The National Scale up of ART in Malawi

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The National Scale up of ART in Malawi

• Dr Kelita Kamoto
• Head of HIV and AIDS Department
• Ministry of Health
• Malawi

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Malawi

• 13 million people GNP 200 per capita
• 900,000 people infected with HIV
• 170,000 people needing ART
• 4,000 people on ART in January 2004
• 9 sites no standardised systems

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Malawi important steps to ART

• Dec 2000 Vice-president AIDS conference
• Aug 2001 DOTS for ART Lancet 2001
• Jul 2002 Global fund submission
• Oct 2003 National ARV Guidelines (1st ED)
• Feb 2004 National ART Scale-up Plan

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The Key is Keep it simple
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ART Plan main elements for the public sector

• Free ART to HIV-positive eligible patients
• One first-line ART regimen only Triomune
• Push system of ART supply to facilities
• Standardized system of monitoring/reporting
• Quarterly structured supervision

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ART Administration-Monthly Follow-up

• Nurse led clinic clinician review 3-monthly
  unless there is an earlier need
  
• Patients weighed and screened with symptom-based
  enquiry
  
• Patient master card completed
• ARV drugs dispensed from clinic

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Standardised Treatment Outcomes

• Primary outcomes
• Alive on ART
• Dead
• Defaulted
• Stopped treatment
• Transferred out

• Of those alive on ART
• Regimen
• Ambulatory
• Work
• Side effects
• Drug adherence

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Progress in the ART Programme
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National Data up to March 31st, 2008
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Patients started on ART (1)

• Quarter Jan Mar 2008
• 18,311 patients registered
• Males 39
• Females 61
• Adults 91
• Children 9

• Cumulative to Mar 2008
• 165,187 patients registered
• Males 39
• Females 61
• Adults 92
• Children 8

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Patients started on ART (2)

• Quarter Jan Mar 2008
• Stage III 61
• Stage IV 14
• Low CD4 count 25
• TB 9

• Cumulative to Mar 2008
• Stage III 64
• Stage IV 20
• Low CD4 count 16
• TB 13

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Outcomes (cumulative analysis)
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Of the 18425 patients dying on ART-

• Dying in first month 32
• Dying in second month 21
• Dying in third month 12
• Dying in first 3 months 65
• Dying in month 4 or later 35

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Of those alive and on ART110,790

• First line regimen 96
• Alternative first line regimen 4 (4,377)
• Second line regimen

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Operational Research (1)

• Study
• A study in the Northern
• Region to determine the
• true outcome status in
• patients who have been
• registered as defaulter

• Results
• 253 defaulters
• 50 dead
• 23 alive 10 still on ART from another site
  and 13 stopped ART
  
• 27 not traced

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Operational Research (2)

• Results
• 5 sites providing CPT and 6 not
• 6-month mortality rate with CPT 11.8
• 6-month mortality rate without CPT 19.7
• Mortality risk reduction of 40

Study A study in the mission hospitals to deter
mine whether 6-month mortality rates are reduce
d in ART patients who are also started on CPT at
the same time
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Operational Research (3)Public and Private
sector outcomes
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Other ART updates

• Drug supplies
• Procurement (to start 6 months earlier)
• Increased complexity
• Revised ART and OI guidelines (3rd edition)
• All stakeholders involved in the review
• Updated to reflect recent insights, e.g. KS and
  CM
  

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New Initiatives
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CHALLENGES

• Human resources (increased demand with limited
  human resources)
  
• Physical infrastructure
• Drug supplies
• Quality training of HCWs in ART
• Ability to continue with national ME
• Integrity of the First Line regimen
• Centralised vs Decentralised management
• HTC services not available in all ART sites in
  the private sector
  
• Some employees are not willing to access ARVs at
  the institutions due to stigma and
  discrimination.
  
• Provision of integrated TB and ART services

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