PROJECT SUMMARY: MALAWIOCTOBER 2010–JUNE 2015

Programmatic Man

agem

ent o

f DR

TB

TB/HIV

Roll o

ut of

Xpert MTB/RIF

Strengthening Labor atory Network for TB

DOTS Expansion & Enhancement

of registered TB patients tested for

HIV

89%

Trained more than

4,000health care workers including

NTP officers, clinicians, nurses, lab technicians, health

surveillance assistants and attendants in TB and DR-TB

management, IC, TB/HIV integration, Gene Xpert, M&E.

645

Strengthen and expand the TB

diagnostic network:

HIV+TB clients are

also on

CPT

95% of

93% on ART

In total,

Xpert tests were performed in the 12 districts supported by TB Care II, and

MTB positives and

Rif Resistant cases were identified; Xpert contribution to case notification was 13%.

26.974

2,368 (8.8%)

75 (0.3%)

Malawi is a low income country with the population of about 15 MILLION. TB remains a major public health problem in Malawi. According to the WHO World TB report 2012, there were an estimated 29,000 new cases of TB (all forms) in the year 2011, and approximately 18,000 of these were HIV positive. The HIV pandemic presents a significant challenge to global TB control.

The Project: The USAID TB CARE II Malawi Project, launched in 2010, is a coordinated effort led by University Research Co., LLC in collaboration with Project HOPE and Partners In Health. The Project assists the National TB Program in improving TB control and expanding access to high-quality TB and TB/HIV services in the public sector.

* Source of data: TB CARE II project data (from target districts)

The target districts

Trained89MDR TBdistrict team

members from all 28 districts

Decentralized TB services: The project established new TB registration and initiation sites in Malawi and contributed to

INCREASING the overall number of TB initiation and registration sites to reaching all districts. 277

177Strengthened community systems for TB control:Established over Community Based Sputum Collection Points; Contributed to identifying 18,220 presumptive and 919 TB confirmed cases.

200

The project procured and placed

68 light & 59 iLED microscopes;

15 Gene Xpert sites,established

20 safety installed

nation-widecabinets

128 peripheral laboratoriesenrolled on External Quality Assurance system.

and 19 microscopy sites in 9 districts

Renovated National TB Reference laboratory

iLED and ZN microscopy and in Xpert use

Trained laboratory staff in

Maintained

69%MDR-TB

treatment success rate at

nationwide

Mortality

33% 25%for MDR-TB Decreased from

to

Heal

th S

yste

ms

Stre

ngth

enin

gTB CARE II in Malawi

This report is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents of this report are the sole responsibility of University Research Co., LLC and do not necessarily reflect the views of USAID or the United States Government.

INTRODUCTION

The United States Agency for International Development (USAID) awarded the TB CARE II Project, a five-year cooperative agreement (2010–2015) in Malawi to assist the NTP in improving TB control and expanding access to high-quality TB and TB/HIV services in the public sector. At the national level this included strengthening the laboratory network and improving the National TB Reference Laboratory (NTRL) capacity, supporting the nascent community based drug-resistant TB (DR-TB) treatment program, piloting novel diagnostics such as Xpert® MTB/RIF roll-out, and strengthening the NTP centrally. Activities in

MAJOR ACCOMPLISHMENTS

With support from TB CARE II, important progress was achieved in the delivery and management of TB diagnostics, care and treatment services. TB CARE II initially worked in 6 target districts and later expanded to cover 12 districts and finally to 17 districts (5 additional ones in the last year of the project where Gene Xpert machines were installed) nationwide. Key achievements are as follows.

Increase in the Number of TB Treatment Sites Across the Country

At the beginning of the project, Malawi had only 60 sites equipped to register and initiate TB patients on treatment making the process of diagnosing and enrolling on treatment complicated both for the provider and the patient. In total, the project established 170 (300%) new TB registration and initiation sites in Malawi and contributed to increasing the overall number of TB initiation and registration sites to 277, reaching all districts. As a result, more patients are able to access reliable, effective TB treatment closer to their homes.

target districts focused on implementing a comprehensive package that included emphasis on DOTS expansion and enhancement; integration of TB/HIV services; improved services for DR-TB and health system strengthening through the decentralization of services; improvement of the laboratory network; and involvement of community structures in diagnosis and patient follow-up.

M A L A W ITB CARE II Target Districts

Expansion Districts

Initial Districts

Neno

MachingaBalaka

Dedza

SalimaMchinji

Kasungu

Karonga

Rumphi

Mzimba

Nkhotakota

NkhataBay

Chitipa

Dowa

Ntchisi

Zomba

Mangochi

Ntcheu

Lilongwe

Nsanje

ChikwawaThyolo

Blantyre

Mulanje

Mwanza

ChiradzuluPhalombe

LILONGWE

Opened with TB CARE II Support

22

2

2

7

4

9

8

8

3

3

3

31

4

5

1111

10

12

14

25

10

Achievements include:

In collaboration with NTP, the policy for decentralization of TB sites was revised from two per district to roll out TB registration in each microscopy site. TB CARE II team worked with DHMTs to train at least five health care workers per site on TB registration and treatment initiation and worked with NTP at zonal and central level to source registers, treatment cards and first-line drugs. In addition, TB CARE II collaborated with stakeholders to provide continuous support to monitoring, supervision and mentoring of staff in the new registration sites to ensure the quality of services. In all new TB initiation and registration sites, an integrated package of services was promoted.

This included the establishment of links to community sputum collection points, establishment of cough corners and placement of cough officers in clinics, and provision of HIV care and treatment services. In collaboration with the NTP and DHMT, the project supported sputum transportation to diagnostic facilities from peripheral sites.

Improvement in the Integration of TB/HIV Services

The proportion of HIV positive clients screened for TB was steadily above 90% in the project supported districts. This was also the case for registered TB patients with a recorded HIV test result. Significant achievement was observed in CPT and ART rates: the CPT uptake increased from 78% to 95%, and the ART uptake increased from 81% to 93% during the project life.

Achievements include:

– TB CARE II worked intensively with both the national TB and HIV programs to increase integrated delivery of TB and HIV services, with an emphasis on improving the availability of TB screening and diagnostic services at HIV care and treatment sites.

– TB CARE II worked with NTP and the Ministry of Health to improve care and treatment outcomes for TB/HIV co-infected patients through a one-stop-shop model of integrated TB/HIV services. Under this model, TB, HIV, and co-infected patients are able to access a full package of services at one location, managed by one HCW or health care team. TB/HIV co-infected patients are able to get both TB treatment and ART during the same visit, from staff who are able to more closely monitor their dual treatment outcomes. Health care teams are trained and equipped to provide TB screening and treatment, HCT, ART, as well as other services, including treatment for opportunistic infections.

– TB CARE II trained HCWs in the supported districts on TB/HIV integrated care, monitoring and evaluation of TB/HIV, TB screening in HIV care settings, and on TB infection control.

60 treatment initiation and registration sites functional before TB CARE II

170 treatment initiation and registration sites opened with TB CARE II support

277 total treatment initiation and registration sites as of 2015

– The project has collaborated with more than 45 CBOs or HIV support groups to strengthen TB case finding through contact tracing, community-based TB screening, and to improve treatment, care and support for TB/HIV patients at the community level.

– The project collaborated with the Ministry of Education’s Department of School Nutrition and Health and the Ministry of Health through the National TB Control Programme to promote TB/HIV awareness messages, screening, and infection control strategies among Teachers and Learners Living Positively with HIV/AIDS.

– TB CARE II worked with a wide assortment of national and community partners to increase awareness and integration of TB, including screening among communities and high risk populations. These included USG partners such as the Support for Service Delivery Integration (SSDI) project, the Bridge Project, Dignitas International (DI) and others, as well as community groups, including Teachers and Learners Living Positively (T’LIPO) and Riders for Health (RFH).

Lab staff of the Neno District Hospital performs the GeneXpert® test.

Strengthened Quality and Access to TB Diagnostic Services

TB CARE II worked closely with the NTP and the NTRL to increase access to TB diagnostic services by strengthening microscopy services and by supporting the adoption of Xpert® MTB/RIF (GXP) technology. Starting from 2012, 26,974 Xpert tests were performed in the 12 districts supported by TB CARE II, and 2,368 (8.8%) MTB positives and 75 (0.3%) Rif resistant cases were identified.

Achievements include:

– The project increased capacity to diagnose and treat TB and TB/HIV by training of more than 4,000 HCWs including NTP officers, clinicians, nurses, lab technicians, health surveillance assistants and attendants in TB and DR-TB management, IC, TB/HIV integration, Gene Xpert, M&E.

– By the end of the project, over 100 microscopy sites were developed and supported with training and supervision, a revised national Xpert algorithm was introduced, and 11 Xpert machines were placed in target districts.

– The project procured additional 35 i-LED microscopes which were distributed to testing facilities across the country and supported the fluorescent microscopy training for laboratory technicians.

– The project assisted NTRL to renovate the cold room which is now fully functional and no malfunction has been reported; as part of the decentralization of TB services, TB CARE II completed renovations of 19 microscopy laboratories in 9 districts.

– The project supported the quality control and assurance systems through the distribution of proficiency test (PT) materials and compilation of results.

Improvement in the Management of MDR-TB Patients

During the life of the project, the treatment success rate for MDR-TB patients was steadily around 69% nationwide while the mortality has decreased from 33% to 25% for the cohorts of 2009 and 2011.

Achievements include:

– TB CARE II worked to further the adoption of community-based treatment for MDR-TB patients, assisting the NTP to develop and adopt a national programmatic management of drug-resistant TB (PMDT) policy.

– TB CARE II worked as a prime partner to advance decentralized systems of care and treatment for MDR-TB patients in order to facilitate access and adherence to treatment. This included providing technical assistance to support the development and distribution of community based MDR-TB guidelines and the training of MDR-TB management teams. TB CARE II also facilitated the establishment of the first national Centre of Excellence for the Programmatic Management of DR-TB at Bwaila Hospital in Lilongwe.

– The project provided support to strengthen the management of MDR-TB cases in Malawi through the development and adaptation of training materials for district MDR-TB management teams. In addition, TB CARE II trained MDR-TB district team members. In total, 89 members were trained from all 28 districts.

– With financial support from the USAID TB CARE II project, Bwaila Hospital’s male and female wards were renovated. The buildings now have a new, more modern look as a result of the renovation work.

Strengthened Systems and Infrastructure for TB Care and Control

TB CARE II project worked hand in hand with NTP, providing routine support in a variety of ways.

Achievements include:

– The project provided intensive hands-on support to complete the National TB Prevalence Survey and development of the TB and HIV joint concept note for submission to the Global Fund.

– The project supported the renovation of a one-stop-shop centre at Mangochi district hospital where TB/HIV services are provided.

– TB CARE II worked as a strong partner to community, civil society, and other donor-funded projects to create a bridge between them and the NTP, strengthening their involvement in TB activities. Over the life of the project, TB CARE II promoted and facilitated the establishment of partnerships in all impact districts with international NGOs and USAID implementing partners such as the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Sue Ryder International, and the University of North Carolina (UNC).

– The project renovated 7 health centres to provide conducive TB/HIV service delivery services in addition to the construction of an anteroom at the national TB reference laboratory (NTRL).

– The project also collaborated with DI in the Balaka and Zomba districts; MSF in Nsanje and Chikhwawa districts; the Support for Service Delivery Integration (SSDI) Project in Balaka & Nkhotakota districts on TB/HIV integration; and the Bridge Project on TB and TB/HIV and community mobilization in Machinga. This effort contributed to improving programmatic coordination amongst different partners and sharing and learning best practices.

CONCLUSIONS

During the five years of project implementation, TB CARE II worked to expand and solidify achievements, especially around increased case finding, decentralization of TB and MDR-TB services and improvements in TB/HIV integration. The strong partnership with the NTP, developed over several years of close collaboration and responsive leadership, provided for a fruitful exchange and allowed the project to support increased access to TB diagnosis and treatment through the establishment of new diagnostic facilities, roll out of new technologies and the opening of new TB registration and initiation sites.

Active and ongoing coordination with the departments of HIV and TB at all levels was critical to this success, as the project worked to support a culture of patient-centred care. Going forward, maintaining a focus on continuous monitoring, ongoing mentoring and supervision and closing remaining performance gaps will be essential for this success to be maintained.

Photos: (right) Participants at World TB Day event wear TB CARE II sponsored t-shirts with the Stop TB Partnership message. (below) Patrick Gomani explains indications found on a patient’s chest x-ray that suggest presence of tuberculosis.

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USAID TB CARE II PROJECTwww.tbcare2.org