Dr Sam Phiri: HIV and AIDS Situation in Malawi

HIV and AIDS Situation inMalawi: Towards Universal Access Dr Sam Phiri Executive Director Lighthouse Trust Global Community Links

Presentation outline•HIV situation and nationalresponse•ART program•The Lighthouse Initiative•Challenges Global Community Links

HIV and AIDS Situation In Malawi•Current statistics: – Population – 13 Million – 12% HIV prevalence among 15-49 years – 1.6% HIV Incidence – 900, 000 people living with HIV/AIDS•Impact of AIDS: – About 70,000 adult and child deaths annually – 700,000 orphans directly related to AIDS•HIV Prevalence in most at risk populations – FSW – 70.7% (2006) – MSM – 21.4% (2009) Global Community Links

HIV Prevalence by Age 19.00%20.00%18.00% 17.10% 15.30%• Content16.00%14.00% 13.80%12.00%10.00% 12.30% 11.30% 8.00% 6.00% 8.00% 4.00% 2.00% 0.00% 45 Le 15 15 20 25 30 35 40 + ss -1 -2 -2 -2 -3 -3 -4 th 9 4 4 9 4 9 4 an 15 Global Community Links

HIV Prevalence by Education 20.0% 17.5% 18.0% 15.5% 16.0% 14.9%• Content 14.0% 16.6% 12.0% 13.9% 14.2% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% -5 -8 -2 -4 ry e on a 1 6 1 3 nd N d d rm rm co St St Fo Fo se st Po Global Community Links

HIV Prevalence by Marital Status 50.00% 45.00% 42.90%• Content 40.00% 35.00% 32.60% 30.00% 25.00% 22.60% 20.00% 17.30% 14.80% 13.30% 15.00% 10.00% 5.00% 0.00% Single Cohabiting Married Divorced Widowed Separated Global Community Links

National HIV Prevalence by Year 20 18.5 16.9 17 15 15% Prevalence 13.5 10 Malawi Median 5 0 1998 2001 2003 2005 2007 Global Community Links

HIV Prevalence by Locality 30 25 25.3 22.5 20.9 21.1 21.7 20 20.8 20.4% prevalence 17 17.6 Rural 15 14.5 15 Semi-Urban 13 12.3 Urban 11.2 10.7 10 5 0 1998 2001 2003 2005 2007 Global Community Links

Prevalence trends in 15-19 and 15-24 age groups 25 20 19.1 18.3% Prevalence 15 15.2 14.3 14.3 15 - 19 12.3 15 - 24 10 10.3 9.5 5 0 1998 2003 2005 2007 Global Community Links

Malawi National HIV and AIDS Response• Prevention and behaviour change•Treatment, care and support•Impact mitigation•Mainstreaming and decentralisation•Research, monitoring and evaluation•Resource mobilisation and utilisation – Main funding from Global Fund and other partners•Policy and Partnerships Global Community Links

ART Scale Up Plans(2004-2005) and (2006-2010)• Phased selection of facilities•Free ART to HIV-positive eligible patients•One first-line ART regimen only “Lamivudine +Stavudine + Nevirapine”•“Push” system of ART supply to facilities•Standardized system of monitoring/reporting•Quarterly structured supervision Global Community Links

Progress in cumulativepatients alive on ART in public and private sector Global Community Links

National outcomes (cumulative analysis) March 2011• Number % Enrolled to ART 365, 191 Alive on ART 264, 512 72 Dead 42, 549 12 Lost to Follow Up 66, 662 16 Stopped ART 1, 761 <1 Global Community Links

Malawi’s response to new WHO recommendations•Eligibility – Stage 3 or 4 – CD4+ cell < 350 – PMTCT Option B+ - All pregnant and lactating HIV infected women•Regimen•Tenofovir + Lamivudine + Efavirenz (TDF – 300 + 3TC 300 + EFV 600)single FDC•Challenge – Round 10 application to Global fund not successful•Phased approach – Maintain current regimen except • New pregnant and lactating women • New TB/HIV co-infected patients • First line alternative for severe lipodystrophy Global Community Links

Challenges - Opportunities•Slow behaviour change response•Inadequate professional human resource•Residual social and cultural practices•Maintaining sustainable financial support•Balancing HIV agenda with general healthagenda•Early mortality among patients initiated onART Global Community Links

Public Trust Initiative tocomplement Government Global Community Links

Lighthouse Strategic Approach Client-centered care based on 3-prong technical approach: •To expand high-quality, integrated HIV and AIDS prevention, treatment, care and support services •To promote innovative approaches for HIV prevention, treatment, care and support through program development, piloting, evaluation and dissemination; •To build and strengthen capacity for HIV and AIDS treatment, care and support in Malawi. Global Community Links

The Lighthouse Trust•Centre of Excellence for integrated continuum ofHIV prevention, treatment, care and support•2 clinics: MPC and Lighthouse 1. HIV Testing and counselling including 31 HC in Lilongwe 2. ART service provision • 10,000 patient visits/month • > 15,000 patients alive on ART • Integrated with TB, FP, STI, and PMTCT 3. Home- and community-based care 4. Capacity building • National trainers in HTC, ART, palliative care • Supports MOH in Supervision, mentoring and coaching Global Community Links

HIV Testing and Counseling (HTC) Global Community Links

HTC ServicesLighthouse urban HTC sites : – Lighthouse and Martin Preuss Centre clinics – Kamuzu Central Hospital medical wards, paediatric wards, antenatal – STI clinic – Maula prison – ChinsapoRural health center outreach  31 rural Lilongwe HTC sites supported for HTC to ANC mothers  Increasing links to prevention of mother to child transmission services Global Community Links

HIV Testing and Counseling Global Community Links

Total HTC client visits HTC Cummulative Encounters 4500 4000 3500Clients Tested 3000 2500 2000 1500 1000 500 0 Jan-01 Jul-01 Jan-02 Jul-02 Jan-03 Jul-03 Jan-04 Jul-04 Jan-05 Jul-05 Jan-06 Jul-06 Jan-07 Jul-07 Jan-08 Jul-08 Jan-09 Jul-09 Jan-10 Jul-10 Jan-11 Jul-11 Clients Testing Positive Clients Testing Negative Global Community Links

The Lighthouse Clinic A Specialist Clinic for HIV and AIDS Global Community Links

Clinic Registration Global Community Links

Clinical Care•Free, public HIV/AIDS clinic – 15,000 on ART by December 2010 – 56% female – 91% on first line medications – 9% children under 15 years•Routine follow-up visits include: – Regular appointments at intervals of 1, 2, or 3 months – Diagnosis and treatment of opportunistic infections – Initiation and maintenance of prophylactic therapy – Referral to other services especially at KCH Global Community Links

Clinical case review Global Community Links

Lighthouse Trust cumulative outcomes: Q4, 2010 Number % of ever enrolledEver enrolled in ART 24,590Alive on ART 14,293 59%Dead 1,771 7%Defaulted 3,310 13%Stopped ART 440 2%Transferred-out 4,766 19% Global Community Links

Total Clinic Reviews 14,000 New Patients 12,000 Follow-ups 10,000 MPC OpenedClinic Client Visits 8,000 Limits Imposed 6,000 Free Lighthouse Centre ARVs Opens 4,000 2,000 0 May-05 Nov-01 Nov-08 Apr-01 Aug-03 Jun-02 Jan-03 Mar-04 Sep-07 Apr-08 Aug-10 Dec-05 Jul-06 Jun-09 Jan-10 Mar-11 Feb-07 Oct-04 Global Community Links

Electronic Data Management•Lighthouse and MPC implemented a real-time electronicdata system (EDS) in 2005•Collection of patient level information on all ART patients – Registration, vitals, nurse visits, clinical care, and dispensing records•Uses touch screen technology•Label scanners and printers facilitate easier monitoringand supervision for blood samples and drug dispensing.•Near completeness of patient level data from 2006onward.•All patient EDS data is accessed through an Accessdatabase for effective monitoring and evaluation Global Community Links

The Lighthouse Community Home Based Care Quality Care at Homefor the Chronically Sick in Lilongwe City Global Community Links

Home based care (HBC) program•Leader in promotion of Palliative Care – End of life care for terminal and dying patients•Works through existing community groups to encourage ownershipand sustainability•Patients identified through: – Lighthouse or MPC referral – Community volunteers – Local hospitals•Dedicated, well-trained community nurses provide quality care – 150 patients, on average, per month – Patients receive 2 nurse visits/week for medication and follow-up – Patients receive visits from community volunteers for psycho-social support Global Community Links

Community Home Based Care Global Community Links

Clients Registered 1000 2000 3000 4000 5000 6000 7000 0 Nov-05 Feb-06 May-06 Aug-06 Nov-06 Feb-07 HBC May-07 CV Aug-07 LH Nov-07 Feb-08 May-08 Aug-08 LHMPC (Bottom) HC Nov-08 uptake Ndife AmodziGlobal Community Links Feb-09 Other May-09 Aug-09 Nov-09 Feb-10 May-10 Aug-10 Nov-10 Feb-11 May-11 Total Ndife Amodzi client

Capacity Building Role•MoH certified Training Courses: – ART, HTC, and palliative care – Over 1,000 clinicians and nurses trained in ART provision•Provides clinical attachment for ART & HTC•National supervision teams for HTC and ART•Mentoring for new ART/HTC sites•Leader in national policy development andpiloting Global Community Links

Challenges… Global Community Links

Space challenges in clinic reception Global Community Links

Lighthouse challenges•Balancing service quality with overwhelming demand•Balancing service delivery with capacity building•Balancing service delivery with operational research•Maintaining high community volunteer retention•Financial support for human resource Global Community Links

A cross section of the Lighthouse Team Global Community Links

•Global Community Links

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Dr Sam Phiri: HIV and AIDS Situation in Malawi

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Dr Sam Phiri: HIV and AIDS Situation in Malawi Presentation Transcript