1. Antiretroviral treatment programme in Thyolo district, Malawi Southern Region. MSF Luxembourg & Thyolo District Health Services - Strategic information used for preparation - Monitoring & Evaluation - Challenges to overcome Dr. Roger Teck – July 1st, 2003

2. HIV/AIDS in Thyolo District Mainly rural population: 475,000 people Prevalence level of HIV infection among pregnant mothers: around 21% People living wih HIV/AIDS: about 50,000 People with AIDS: 5,000 – 10,000 ?

3. HIV Continuum of Care in Thyolo district (June, 2003) 7 VCT sites and one PMTCT site: - 1,300 – 1,500 tested monthly - 35 – 40 % test HIV + Close to 2,300 a-symptomatic and symptomatic HIV+ patients supported through HBC and health centres. Access for TB patients (1,200 per year) to VCT (> 90 % uptake, > 70 % HIV+) and CTX prophylaxis. 1,700 symptomatic HIV + patients registered at district hospital based HIV/AIDS clinic

4. Strategic information (1) Institutional back-up Perspectives for sustainable financing - Through MSF - Global Fund - Other mechanisms

5. Strategic information (2) Policy environment allowing importation of generic ARV medicines Elaboration of draft Malawi ART guidelines - Organisational framework - Objectives & targets (Global Fund proposal) - Input and output indicators - Eligibility criteria. - First line treatment regimens - Clinical guidance for drug toxicity & treatment failure - Monitoring & evaluation framework

6. Strategic information (3) Estimates on the burden of HIV infection and AIDS Assessment of health facilities - District hospital and 9 health centres - Missionary hospital and 8 health centres Community - Perception of HIV/AIDS and HIV/AIDS/TB services - Expectations on ART treatment.

7. Main target and strategies for “scaling up” of the ART programme Over five years period: access to HAART for at least 50 % of people with AIDS Simplified clinical protocol Fixed drug combination With national staff Screening & preparation in HBC and PMTCT population Two HIV/ART clinics (two hospitals) Decentralisation through health centres Adherence follow-up through guardians and HBC

8. Organisational plan for HIV/ART clinic Infrastructure and staffing for the HIV/AIDS clinic to manage “in addition” a maximum of 700 patients during first 6 months of treatment: - One receptionist - Two “consultation units” (one clinical officer + nurse) - Two “ART units” with each one nurse counsellor - Patient archive and data base: data entry technician (supported by one expatriate medical doctor) Patient flow: quick and slow circuit Week programme

9. Patient follow-up timingGroup session Counsel- ling, weight & ART Clinical consult. Parallel laboratory monitoring -7 daysXX Day 1XXX 14 daysXXX XXX Every 28 days X 6 MonthsXXX

10. Programme Monitoring & Evaluation (1) according to Malawi treatment guidelines Outcome Indicators of Global Fund targets Similar to NTP M&E system Paper- based - patient identity card/stamp (“health passport”) - patient master card (file) for registration of monthly treatment outcome, “functional” status, side effects and adherence - quarterly cohort analysis forms - drug security form

11. Programme Monitoring & Evaluation (2) “Fuchsia” Software Electronic Data base Epicentre and Mèdecins sans Fontieres Monthly & cumulative reporting on: - HIV clinic - ART programme Patient summaries

12. Antiretroviral treatment programme update April 22nd - June 27th. Total on ART103 Stage III55 Stage IV43 Children5 Deaths2 Serious side effects 2

13. Strategic information and monitoring & evaluation: challenges WHO staging Decentralisation to health centres: - Continuation of follow-up of ART for children - Drug security - Staff capacity - Monitoring & evaluation Linking to other treatment centres - Transfers - ART “shopping”