Malawi ProTEST Lessons Learned

1. Malawi ProTEST Lessons Learned Presented by Rhehab Chimzizi TB/HIV Programme Officer Malawi National TB Control Programme

2. Main aim of the Malawi ProTEST Project • To reduce the burden of dual TB/HIV epidemic in Lilongwe, Malawi

3. Malawi ProTEST project outputs • Increased dialogue,co-operation and coordination between the NTP, NACC and non governmental partners addressing TB/HIV care • Increased capacity in key HIV and TB service providers • Increased use of VCT services • A network of services for people living with HIV/AIDS • Increased community involvement in TB and HIV/AIDS care • Cost and cost –effectiveness analyses of the interventions

4. Increased Dialogue and Coordination (output 1) • Need for better coordination of TB/HIV activities at district level • Regular district TB/HIV coordinating meetings catalyses collaboration • Regular TB/HIV meetings require funding for transport, stationery, and preparation and circulation of minutes • To achieve better collaboration a coordinating body/person needs to be identified at district level • The DHMT should be the entry point for future collaborative TB/HIV activities

5. What succeeded? • Increased collaboration between TB and HIV/AIDS control programme more evident • Full-time coordinating personnel • Focal coordinating body • Key TB/HIV stakeholders keen to participate in district coordinating meetings • Regular TB/HIV coordinating monthly meetings with minutes

6. What were some of problems encountered • Restructuring of the NACP • No full involvement of the DHMT due to the absence/weak District AIDS Coordinator • Three parallel AIDS Coordinating Committee in one district • Collaboration doesn’t always come naturally…..

7. Increased capacity in key HIV and TB service providers (output 2) • New organisations established to care for TB and HIV/AIDS require capacity building input • Building capacity in these organisations does not necessarily require huge financial input, however considerable investments of time, particularly for strategic planning and supervision is critical

8. Output 2 continued • The district TB/HIV coordinating body is required to recognise the potential of new organisations that need capacity building in- puts • Recording and reporting system allows new organisations to monitor their progress • Future plans for district TB/HIV activities should consider ways of training district staff in capacity-building of organisations

9. What succeeded? • Flexibility in allocating immediate funds for capacity building (donors and implementers) • Capacity developed in the following organisations: LCH HBC group, Lighthouse clinic and NAPHAM • As a result of increased capacity technical partners became interested to fund activities in these organisations

10. Increased use of VCT services (output 3) • There is unmet demand for VCT services • The provision of “while you wait” HIV test-results using whole blood rapid HIV test kits is attractive to the clients • It is feasible for non-laboratory medical/nursing staff to perform HIV testing using whole blood HIV testing kits • Whole blood HIV test kits have the potential to facilitate rapid scaling-up of VCT services both in urban and rural areas

11. Output 3 continued • Integrated and stand alone VCT services attract different types of clients, therefore complimentary • Regular evaluation of the quality of VCT services results in improvements in the quality of VCT services • Evaluation of VCT services can be performed simply using UNAIDS quality evaluation tools, adapted to the local situation • VCT counsellors need system of support to deal with the stress of service provision • Countries need to established new cadre of VCT counsellors instead of depending on medical and nursing personnel who are already busy with other activities

12. What succeeded (Output 3) • Clients accessing VCT services increased due to: • Use of rapid HIV kits • Radio advert about VCT services • on site clinical care at stand alone VCT centre • CPT in TB patients

13. What succeeded (output 3) • Simple quality evaluation improved VCT services • Quality evaluation tools used in supervision of VCT services • Quality evaluation tools for VCT services helped to facilitate support for counsellors

14. What failed? • Adequate access to VCT services for people living in rural areas • Development of VCT IEC materials • Sustainable quality control of rapid HIV test kits • Sustainable VCT services in mission hospitals and health centres

15. A network of services for people living with HIV/AIDS (output 4) • Referral Networks • District service providers keen to collaborate • Facilitated by duplicate referral books • Involvement of HBC providers encouraged two-way referral of clients between hospital and community • Enhanced by data feedback

16. Output 4 Continued • Clinical care of clients accessing VCT services • Clients welcome on-site provision of clinical services at a stand alone VCT centre • PLWHA welcome access to care at a specialised HIV clinic, and existence of these services may help to de-stigmatise HIV • Clinical services for PLWHA at government facilities limited by poor availability of essentials drugs for OIs and palliative care • The quality of HBC services can be improved through collaboration with medical services

17. Output 4 continued • Cotrimoxazole preventive therapy (CPT) • TB patients are willing to access VCT and CPT, but access to VCT limits CPT in rural areas • Side-effects from CPT are rare if TB patients are asked about the allergy to sulpher drugs prior to commencing CPT • Significant proportion of TB patients continue take CPT after completing TB treatment

18. Output 4 continued • Isoniazid Preventive therapy (IPT) • HIV-positive VCT clients appear to be keen to start IPT after ruling out active TB • The proportion clients that complete six months of IPT is low (32%)

19. Network of services: What failed? • No VCT services in the rural for TB patients to access CPT • TB/HIV care by traditional Healers not successfully monitored • Development of IPT brief pack for individual HIV positive clients

20. Increased involvement in TB and HIV/AIDS care (output 5) • Improving quality of HBC services • Frequent meetings and dialogue between different HBC providers are vital to ensure better collaboration • Medical support given to HBC patients can be improved by linking community volunteers to community nurses, health centres and HIV/AIDS/palliative care clinics

21. Output 5 continued • Involving the community in TB/HIV/AIDS case-finding, care and prevention • HBC volunteers have great potential to increase case-finding for active TB • HBC community volunteers may not be acceptable as DOT supporters for many TB patients unless the volunteer has been involved in the diagnosis of active for particular patients

22. Output 5 continued • HBC providers need training to promote VCT • Traditional healers and private practitioners have the interest and potential to become involved in TB/HIV diagnosis and care • Religious leaders are keen to engage with NTP, and NACP • Religious leaders and traditional healers have expressed reservations to promote condom use

23. Data we would have liked to have collected • Condoms distributed for all partners • TB treatment outcome for clients screened for TB • Contra-indication to CPT identified by VCT counsellors • Impact of IEC strategies (leaflets, peer education) • Patient concordance with CPT

24. Key recommendations for scaling-up collaborative TB/HIV activities • Both TB and HIV/AIDS programmes to be equally involved in the planning process • Entry into the district should be through the DHMT • Training, capacity building and supervision should be allocated adequate funds • Select districts that have both strong HIV and TB services in the initial stage • Activities should be introduced in a phased manner both in scope and time • Don’t lose emphasis on prevention (esp ARVs)

25. Key requirements for national scale-up of TB/HIV activities • Government/political commitment • Adequate financial and technical assistance • Equal involvement of TB and HIV/AIDS programmes in planning TB/HIV activities • Establish a TB/HIV working group at national level • Establish district TB/HIV coordinating committee • Establish a new position of a National TB/HIV Officer/coordinator • Involve the DHMT in the planning process • Conduct situation of TB/HIV services at district level

26. Engagement of Directors for NTP and NACC in national scale-up • Establishment of National TB/HIV steering committee • Establishment of national TB/HIV working group • An officer in NTP responsible for HIV and an officer in NACC responsible for TB activities

27. Acknowledgement • All ProTEST Partners in Lilongwe, Malawi • The Ministry of Health and Population • The Royal Norwegian Government • The World Health Organisation (WHO) • The London School of Hygiene and Tropical Medicine (LSHTM) • The Liverpool School of Tropical Medicine