit MOH Malawi Achievements ART programme based on ‘public health principles’ works (4 th highest coverage of ART in SSA). Task shifting is accepted by government and was at the basis of the scale up of ART. Quarterly supervisory and monitoring visits with feedback on quality of services provided (certificate of excellence or letter to improve the service) providing good data on ART scale up. Government and regulatory bodies commitment in enhancing ART programmes.

26. HIV & AIDS Unit MOH Malawi Challenges Demand for training in ART is in excess of supply. ART curriculum in pre-service in the teaching institution does not lead to certification (duplication of training). HSAs is an unregulated cadre. Step to allow non-health workers providing ART services is difficult and can only be made after positive results of research. Financial sustainability of the programme. Equity and access.

27. HIV & AIDS Unit MOH Malawi Thank you