Scaling up antiretroviral therapy in Malawi-implications for managing other chronic diseases in resource-limited countries.

The national scale-up of antiretroviral therapy (ART) in Malawi is based on the public health approach, with principles and practices borrowed from the successful DOTS (directly observed treatment, short course) tuberculosis control framework. The key principles include political commitment, free care, and standardized systems for case finding, treatment, recording and reporting, and drug procurement. Scale-up of ART started in June 2004, and by December 2008, 223,437 patients were registered for treatment within a health system that is severely underresourced. The Malawi model for delivering lifelong ART can be adapted and used for managing patients with chronic noncommunicable diseases, the burden of which is already high and continues to grow in low-income and middle-income countries. This article discusses how the principles behind the successful Malawi model of ART delivery can be applied to the management of other chronic diseases in resource-limited settings and how this paradigm can be used for health systems strengthening

Providing insecticide treated bed nets in antiretroviral treatment clinics in Malawi: a pilot study

HIV infection and malaria, two of the most common and important health problems in sub-Saharan Africa, have been demonstrated to have interactive pathology. In Malawi, where malaria is endemic, and antiretroviral therapy (ART) delivery is scaling up, we piloted integration of long-lasting insecticide-treated bednets (ITN) provision in three ART clinics. In July 2006, 1,910 ITNs were delivered to pilot sites, and ART clinic staff personnel were briefed on ITN provision and use of a monitoring system. Sites were assessed using a structured questionnaire in December 2006. During the pilot period, 1,282 ITNs were distributed to patients. A large proportion (70%) of ART patients at these sites received pilot study ITNs. Site adherence to the monitoring system was variable. Seventeen patients were interviewed, 14 of whom were ART patients who had received ITNs; 11 of these (79%) had slept under the net the previous night. This pilot demonstrates the feasibility of ITN distribution to patients attending ART clinics in Malawi. Programmatic and policy considerations for national roll-out include the need to: 1) adopt a standardized monitoring system, 2) develop information, education, and communication materials, 3) develop in-service training for ART clinicians, and 4) identify systems for forecasting, procuring and distributing ITNs. Malawi Medical Journal Vol. 19 (3) 2007: pp. 111-11

Antiretroviral Therapy in the Malawi Police Force: Access to Therapy and Treatment Outcomes

A national survey was carried out in all the 103 public sector and 38 private sector facilities in Malawi providing antiretroviral therapy (ART) to determine uptake of ART and subsequent treatment outcomes in police force personnel. All patients registered for ART and their subsequent treatment outcomes were censored on December 31st 2006. There were 85168 patients started on ART in both public and private sectors, of whom 463 (0.6%) were police force personnel. Of police force personnel starting ART, 17% were in WHO clinical stage 1 or 2 with a CD4-lymphocyte count of ≤250 cells/μL and 83% were in stage 3 or 4. Treatment outcomes of police force personnel by the end of December 2006 were 302 (65%) alive and on ART at their registration facility, 59 (13%) dead, 30 (7%) lost to follow-up, 1 stopped treatment and 71 (15%) transferred to another facility. Their probability of being alive on ART at 6-, 12- and 18-months was 83.2%, 78.6% and 76.7% respectively. There has been a good access of police force personnel to ART since national scale up commenced with good treatment outcomes, and this should serve as an example for other police forces in the region. Malawi Medical Journal Vol. 20 (1) 2008 pp. 23-2

Mortality Reduction Associated with HIV/AIDS Care and Antiretroviral Treatment in Rural Malawi: Evidence from Registers, Coffin Sales and Funerals

BACKGROUND: To report on the trend in all-cause mortality in a rural district of Malawi that has successfully scaled-up HIV/AIDS care including antiretroviral treatment (ART) to its population, through corroborative evidence from a) registered deaths at traditional authorities (TAs), b) coffin sales and c) church funerals. METHODS AND FINDINGS: Retrospective study in 5 of 12 TAs (covering approximately 50% of the population) during the period 2000-2007. A total of 210 villages, 24 coffin workshops and 23 churches were included. There were a total of 18,473 registered deaths at TAs, 15781 coffins sold, and 2762 church funerals. Between 2000 and 2007, there was a highly significant linear downward trend in death rates, sale of coffins and church funerals (X(2) for linear trend: 338.4 P<0.0001, 989 P<0.0001 and 197, P<0.0001 respectively). Using data from TAs as the most reliable source of data on deaths, overall death rate reduction was 37% (95% CI:33-40) for the period. The mean annual incremental death rate reduction was 0.52/1000/year. Death rates decreased over time as the percentage of people living with HIV/AIDS enrolled into care and ART increased. Extrapolating these data to the entire district population, an estimated 10,156 (95% CI: 9786-10259) deaths would have been averted during the 8-year period. CONCLUSIONS: Registered deaths at traditional authorities, the sale of coffins and church funerals showed a significant downward trend over a 8-year period which we believe was associated with the scaling up HIV/AIDS care and ART

Realizing Inclusive SAI: Contextualizing indicators to better evaluate gender and intergenerational inequity in SAI processes and outcomes - Cases from Southern and Western Africa

Despite increasing sustainable agricultural intensification (SAI) investments, indicators for detecting gender and intergenerational inequities in SAI costs and benefits sharing often remain overgeneralized, theoretical, or locally irrelevant. We examine the relative value of, and how to, customize standard SAI indicators to detect such inequities in specific socio-cultural contexts to enhance data collection for evidence-based decision making in fostering gender/youth inclusive SAI. Using focus-group discussions and key informant interviews among farmers and diverse government, NGO, private sector, and academic stakeholders in two districts in Malawi and three in Ghana, we assess the perceived roles, differentiated needs/ priorities of men, women and youth, and the sharing of SAI burdens and benefits within farming households. We investigate what context-appropriate questions to ask, to whom, and how, to collect reliable information on indicators of SAIinvestment inequities. Results illuminate context-specific, gendered and intergenerational factors shaping access to and ownership of productive resources, household decision making, SAI participation, and appropriateness of selected indicators. Combining farmers’ and local field-expert’ perspectives offers practical insights for customizing inequity indicators. Findings highlight advantages of local contextualization of SAI indicators, including insights on appropriate data-collection approaches that challenge orthodox survey/quantitative methods for detecting and assessing gender/age inequities to foster inclusive SAI

A decision makers’ guide to equitable sustainable agricultural intensification

In many parts of the world, there is a clear need for investment in agriculture to counteract low yields and food insecurity. Focusing only on short-term production gains, however, through technologies such as improved seeds, irrigation, fertilizers and pesticides, increases risks to the environment and human health. Assessing the sustainability of agricultural intensification must go beyond simply finding economical ways to preserve agriculture’s natural resource base and reduce environmental harm from agriculture. The process of sustainable agricultural intensification (SAI) has to also be inclusive and move towards social equity if it is to be truly sustainable. There are many tools for assessing agriculture through an environmental or economic lens, but relatively few that use social criteria. This leaves a gap as more SAI projects and investments aim to achieve equitable benefits across gender and age lines. This guide provides decision-makers with data collection tools to assess gender and youth inequities associated with changes during SAI. These tools were developed and refined following workshops, field work and interviews with decisionmakers in Ghana and Malawi. In agricultural research, important social data often comes from large-scale household surveys that need significant investment of time and money. This guide focused on non-survey data collection tools, many of which originate from participatory learning and action, for two reasons: participatory tools encourage reflection by participants to increase stakeholder equity, and they are often better matched to the resource requirements and time constraints of those involved. Tools are presented based on their ability to provide information about three identified risks to equity from the SAI process: (i) unequal increases in workload, (ii) unequal access to and use of agricultural resources and (iii) inequitable impacts from changes in technologies and markets. For each tool, an overview explains how the tool relates to SAI. Then, the steps needed to facilitate use are presented, followed by special considerations for effective implementation. The guide supports decision-makers in choosing appropriate data collection tools and in effectively using the information. To make the choice of tool easier, information is provided on affordability, timeliness and human resource requirements for each. Also considered is each tool’s ability to assess potential technologies ex ante, so decision-makers can adapt them before implementation to better foster gender and youth equity. Finally, a number of examples of decision-making tools are presented with how to use the data collected to inform more inclusive SAI. The goal is to enhance the capacity of decision-makers to make a robust analysis of the distribution of benefits and burdens resulting from SAI investments. Decision-makers are encouraged to apply the tools within a community-driven gendertransformative process that aims to change the norms that perpetuate social inequities, by simultaneously influencing household, community, market and political domains

Nurses and medical assistants taking charge: task-shifting HIV care and HAART initiation in resource-constrained and rural Malawi

Mexico AIDS Conference 200

A National Survey of Teachers on Antiretroviral Therapy in Malawi: Access, Retention in Therapy and Survival

BACKGROUND: HIV/AIDS is having a devastating effect on the education sector in sub-Saharan Africa. A national survey was conducted in all public sector and private sector facilities in Malawi providing antiretroviral therapy (ART) to determine the uptake of ART by teachers and their outcomes while on treatment. METHODOLOGY/PRINCIPAL FINDINGS: A retrospective cohort study was carried out based on patient follow-up records from ART Registers and treatment master cards in all 138 ART clinics in Malawi; observations were censored on September 30(th) 2006. By this date, Malawi's 102 public sector and 36 private sector ART clinics had registered a total of 72,328 patients for treatment. Of these, 2,643 (3.7%) were teachers. Adjusting for double-registration caused by clinic transfers, it is estimated that 2,380 individual teachers had ever accessed ART. There were 15% of teachers starting ART in WHO clinical stage 1 or 2 with a CD4-lymphocyte count of <or=250/mm(3) and 85% starting in stage 3 or 4. By 30(th) September 2006, 1,850 teachers were alive on ART (3.5% of all teachers in Malawi). The probability of being alive on ART at 6-months, 12-months, 18-months and 24-months after treatment initiation was 84%, 79%, 75% and 73% respectively. Retention in treatment was better for women (adjusted HR = 1.8) and in those starting ART in WHO Clinical Stage 1 and 2 (adjusted HR = 1.8). CONCLUSION/SIGNIFICANCE: Rapid scale up of ART has allowed 2,380 HIV-positive teachers to access life-prolonging treatment. There is evidence that this intervention can help to mitigate some of the shortages of teaching personnel in resource-poor countries affected by a generalised HIV epidemic

Gender- and youth-sensitive data collection tools to support decision making for inclusive sustainable agricultural intensification

Open Access Article; Published online: 15 Sep 2020To achieve equitable sustainable agricultural intensification (SAI), it is essential to understand differential access and control over agricultural resources by women and youth, and to assess how intensification interacts with gendered and age-dependent relationships. Existing packages for assessing women’s empowerment in agriculture tend to be large-scale surveys that do not provide timely results, nor are they easily integrated into a gender-transformative process. This paper applies concepts from Kabeer on gender analysis and empowerment to evaluate promising tools available for assessing inequities in SAI and supporting a gender-transformative approach. We interviewed decision makers in Malawi and Ghana to understand their needs and practices for equityanalysis. We evaluated, adapted and tested tools to detect inequities from SAI. Our results demonstrate the suitability of tools to decision makers’ needs for ex-ante assessment and early detection of disparities. We synthesize information from the testing and adaptation of tools about the resources required, the equity issues they can reveal and their potential role in a gender-transformative approach. The use of the tools needs to be part of an inclusive and culturally specific process for identifying gaps and facilitating a more equitable sharing of SAI responsibilities and benefits through iterative cycles of action and learning