100 000 people started on ART with very

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 HIV & AIDS Unit MOH Malawi

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

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

Vacancies in MOH and CHAM Posts EHP Posts filled % vacancies 433 162 63% Clinical Officers 1, 405 1, 033 26% Nurses 8, 440 3, 416 60% Medical Assistants 1500 491 67% Pharmacy technician 269 134 50% Med Lab technician 507 182 64% Health Surv. Assist. 11, 000 4, 664 58% Medical Doctors June 2006 HIV & AIDS Unit MOH Malawi

Human Resources Go. M declared a crisis of human resources; the health sector ‘has collapsed’ (Secretary for Health) n 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 n This lead to 6 -year Human Resources Emergency Relief Plan (US$ 273 million) n HIV & AIDS Unit MOH Malawi

Principles of ART Programme Based on realities (a public health approach): n Simple (1 st Line regimen only, one regimen for all, no laboratory monitoring or CD 4 count needed, drug supply, short training, intensive quarterly supervision) n Standardised (case finding, treatment regimen, reporting and monitoring). All providers following national protocol. n Inclusive (all providers involved: mission hospitals, profit and not-for profit private sector) n Lower cadres of staff involved (task shifting) HIV & AIDS Unit MOH Malawi

Task shifting in Malawi n n n 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) HIV & AIDS Unit MOH Malawi

ART health care provider model n n n 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 HIV & AIDS Unit MOH Malawi

ART health care provider model (2) n n n 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 HIV & AIDS Unit MOH Malawi

National laws or policies that facilitates task shifting n n n 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 antimalarials and pain-killers The government at all levels including regulatory bodies have accepted task shifting with the aim of: q Increasing access to health services q To utilise available human resource at nearest community/facility HIV & AIDS Unit MOH Malawi

Outcomes ART programme n n 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, 000 1% 2010 160, 000 2. 5% 2015 210, 000 3. 5% HIV & AIDS Unit MOH Malawi

HIV & AIDS Unit MOH Malawi

HIV & AIDS Unit MOH Malawi

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 HIV & AIDS Unit MOH Malawi

Do ART services take away staff from other essential health services? In June 2006: q q q 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) HIV & AIDS Unit MOH Malawi

Mortality in 8 private sector companies and Malawi Defence Forces n n 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” HIV & AIDS Unit MOH Malawi

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

HIV & AIDS Unit MOH Malawi

Costs of the ART programme n By 2015 costs of ART only will be US$ 40 – 50 million per year. This would increase the health budget by approximately 30% HIV & AIDS Unit MOH Malawi

Costs of the ART programme Average costs of ART person per year Costs of ARVs pppy (see next slide) US$ 148. 09 CTX for CPT 10. 37 Drugs for HIV related diseases 10. 00 Therapeutic feeding 21. 35 Costs for training, IEC, M&E, supervision, OR, health education, infrastructure, etc. 24. 35 Staff costs person per year on ART Other service delivery costs (running costs clinic, laboratory support) Average costs 4. 80 10. 00 US$ 228. 96 HIV & AIDS Unit MOH Malawi

Average costs of ARVs person per year Monthly Costs of ARVs (FOB) Costs per year Proportion of (US$) people on inclusive of all each costs regimen 7. 76 13 0. 08 95. 0% 16. 43 27 5. 53 3. 0% alt 1 st line regime II (d 4 T, 3 TC, EFV) 26. 50 44 4. 41 1. 0% 2 nd line regime (ZDV, 3 TC, Tenofovir, Lopinavir/Ritonavir) 70. 35 1 st line regime (d 4 T, 3 TC, NVP) alt 1 st line regime I (ZDV, 3 TC, NVP) 1, 179. 77 1. 0% Average costs for ARVs person per year 148. 09 HIV & AIDS Unit MOH Malawi

Achievements n n 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. HIV & AIDS Unit MOH Malawi

Challenges n n n 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. HIV & AIDS Unit MOH Malawi

Thank you HIV & AIDS Unit MOH Malawi