MALAWI NATIONAL AIDS COMMISSION

Transcription

1 MALAWI NATIONAL AIDS COMMISSION Annual National Malawi HIV/AIDS Monitoring and Evaluation Report 2003

2 Foreword Insert photo here The Malawi National AIDS Commission (NAC) is proud to present to you its first annual HIV/AIDS Monitoring and Evaluation report on Malawi s multi-sectoral HIV/AIDS response. This report, which covers the period January to December 2003, is one of the major outputs of Malawi s national HIV/AIDS Monitoring and Evaluation (M&E) system. The publication of this report is a defining moment for Malawi s National AIDS Commission (NAC), as it (a) celebrates the fact that Malawi is one of the first countries in sub-saharan Africa that has produced such an annual HIV/AIDS M&E report, (b) cements the progress that Malawi has made to quantify and monitor HIV service coverage, and (c) underlines the NAC s ongoing commitment and dedication in ensuring that HIV/AIDS M&E remains a priority on the national HIV agenda. The national HIV/AIDS M&E system is built around 20 formal data sources, submitted at different intervals by a number of NAC s partners, including the Malawi Government, NGOs, faith-based society and the private sector. The majority of these partners are required to submit the data sources, covering one calendar year of operations, to NAC s Department of Planning Monitoring and Evaluation by the 31 st of January of the following year. One of the major data sources is programme monitoring data that is gathered on a monthly basis through the NAC Activity Reporting System (NACARS). The NAC ARS requires that all organisations that implement HIV interventions (prevention, treatment, care and support interventions) send monthly activity reports to NAC on the coverage of HIV/AIDS services at district level. It is important to track the HIV/AIDS response over time through periodic monitoring and evaluation efforts. However, it is paramount that the information on HIV/AIDS that the NAC collects, captures and summarises in this annual publication, is used effectively and appropriately by the NAC and its partners to improve HIV policies and to improve the planning and implementation of future HIV programmes. I would like to sincerely thank all those organizations that contributed to the monitoring and evaluation process by reporting on activities implemented from July to December 2003 on monthly basis, attending national HIV M&E system orientation workshops and sending annual reports to NAC. I am also very grateful to organizations that have not yet started reporting to NAC but are in the process of making arrangements to do so. I am confident that in the near future all HIV/AIDS implementers will be active participants in the national HIV M&E system. Although the NAC is the custodians of the national HIV/AIDS M&E system, this system and the information it contains, belongs to the nation. It is our collective privilege to responsibly manage this system and to use it to protect our nation and improve the plight of those affected and infected by this epidemic. Dr B M Mwale Executive Director: Malawi National AIDS Commission [[[MG question: should it not be the chairperson of the Malawi NAC Board of Commissioners that signs this foreword?]]]

3 Table of Contents GLOSSARY OF TERMS SUMMARY OF INDICATOR SCORES IMPACT ASSESSMENT OUTCOMES ASSESSMENT INTRODUCTION NATIONAL HIV/AIDS MONITORING AND EVALUATION FINDINGS MONITORING NATIONAL MANAGEMENT AND COMMITMENT RESEARCH STATUS OF NATIONAL M&E SYSTEM REPORTING ON M&E SYSTEM INDICATORS IN NATIONAL M&E PLAN Monthly Activity Reporting Annual Reports From Data Source Institutions Shortcomings QUALITY OF DATA SOURCES QUALITY AND FREQUENCY OF AD HOC INFORMATION REQUESTS STATUS OF NAC DATABASE AND WEBSITE NAC PARTNERS... ERROR! BOOKMARK NOT DEFINED. 7 CONCLUSIONS RECOMMENDATIONS POLICY IMPLICATIONS OF M&E FINDINGS AND RECOMMENDATIONS NAC S M&E WORK PLAN ACHIEVEMENTS GAPS IN THE PLAN ACTIVITIES FOR (INCLUDING MAJOR SURVEYS) RESEARCH TO BE PUBLISHED IN

4 GLOSSARY OF TERMS AIDS ARV BCI BLM BSS CBO CHAM CHS Unit CMS CWIQ DAC DACC DHS EMAS FBO FMA GFATM HIV HMIS HPME HTS IT LMIS M&E MEIS MOEST MOGCS MOHP MOLVT NAC NCPI NGO NSO NTBS OI PLWHA PMTCT PSI QSCR STD STI TWG UNAIDS UNGASS USAID VCT WHO Acquired Immune Deficiency Syndrome Anti-retroviral (treatment) Behavioural Change Intervention Banja La Mtsogolo Behavioural Surveillance Survey Community Based Organization Christian Hospital Association of Malawi Community Health Sciences Unit Central Medical Stores Core Welfare Indicator Questionnaire District AIDS Coordinator District AIDS Coordinating Committee Demographic and Health Survey Education Methods Advisory Services Faith Based Organisation Financial Management Agent Global Fund to fight AIDS, Tuberculosis, and Malaria Human Immunodeficiency Virus Health Management Information System Head of Planning, Monitoring and Evaluation at National AIDS Commission Health Technical Services Information Technology Logistics Management Information System Monitoring and Evaluation Monitoring, Evaluation and Information Systems Ministry of Education Science and Technology Ministry of Gender and Community Services Ministry of Health and Population Ministry of Labour and Vocational Training Malawi National AIDS Commission National Composite Policy Index Non-governmental Organization National Statistics Office National Blood Transfusion Service Opportunistic Infection Persons Living With HIV/AIDS Prevention of Mother-to-Child Transmission Population Services International Quarterly Service Coverage Report Sexually Transmitted Disease Sexually Transmitted Infection Malawi Technical Working Group on HIV/AIDS Joint United Nations Programme on HIV/AIDS United Nations General Assembly Special Session on HIV/AIDS United States Agency for International Development Voluntary Counselling and Testing World Health Organisation

5 1 SUMMARY OF INDICATOR SCORES 1.1 IMPACT ASSESSMENT The goal of the NSF is (a) reduced HIV incidence and (b) improved quality of life of those infected and affected. This is measured through these indicators: EXECUTIVE SUMMARY Table 1: Impact-level indicator scores for 2003 INDICATOR/S % of people who are HIV-infected (by age group (15 19, and 25 49), gender and residence) (GFATM) Syphilis prevalence among pregnant women (by age group (15-19, and 25 49), and residence) (GFATM) 2003 INDICATOR SCORE 14.4% of adults (15 to 49 years), of which 58% are women 760,000 (15 to 49 years) infected (all age groups) infected In rural areas: 12.4% In urban areas: 23.0% Overall prevalence (2003): 2.7% Overall prevalence (2001): 3.9% 15 to 19 years: 2.1% 20 to 24 years: 2.5% 25 to 49 years: 3.1% % of HIV-infected infants born to HIV-infected mothers 26.9% 1 % of orphans and vulnerable children 2 to whom community support is provided (by gender and residence) Ratio of current school attendance among orphans to that among non-orphans, among year-olds (by gender and residence) Data not available for 2003 (only to be included in 2004 DHS survey) Ratio of OUTCOMES ASSESSMENT In order for the NSF s goal in terms of HIV/AIDS in Malawi to be achieved, it is necessary for there to be (a) reduced high-risk sexual behaviours, (b) increased knowledge of HIV/AIDS prevention and (c) decreased stigma and discrimination among general population towards PLWHAs. These are referred to as outcomes, as they represent the result, or outcome, of a number of HIV prevention, care and support interventions. This is measured through the following indicators: 1 Formula-based estimate, using 2002 data 2 In Malawi, an orphan is defined as any person of age younger than 18 years who has lost one or both parents - 1 -

6 Table 2: Outcome-level indicator scores for 2003 INDICATOR/S % of sexually active respondents who had sex with a non-regular partner within the previous 12 months (by gender, residence and marital status) % of people reporting the consistent use of a condom during sexual intercourse with a non-regular sexual partner (by gender, residence and age (15 24, 25 49)) (GFATM) Median age at first sex among year-olds (by gender, residence) (GFATM) % of young people aged who had sex with more than one partner in the last 12 months (by gender, residence) 2003 INDICATOR SCORE BASED ON 2000 DATA 13% of sexually active persons (2000 data) 8.3% of sexually active females aged (2000 data) 33% of sexually active males aged 15 to 54 (2000 data) Summary (2000 data:) 29% of sexually active women 39% of sexually active men Per age group (2000 data): 15 to 19 years 31.9% of women, 28.9% of men 20 to 24 years 32.6% of women, 46.9% of men Per location (2000 data): Urban areas 44.3% of women, 49.6% of men Rural areas 23.4% of women, 36.0% of men Median age for women (aged 20-24): 17.1 years Median age for men (aged 20 24) 17.7 years AGE GROUP Men Women Overall Married 17.4% 1.2% 2.4% Unmarried 70.7% 57% 62% EXECUTIVE SUMMARY % of young people aged who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission (by gender and residence) (GFATM) % of people in general population exposed to HIV/AIDS media campaign (by gender, type of employment and residence) % of population expressing accepting attitudes towards PLWH/As (by gender and level of education) 10% of youth had misconceptions in 2000 Healthy looking person could have HIV o 81.5% of women aged 15 to 19 years o 86.8% of men aged 15 to 19 years o 85.5% of women aged 20 to 24 years o 90.6% of men aged 20 to 24 years This data was not available, as it was not one of the questions in the 2000 Malawi DHS Women indicating that HIV positive person should continue working: 48.7% Men indicating that HIV positive person should continue working: 53.1% Please note that all the indicator scores in this Outcome-level Assessment table for 2003 was taken from the 2000 Malawi DHS. Another DHS is being planned for 2004, and this implies that trends will be evident and missing data will be completed after this round of DHS surveys

7 1.3 MONITORING PROGRAMME OUTPUTS Outcomes in terms of HIV prevention, care and support cannot be achieved unless HIV interventions in the areas of HIV prevention, care, support and treatment are being implemented as part of a nationally coordinated effort are carried out by skilled and experienced organisations. Thus, it is necessary to monitor the extent and coverage of HIV interventions and capacity building efforts. This has been done in the national HIV/AIDS M&E system by focusing on the following aspects of the national HIV response: EXECUTIVE SUMMARY AREA 1: HIV PREVENTION (FOR REDUCED HIV INCIDENCE) A. Information, Education, and Communication (IEC), in order to have an improved, standardized, comprehensive, and effective IEC strategy INDICATOR/S # of HIV/AIDS radio/television programs produced and number of hours aired in the past 12 months (by type of media (radio/television)) # of HIV/AIDS brochures/booklets produced and number of copies distributed in last 12 months (by district) 2003 INDICATOR SCORE HIV/AIDS radio and television programmes, with 46 hours for radio and 36 hours for TV programmes (July Dec 2003) HIV/AIDS brochures/booklets produced (July Dec 2003) HIV/AIDS brochures/booklets distributed (July Dec 2003) B. Promotion of Safer Sex Practices (ABCs), in order to have reduced high-risk sexual behaviour, especially among priority groups such as youth INDICATOR/S % of schools with teachers who have been trained in life-skills-based HIV/AIDS education and taught it during the last curriculum year (GFATM) # of young people aged exposed to lifeskills-based HIV/AIDS education in past 12 months (by gender, district and whether they are in-school or out-of-school youth) # of condoms distributed by social marketing agencies in last 12 months (by type of outlet, district and type of condom) # of condoms distributed to end user 1 in last 12 months (by type of condom and district) 2003 INDICATOR SCORE 6.2% of primary and secondary schools as per 2002 UNGASS report Later information from Ministry of Education teachers from 1577 out of 1808 primary schools were trained, but no data on whether the subject has been taught. 21,114 young people aged 15 to 24 8,039 (38%) out of school youth 13,075 (62%) in-school youth 24,991,484 condoms distributed (Nov 2002 Oct 2003) 10,764, 316 were sold through social marketing agencies For 2003, 1,421,272 condoms per month by MOHP, CHAM, private institutions and NGOs 1 These are condoms distributed by MOHP, CHAM, NGOs and private institutions, and NOT through a social marketing programme. Distribution is tracked in MOHP s Supply Chain Manager System, and other condoms distributed to end users (last point in supply chain) - 3 -

8 C. Prevention of Mother-to-Child Transmission (PMTCT), to have reduced mother-to-child (vertical) transmission of HIV INDICATOR/S % of HIV+ pregnant women receiving a complete course of ARV prophylaxis to reduce the risk of MTCT (by type of provider, district and age (0 24, older than 24) (GFATM) % of health facilities providing at least the minimum package of PMTCT services in the past 12 months (by location and district) % of pregnant women who have been counselled in PMTCT, tested and received their serostatus results in the past 12 months (by age group (0 24, older than 24), type of institution (private/public) and district) % of pregnant women that have been tested, who are HIV positive in the past 12 months (by age group (0 24, older than 24) and district) % of HIV positive mothers who have been provided with 3 month supply of alternative infant feeding in the past 12 months (by age group (0 24, older than 24) and district) % of HIV positive pregnant women offered PMTCT who are referred for care and support services in the past 12 months (by age group (0 24, older than 24) and district) 2003 INDICATOR SCORE 2.0% in % in 2002 (UNGASS indicator 3.6% of health facilities provide PMTCT services were tested for HIV (according to HMIS, % tested not known) According to HMIS: 13% According to NAC ARS data: 18% 456 women (% not known, only partial reporting by one organisation) 62% of those who tested positive were referred for care and support services (partial reporting from one organisation only) EXECUTIVE SUMMARY D. STI Treatment, in order to have improved management and reduced incidence of STIs other than HIV INDICATOR/S % of patients with STIs at health facilities who have been diagnosed, treated, and counselled according to national management guidelines (by gender and age (> 20, and 20 years and older) (GFATM) % of health facilities with STI drugs in stock and no STI drug stock outs of greater than one week within last 12 months (by district) list of drugs selected for survey are available from NAC # of STI cases seen at health facilities in the past 12 months (by type of case (new case or referred partner), district and by gender) 2003 INDICATOR SCORE Data not available, as the MOHP Health Facility Survey was not undertaken in 2003 Frequent drug stock outs are experienced in every site new STIs diagnosed from Jan - Sept 2003 E. Blood Safety, Injection Safety, and Health Care Waste Management, in order to have improved blood safety, injection safety, and health care waste management INDICATOR/S % of health facilities that apply national guidelines for blood screening, storage, distribution & transfusions (by district) % of health care facilities that apply national standards for infection prevention and health care waste storage and disposal (by district) % transfused blood units in last 12 months that have been screened for HIV according to national guidelines (by district) 2003 INDICATOR SCORE No information available, as MOHP Health Facility Survey was not undertaken in 2003 No information available, as MOHP Health Facility Survey was not undertaken in 2003 No information available, as NTBS has not been set up - 4 -

9 F. Voluntary Counselling and Testing (VCT), in order to have improved access to ethically sound VCT services INDICATOR/S % of districts where VCT sites (integrated or stand alone) are located as per national guidelines (every 8 kms in rural areas, and 1 site for every people in urban areas) # of VCT clients tested for HIV at VCT sites and receiving their serostatus results in the past 12 months (by age (0 12, 12+ to 24, older than 24), district and gender) % of clients who have been tested for HIV, who are HIV positive in the past 12 months (by age (0 12, 12+ to 24, older than 24), district and gender) % of HIV positive VCT clients who are referred to care and support services in the past 12 months (by age (0 12, 12+ to 24, older than 24), district and gender) 2003 INDICATOR SCORE 0% of districts in Malawi 86,631 persons (excluding PMTCT) provided with VCT by the public/ngo sectors in persons from July Dec 2003, of which: 61% men 39% women 10,347 were aged 15 to were aged 25 to % tested positive (Jul Dec 2003), of which: 58% men 42% women 81.7% (4095) referred to support services of these: 23% younger than 24 77% older than 24 61% females 39% males EXECUTIVE SUMMARY AREA 2: HIV/AIDS TREATMENT, CARE, AND SUPPORT (TO IMPROVE THE QUALITY OF LIFE OF INDIVIDUALS AND FAMILIES INFECTED AND AFFECTED BY HIV/AIDS) A. Clinical Care (including OI Treatment and ARV Therapy), to ensure increased access to improved and comprehensive health treatment for persons infected with HIV INDICATOR/S % of persons with advanced HIV infection receiving ARV therapy (By age group (0-12, 12+ to 20, older than 20), gender and by type of health facility (public/private)) (GFATM) % of AIDS cases managed for OIs in the past 12 months (by gender and district) (GFATM) % of health facilities with drugs for Opportunistic Infections in stock and no stock outs of greater than 1 week in last 12 months (by district) % of health facilities where ARV services are being offered with no ARV drug stock outs of greater than 1 week in last 12 months (by district) % of detected TB cases who have successfully completed the treatment (by gender, district and by type of TB) 2003 INDICATOR SCORE At least 1,534 persons with advanced HIV (Jul - December 2003): 676 (44%) younger than (56%) older than 20 cotrimoxazole prophylaxis to HIV-positive adults and 584 HIV positive children isoniazid prophylaxis to no one cotrimoxazole to 87% of the 2,734 TB patients who tested positive for HIV No information available, as MOHP Drug Stock Supply Survey for 2003 was not undertaken No information available, as MOHP Drug Stock Supply Survey for 2003 was not undertaken, and ARV drugs are not yet on the list of drugs to be surveyed 70% of smear positive TB cases were cured - 5 -

10 B. Community and Home-based Care and Support, to provide improved quality of life for PLWAs and affected communities: INDICATOR/S # of households receiving external assistance in the past 12 months to care for adults who have been chronically ill for 3 or more months during the past 12 months (by residence, district and type of help) # of persons enrolled at PLWA organisations in the part 12 months (by gender, district and age group (0 15, 15+ to 24, older than 24)) # of community home based care visits in the past 12 months (by residence (rural / urban), district and by type of visit (health care worker / volunteer)) 2003 INDICATOR SCORE households (partial information, from July to December 2003) 1,038 persons (July - Dec 2003) 94% aged 25 years and older 61 PLWAs were 15 to 24 54,070 visits (July Dec 2003), of which 33,086 in rural areas 20,984 in urban areas 13% by health care workers 87% by volunteers EXECUTIVE SUMMARY AREA 3: HIV/AIDS IMPACT MITIGATION To ensure increased social, financial and legal support for orphans and vulnerable children: INDICATOR/S # of orphans and other vulnerable children receiving care/support in past 12 months (by type of support (psychosocial, nutrition, financial), district and gender) # of community initiatives or community organizations receiving support to care for orphans in the past 12 months (by district) 2003 INDICATOR SCORE 24,767 OVCs (July Dec 2003) No data available, as the grants mechanism was not yet in place AREA 4: SECTORAL MAINSTREAMING To provide an increased level of resources, effort, and coordination to respond to the HIV/AIDS epidemic in all sectors: INDICATOR/S % of large private companies and public institutions that have HIV/AIDS workplace policies and mainstreaming programmes (by type of institution (public/private) and by type of expenditure) (GFATM) # and % of employees and their spouses in all sectors that have been reached by interventions defined in their employers workplace policy in the past 12 months (by sector (public/private/civil society), gender and type of support (prevention / care & support)) 2003 INDICATOR SCORE No data available, as the workplace survey was not undertaken by the Ministry of Labour 473 employees, of which 63% women, and 37% males (July Dec 2003) - 6 -

11 AREA 5: CAPACITY BUILDING AND PARTNERSHIPS To provide increased capacity and participation in decision-making and action among all organizations engaged in the national HIV response: INDICATOR/S Amount and % of overall funding received by the NAC that is granted to CBOs, local NGOs, international NGOs, FBOs, government, private sector, educational institutions and international organisations in the last 12 months (by type of organisation) (GFATM) # of CBO alliances created by the NAC or in which the NAC participates in order to increase demand for and supply services to target population (GFATM) Average # of days for grant proposals received by NAC in the past 12 months to be processed (from when the grant proposal is received to when funding is provided) # of project staff and volunteers trained in HIV/AIDS related issues for the purposes of HIV interventions in the past 12 months (by gender and district) 2003 INDICATOR SCORE EXECUTIVE SUMMARY 1.4 MONITORING NATIONAL EFFORT NATIONAL MANAGEMENT AND COMMITMENT To monitor the goal of this area, i.e. to ensure improved national commitment, leadership, and management of the national response to the HIV/AIDS epidemic, the following indicators have been agreed upon: INDICATOR/S Amount of funds spent on HIV/AIDS (by category of expenditure and funding source (government, civil society and donor agencies)) National Composite Policy Index (by questionnaire component) # of times in which the NAC decision-making structures operate to review progress data or to decide program management issues in the past 12 months (# of meetings, agenda, list of participants, decisions made) (GFATM) 2003 INDICATOR SCORE MONITORING AND EVALUATION To generate empirical data and information through biological and behavioural surveillance, research, programme monitoring, and financial monitoring that will direct HIV/AIDS prevention, care and support, and impact mitigation efforts: INDICATOR/S Dissemination of annual publication, the National HIV/AIDS M&E Report, by NAC at the annual NAC M&E dissemination seminar (by sector) % of organisations that have submitted the required number of completed NAC Activity Report Forms on time to NAC in the past 12 months (by type of organisation and whether the organisation is funded by NAC or not) Annual sentinel surveillance at antenatal clinics has been completed on time by MOHP 2003 INDICATOR SCORE - 7 -

12 Development of functioning, accessible research inventory database that registers HIV/AIDS-related research implemented in Malawi % of HIV/AIDS-related research studies in Malawi that are in line with national research strategy, and tracked annually in the national HIV/AIDS research database (by HIV programme area) % of new research studies submitted to the NAC research inventory database in the past 12 months that have been approved for submission at the annual HIV/AIDS Research conference (by HIV programme area) EXECUTIVE SUMMARY - 8 -

13 2 INTRODUCTION TO MALAWI HIV/AIDS M&E SYSTEM Malawi s response to HIV Upon diagnosis of the first AIDS case in Malawi, the Government responded primarily with a health sector-driven response from In October 1999, the National HIV/AIDS Strategic Framework (NSF) was adopted. This changed the focus for the Malawi Government and led, amongst other developments, to the formation of the Malawi National AIDS Commission (NAC). EXECUTIVE SUMMARY The Malawi National AIDS Commission (NAC) The NAC 1, established in July 2001, was mandated to coordinate Malawi s national HIV/AIDS response, within the auspices of the goal of the NSF (to reduce incidence of HIV and other sexually transmitted infections and improve the quality of life of those infected and affected by HIV/AIDS). Further, the NAC was also mandated to provide technical and financial support to implementing agencies and to mobilize resources to support the various initiatives underway against HIV/AIDS. Finally, the Commission was mandated to monitor and evaluate progress and impact of HIV/AIDS prevention, care and impact mitigation interventions. Following 2 years of successful discussions and negotiations to source funding for Malawi s national HIV response, the NAC underwent a further metamorphosis in 2003 when the NAC also assumed the role of a grants disbursement agency. This new role implied that the NAC was responsible to disburse funds to HIV implementers on a grants-basis and in a manner that would be transparent and accountable to the NAC s various donors. One of the requirements of the donors that provided the funding for the NAC s HIV/AIDS grants mechanism, is that the NAC had to develop a system with which to monitor and evaluate the country s response to HIV/AIDS. The National HIV/AIDS M&E System The purpose of Malawi s National HIV/AIDS M&E system is to allow the country to track its progress towards the goals and objectives as stated in the National HIV/AIDS Strategic Framework (NSF). Considering the steady spread of HIV/AIDS, it is important to develop appropriate monitoring and evaluation tools to enable Malawi to assess whether programmes are meeting goals and producing the desired impact on the lives of individuals, families, and communities. The national HIV/AIDS M&E system is documented in the national HIV/AIDS M&E plan. The National HIV/AIDS M&E Plan This Plan is documented in two parts - Part A, the Conceptual Framework and Part B, the M&E operations plan. Whilst Part A is theoretical and conceptual in nature, Part B focuses on all operational aspects associated with the operationalisation of Malawi s national HIV/AIDS M&E system. To this extent, Part B has been conceptually organised into the following sections: (a) definition of 59 national HIV indicators at impact, outcome, and output levels, (b) nomination of a set of 20 data sources through which information for the 59 national HIV indicators would be gathered, (c) description of information products, or reports, which would be produced by the NAC on a periodic basis and used by the NAC to communicate M&E findings to its partners in the fight against HIV and, finally (d) distribution to stakeholders, which included a description of the mechanisms and stakeholders to whom the information products would be disseminated. This is illustrated below: It is essential to note that whilst the Malawi NAC is the custodians of the national HIV/AIDS M&E system and carries the responsibility for the operationalisation of the HIV/AIDS M&E plan, that this is a national HIV/AIDS M&E system and as such, the results, conclusions and recommendations contained in this report, is one of the 1 The NAC is composed of a Board of Commissioners and a Secretariat (NAS). The Board's 19 commissioners are drawn from civil society (including faith communities) and the public and private sectors

14 The M&E Plan emphasizes Malawi's commitment to fighting the epidemic both on the local scene and at international level. Malawi is signatory to multiple international declarations, such as the United National Special Session on HIV/AIDS Declaration (UNGASS) and the Millennium Development Goals. NAC Activity Report System EXECUTIVE SUMMARY

15 3 DETAILED FINDINGS 3.1 IMPACT ASSESSMENT % OF PEOPLE WHO ARE HIV-INFECTED (GFATM) The estimated HIV/AIDS prevalence in adults (15 to 49 years) in 2003 in Malawi was 14.4%, with a range from 12 to 17%. Prevalence is the percent of the population that is infected with HIV. This level of HIV infection in the adult population has remained constant for the last seven years. This means that there are currently about 760,000 adults aged 15 to 49 years infected with HIV, 58% of those infected are women. About women were infected compared to men. The new 2003 prevalence estimates also indicate that HIV infection among adults in urban (23%) areas is almost twice as high as in rural areas (12.4%), and about twice as high in the South as in the North and Central regions. About children aged less than 15 years were infected. In total about Malawians of all ages were infected with the HIV virus in SYPHILIS PREVALENCE AMONG PREGNANT WOMEN Syphilis prevalence among antenatal clinic attendees was 2.7%. Prevalence was not significantly different among women coming from different residences as follows: rural areas (2.8%), semi-urban (2.2%) and urban (2.5%). Syphilis prevalence by age was as follows 15 to 19 years (2.1%), 20 to 24 years (2.5%) and 25 to 49 (3.1%). In 2001, prevalence was 3.9%. % OF HIV-INFECTED INFANTS BORN TO HIV-INFECTED MOTHERS About 26.9% of infants born to HIV-infected mothers were infected with HIV. This data is based on 2002 data, using the UNGASS formula for calculating this indicator score.???? Insert formula % OF ORPHANS AND OTHER VULNERABLE CHILDREN TO WHOM COMMUNITY SUPPORT IS PROVIDED Information was not available for this indicator at outcome level. This is due to the fact that this question was not part of the 2000 Malawi Demographic and Health Survey (DHS). However, (a) this data will be collected during the 2004 DHS and (b) some information was collected at output/process level; it has been included in section??? of this report. RATIO OF CURRENT SCHOOL ATTENDANCE AMONG ORPHANS TO THAT AMONG NON-ORPHANS, AMONG YEAR-OLDS The ratio of school attendance among orphans to that among non-orphans among year olds was OUTCOMES ASSESSMENT % OF SEXUALLY ACTIVE RESPONDENTS WHO HAD SEX WITH A NON-REGULAR PARTNER Overall, 13% of sexually active females and males reported to have had sex with a non-regular partner in Amongst sexually active females aged 15-49, 8.3% respondents reported to have had sex with non- 1 Information from the 2002 UNGASS report Malawi

16 regular partners, in the previous 12 months in the year 2000, while 33% of sexually active males aged 15 to 54 reported likewise1. % OF PEOPLE REPORTING THE CONSISTENT USE OF A CONDOM DURING SEXUAL INTERCOURSE WITH A NON-REGULAR SEXUAL PARTNER (GFATM)1 Condom use during last sexual intercourse with a non-cohabiting partner was 29% and 39% respectively among sexually active women and men. Condom use by age among young females was as follows; 31.9% among women aged 15 to 19 years and 32.6% among women aged 20 to 24 years. More females in urban areas (44.3%) compared to rural areas (23.4%) reported using condoms during last sexual intercourse with non-cohabiting partners. Similarly, condom use by age among young males was as follows; 28.9% among men aged 15 to 19 years and 46.9% among men aged 20 to 24 years. More males in urban areas (49.6%) compared to rural areas (36.0%) reported using condoms during last sexual intercourse with non-cohabiting partners. MEDIAN AGE AT FIRST SEX AMONG YEAR-OLDS (GFATM) Median age at first sexual intercourse for females aged 20 to 24 years was 17.1 years while that for males of the same age group was 17.7 years. Median age at first sexual intercourse for persons aged 20 to 24 years was 17.8 and 17.0 years in urban and rural areas respectively. % of young people aged who had sex with more than one partner in the last 12 months Amongst married youth aged years, 2.4% had sex with more than one partner; 1.2% among females and a higher proportion (17.4%) among males. The proportion was very high for unmarried youth aged 15 to 24 years (62%); 57% among unmarried females and 70.7% among unmarried males. High percentages of unmarried youth aged 15 to 19 years had sex with more than one partner in the previous 12 months as follows; boys (70.6%) and girls (67.5%). Among persons aged 20 to 24 years, more unmarried men (70.7%) had sex with more than one partner compared to unmarried women (42.5%). Married young men (29.4%) and women (2.2%) aged 15 to 19 had sex with more than one partner in the previous 12 months. Among persons aged 20 to 24 years, more married men (26.4%) had sex with more than one partner compared to women (0.8%). % of young people aged who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission (UNGASS) At least eighty-one percent (81.5%) of women aged 15 to 19 years and 85.5% of women aged 20 to 24 years reported that a health looking person could have HIV. Comparatively a higher percentage of men aged 15 to 19 years (86.8%) and those aged 20 to 24 years (90.6%) reported that a health looking person could have HIV. At least 10% of the youth had misconceptions about a healthy looking person in % of people in general population exposed to HIV/AIDS media campaign data not available % of population expressing accepting attitudes towards PLWAs High percentages of women (93.6%) and men (95.9%) expressed willingness to care for AIDS affected relatives. However lower percentages of women (48.7%) and men (53.1%) believed an HIV positive coworker should be allowed to keep working. The latter would reflect the true attitude towards PLWAs. 1 information based on MDHS

17 3.3 PROGRAMME MONITORING OUTPUT ASSESSMENT HIV PREVENTION AND ADVOCACY a) ABCs of Safe Sex % of schools with teachers who have been trained in life-skills-based HIV/AIDS education and taught it during the last curriculum year (GFATM) Information was only available for schools in Southern Malawi. According to reports from MOEST at least 1,577 schools in the southern region of Malawi had primary school teachers trained in standard 4 life skills based education 1 out of 1,808. But there is no evidence that the trained teachers taught the subject. In 2003, about 4,385 primary school teachers were trained in life-skills based HIV education in the southern region of Malawi. About 840 secondary school teachers and 104 tutors from teachers training colleges were trained in throughout Malawi. In % of schools had teachers trained in life-skills-based education who taught the subject during the last academic year in the country 2. # of young people aged exposed to life-skills-based HIV/AIDS education From July to December 2003 at least 21,114 young people aged 15 to 24 were exposed to life-skills-based HIV/AIDS education. Out of the total 8039 (38%) were out of school youth while 13,075 (62%) were inschool youth. Life skills based education was reported for 8 districts only. These are Dedza, Lilongwe, Mchinji, Mzimba, Nkhotakota, Nsanje, Salima and Thyolo. More male in-school-youths 9315 (71%) were exposed to HIV/AIDS education than females 3,760 (29%). Similarly, more male out of school youths 4373 (54%) were exposed to HIV/AIDS education than females 3,666 (46%). Life-skills-based HIV/AIDS education was only reported in 8 districts; 1 in Northern Region, 5 in the Central Region and 2 districts in the Southern Region of the country. Number of young people aged exposed to life-skills-based HIV/AIDS education, July to December 2003 District In school youth Out of school youth Male Female Subtotal Male Female Subtotal Total Dedza Lilongwe Mchinji Mzimba MOEST Division Reports on training of standard 4 teachers and head teachers in life skills education 2 Follow-up to the declaration of commitment on HIV/AIDS (UNGASS):Country report for Malawi

18 Nkhotakota Nsanje Salima Thyolo 7,766 2,872 10,638 3,816 3,169 6,985 17,623 Total 9,315 3,760 13,075 4,373 3,666 8,039 21,114 # of condoms distributed by social marketing agencies in 2003 A total of 24,991,484 condoms were distributed free or sold to consumers by public/ngo sectors from November 2002 to October Seventy eight percent of socially marketed condoms were sold by PSI. BLM sold 2, 350, 000 condoms. Therefore approximately 10,764,316 socially marketed condoms were sold in PSI condoms are widely sold in the country throughout the country. However, lower sales were reported for Nsanje, Chitipa and Likoma districts. PSI condom sales by district, Region District Condoms (number) South Balaka Blantyre Chikwawa Chiradzulu Machinga Mangochi Mulanje Mwanza Nsanje Phalombe Thyolo Zomba 110,700 2,769, ,824 6, , ,684 87,480 66,852 26,784 88, , ,996 Condoms (percent) South Total 4,310, Coverage of essential HIV/AIDS services in Malawi 2 PSI annual report

19 Centre Dedza Dowa Kasungu Lilongwe Mchinji Nkhotakota Ntcheu Ntchisi Salima 109, , ,760 1,850, , , ,680 41, , Centre Total 3,083, North Chitipa Karonga Likoma Mzimba Mzuzu Nkhatabay Rumphi 12, , , , , , North Total 1,019, PSI condom sales by outlet, 2003 Out let Number of Condoms Chain W/S 981,072 Government 75,168 Independent retailers 605,052 Independent W/S 3,258,036 Institutions 332,640 NGOs 2,340,720 Private hospitals 21,600 Retain Chain 338,904 High Risk 325,476 Other 135,648 Total 8,414,316 # of MOHP condoms dispensed to end user in

20 Consumption of condoms for the year 2003 was 1,421,272 pieces per month. The data was collected from the LMIS-07 and LMIS-06, which were part of Logistics Management Information Systems forms for the Reproductive health Logistics Management Information System (RHLMIS) 1. The condom figure represents condoms distributed by MOH, CHAM, Private institutions and NGOs. b) Information Education and Communication # of media HIV/AIDS radio/television programs produced and number of hours aired At least 1055 HIV/AIDS radio and television programmes were produced from July to December These programmes comprised about 46 hours for radio and 36 hours for TV programmes. Media HIV/AIDS radio/television programs produced and number of hours aired, July to December 2003 Process Radio Television Total # Programs produced ,055 # Hours Aired # of HIV/AIDS brochures/booklets produced and number of copies distributed From July to December 2003 at least HIV/AIDS brochures/booklets were produced and were distributed for public consumption. Brochures book lets were distributed at least in 12 districts from July to December # of HIV/AIDS brochures/booklets produced and number of copies distributed District Number of Number of Brochures/Booklets Brochures/Booklets Produced distributed Balaka Blantyre 200 8,352 Dowa 7,375 7,485 Kasungu - 12 Machinga 888 3,770 Mangochi Mzimba Mzuzu Nkhatabay - 10 Nsanje 4 4 Phalombe 3,000 3,000 Thyolo 504 4,120 1 JSI Delever Project, MOH

21 Total 12,060 27,538 c) Infection Prevention and Health Care Waste Management % of health facilities that apply national guidelines for blood screening, storage, distribution & transfusions. Information not available % of health care facilities that apply national guidelines for infection prevention and safe health care waste storage and disposal In 2002, 75% of health facility departments did not have more than 2 health care waste containers in the country. As many as 47% of health facility departments did not have safety boxes for sharps 1. % transfused blood units in last 12 months that have been screened for HIV according to national guidelines Information not available d) Prevention Of Mother to Child Transmission % of HIV positive pregnant women receiving a complete course of ARV prophylaxis to reduce the risk of MTCT (GFATM) According to the 2003 sentinel surveillance, 19.8% of pregnant women were HIV positive births were expected in Therefore about pregnant women were HIV positive. About 2198 women received ARV to prevent mother-to-child transmission 2. Therefore, only 2% of HIV positive pregnant women received a complete course of ARV prophylaxis to reduce the risk of MTCT. There is evidence of provision of nevirapine for PMTCT in 10 districts only, 3 in the Northern Region, 3 in the Central Region and 4 in the Southern Region. PMTCT prophylaxis Hospital District Number of women given nevirapine Chitipa District Chitipa 0 Karonga (KPS) Karonga 18 Livingstonia Mission Rumphi 10 Ekwendeni Mzimba 33 Embangweni 52 Kasungu District Kasungu 11 1 Injection safety and health care waste management policy and action plan assessment report 2 Report of a Country-Wide Survey of HIV/AIDS Services in Malawi: for the year MOH, NAC

22 St Annes Mission Nkhotakota 11 LLW Central Hosp Lilongwe 1600 LLW Mlale Mission 0 Likuni Mission 24 St Gabriels Mission 53 Mangochi District Mangochi 0 Thyolo District Thyolo 255 Malamulo Mission 2 Mwanza District Mwanza 87 Chiradzulu District Chiradzulu 23 St Josephs Mission 19 % of health facilities providing at least the minimum package of PMTCT services in 2003 About 473 hospitals, rural hospitals and health centres provide ANC services in the country 1. Seventeen health facilities 2 (3.6%) provided PMTCT services in % of pregnant women who have been counselled, tested and receiving their serostatus results in 2003 Number of women tested for HIV Hospital Number of women Number tested for HIV women positive Chitipa District 37 3 Karonga (KPS) Livingstonia Mission Ekwendeni Embangweni Kasungu District St Annes Mission LLW Central Hosp LLW Mlale Mission Likuni Mission St Gabriels Mission Mangochi District 1 0 Thyolo District Malamulo Mission 19 2 Mwanza District Chiradzulu District St Josephs Mission HMIS Bulletin: Annual report, July 2002-June Report of a Country-Wide Survey of HIV/AIDS Services in Malawi: for the year MOH, NAC of HIV

23 At least pregnant women were tested for PMTCT as shown in table ##. From July to December 2003 at least 1850 pregnant women were counselled tested and received their results from the following districts: Mwanza, Mzimba, Mzuzu and Thyolo. Of these 1040 (56.2%) were aged 15 to 24 while 810 (43.8%) were aged 25 to 49 years. % of pregnant women that have been tested in 2003, who are HIV positive At least 3,383 (13%) pregnant women who were tested were HIV positive 1. See table ##. According to NACARS 337 out of the 1,850 who were tested between July and December 2003 were HIV positive (18%). % of HIV positive pregnant women who have been provided with 3 month supply of alternative infant feeding in 2003 From July to December 2003 at least 456 women were provided with supplies of alternative infant feeding. These were only reported for Thyolo by MSF Luxemborg.. % of HIV positive pregnant women offered PMTCT who are referred for care and support services Out of 337 who tested positive at least 209 (62%) pregnant women were referred for care and support services from July to December PMTCT clients referred for care and support services, July to December 2003 District Younger than 24 Older than 24 Kasungu - 6 Mwanza Mzuzu 1 5 Thyolo Total e) Treatment of STIs #% of patients with STIs at health facilities who have been diagnosed, treated and counselled according to national management guidelines (GFATM) Data for this indicator is not available due to the fact that the data source required to provide this indicator score, an MOHP-coordinated health facility survey, did not take place in time. #% of health facilities with no STI drug stock outs of >1 week within last 12 months data not available 1 Report of a Country-Wide Survey of HIV/AIDS Services in Malawi: for the year MOH, NAC

24 Health centres received 2 tins of STI drugs per month 1. This could not take them to the end of the month before getting another supply. As such there were frequent stock outs not because the country has no drugs but because the district did not supply enough quantity. # of STI cases seen at health facilities in 2003 At least new sexually transmitted infections were diagnosed from January to September f) Voluntary Counselling and Testing % of districts where VCT sites (integrated or stand alone) are located as per national guidelines (every 8 kms in rural areas, and 1 site for every people in urban areas) Zero districts had VCT sites, integrated or stand alone, located every 8 kms in rural areas and one site for every 10,000 people in urban areas. # of clients tested for HIV at VCT sites and receiving their serostatus results 86,631 persons (excluding PMTCT) were provided with HIV counselling and testing by the public/ngo sectors in Seventy sites (public/ngo) offered VCT services in the country. From July to December 2003 at least persons were offered VCT. Out of these, 13,752 (61%) were males, 8,895 (39%) were females, 10,347 (46%) were aged 15 to 24 and 12,300 (54%) were aged 25 to 49 years. VCT was reported only in 13 districts (46% of districts), 1 in the Northern Region, 6 in the Central Region, and 5 districts in the Southern Region. Clients tested for HIV at VCT sites and receiving their serostatus results, July to December District Male Female Total Blantyre ,596 Dedza Dowa Lilongwe 3,375 3,355 1,430 1,253 9,413 Mangochi Mchinji Mwanza Mzimba ,407 Mzuzu Nkhotakota Nsanje Salima Thyolo 2,109 2,671 1,796 2,990 9,566 Total 6,558 7,194 3,789 5,106 22,647 1 Supply Chain Manager through JSI Deliver Project

25 % of VCT clients who have been tested for HIV, who are HIV positive At least (22%) were positive amongst those accessing VCT from July to December More females (58%) were HIV positive than males 2097 (42%) though more males attended VCT sites. More clients tested HIV positive among people aged more than 24 years, out of (31.6%), compared to youth aged 15 to 24. Amongst the youth, 1127 out of (10.9%) tested positive. VCT clients who have been tested for HIV, who are HIV positive, July to December 2003 District Male Female Total Blantyre Dedza Dowa Lilongwe ,225 Mangochi Mchinji Mwanza Mzimba Mzuzu Nsanje Salima Thyolo 207 1, ,392 3,098 Total 334 1, ,123 5,013 % of HIV positive VCT clients who are referred to care and support services in the past 12 months Out of those who tested positive, 4,095 (82%) were referred to support services; 937 (23%) were aged 24 and below while 3,158 (77%) were aged above 24 years. More females (61%) were referred compared to men (39%). HIV positive VCT clients who are referred to care and support services, July to December 2003 District 24 years and below Above 24 TOTAL Male Female Male Female Blantyre Kasungu Lilongwe

26 Mchinji Mzimba Mzuzu Nsanje Salima Thyolo ,104 2,500 Total ,378 1,780 4, TREATMENT CARE AND SUPPORT a) Clinical Care % of persons with advanced HIV infection receiving ARV therapy (GFATM) Ever since ART programmes started in the country, 6, 414 patients had been started on ARV drugs 1 by the end of At least 3,703 patients started ART in At least 1534 persons with advanced HIV were on ARV from July to December 2003; 676 (44%) were aged 20 and below whereas 858 (56%) were aged over 20 years. Persons with advanced HIV infection receiving ARV therapy, July to December 2003 Gender <= 20 years > 20 years Grand Total Male Female ,240 Total ,534 Nine sites were offering ARV by the end of Six were paying sites while 3 were for free (these are Chiradzulu Hospital, St Joseph Hospital and Thyolo Hospital supported by MSF Luxemborg). Three of the health facilities providing ARV therapy are public institutions. Health facilities providing ARVs in 2003 Health facility No. months No. patients Type of health providing the started on ART in facility service 2003 Ekwendeni MH 6 59 CHAM 1 Report of a Country-Wide Survey of HIV/AIDS Services in Malawi: for the year MOH, NAC

27 Lighthouse LLW Private Mtengwathenga MH CHAM ABC Hospital LLW Private Mikoke Hosp Ntcheu CHAM Chiradzulu DH Public St Josephs CHAM MH Nguludi Thyolo DH Public QECH Blantyre Public Total % of AIDS cases managed for OIs in the past 12 months (GFATM) At least HIV-positive adults and 584 HIV positive children were receiving cotrimoxazole prophylaxis. No persons were reported to be prescribed isoniazid prophylaxis. Eighty seven percent of HIV positive TB patients were prescribed cotrimoxazole out of the 2734 TB patients who tested positive for HIV 1. % of health facilities with drugs for OIs in stock and no stock outs in last 12 months of > 1 week By district Data not available % of health facilities where ARV services are being offered with no ARV drug stock outs of > 1 week in last 12 months By district Data not available % of detected TB cases who have successfully completed the treatment in the past 12 months By gender, district and type of TB (smear negative and extra pulmonary, smear positive) In 2003 a total of 26, 836 TB cases were registered in the country in 44 health facilities 2. This data is for new smear positive TB cases registerd the whole year of 2002.Total cases were 7,686 and those that were cured were 5,365,representing 70%,Failures were 100, representing 1%,those that completed treatment were 207, representing 3%, those that died 1500 representing 19%. defaulters were 331 representing 4% and Transfer out cases were 198,representing 3%. But you will see that cases notified are less than cases evaluated.this is due to delays by certain microscpy centres that are doing sputum smears to send smear positives cases diagnosed in those centres hence by the time the data is collected they are left out but when it comes to RX outcomes they are evaluated. 1 Report of a Country-Wide Survey of HIV/AIDS Services in Malawi: for the year MOH, NAC 2 Report of a Country-Wide Survey of HIV/AIDS Services in Malawi: for the year MOH, NAC

28 b) Community Home-Based Care # of households receiving external assistance in the past 12 months to care for adults who have been chronically ill for 3 or more months during the past 12 months At least 19,706 households received external assistance from July to December 2003 to care for chronically ill adults. The majority of households, (55%) received psychosocial support. Nutritional (19%), medical (13%), domestic (11%) and financial (2%) support services were also provided. Households receiving external assistance to care for adults who have been chronically ill for 3 or more months, July to December 2003 District Type of support Psychosocial Nutritional Financial and resources Medical Domestic Total Blantyre ,699 Dowa Kasungu ,305 Lilongwe 7,987 1, ,340 2,026 14,206 Machinga Mangochi Mchinji ,942 Mzimba ,000 Mzuzu Nkhatabay Nsanje Ntchisi Phalombe 85 1, ,039 Salima Thyolo 9,015 1, ,327 Total 19,706 6, ,683 3,797 35,846 # of persons enrolled at PLWA organisations At least 1,038 persons were enrolled at PLWA organisations from July to December Ninety four percent of these (977) were aged 25 years and above. Only 61 (6%) registered PLWAs were 15 to 24 years old; 545 were females whereas 493 were male. Persons enrolled at PLWA organisations DISTRICT Age 15 to 24 years Age above 24 years Male Female Sub total Male Female Sub total TOTAL

29 Blantyre Chikwawa Kasungu Lilongwe Mangochi Mchinji Mwanza Mzimba Mzuzu Salima Thyolo Total ,038 # of community home based care visits A total of 54,070 CHBC visits were made: 33,086 (61%) in rural areas and 20,984 in urban areas (39%), from July to December In both rural and urban areas more volunteer visits than health worker visits were made. In total health workers made 7,205 (13%) visits while volunteers made 46, 865 (87%) visits. CHBC visits were reported in 14 districts. # community home based care visits District # Visits Health care worker Volunteer Sub Rural Urban total Rural Urban Sub total Grand Total Blantyre ,706 1,995 Chikwawa Dowa ,839-5,839 5,839 Kasungu ,096-3,096 3,311 Lilongwe 29 4,474 4, ,480 12,521 17,

30 Machinga Mangochi Mchinji ,308-5,308 5,732 Mzimba 3-3 1,363-1,363 1,366 Mzuzu ,050 2,404 4,454 5,169 Nsanje Ntchisi 8-8 1, ,832 1,840 Phalombe Salima ,069-2,069 2,608 Thyolo ,940-7,940 8,336 Total 2, ,205 30,682 16,183 46,865 54, IMPACT MITIGATION a) Orphans and Vulnerable Children # of orphans and vulnerable children receiving care/support in 2003 At least 24,767 orphans and vulnerable children received care and support from July to December in 2003; 24,767 (42%) received psychosocial support 18,733 (32%) received nutritional support and 11,526 (20%) received school fees support. Orphan support was reported for 12 districts. # orphans and vulnerable children receiving care/support District Type of support Total Counselling Nutrition Fees Other Balaka Blantyre Lilongwe , ,138 Machinga ,243 Mangochi ,045 Mchinji 1,714 1, ,810 Mulanje 3,605 3, ,206 Mwanza

31 Mzimba 2,928 3,308 6,205 2,903 15,344 Mzuzu 3, ,997 Neno 9,831 6, ,935 Salima Thyolo 886 1,134 2,020-4,040 Total 24,767 18,733 11,526 4,150 59,176 # of community initiatives or community organizations receiving support to care for orphans data not available SECTORAL MAINSTREAMING % of large enterprise/companies and public sector institutions that have HIV/AIDS workplace policies and programmes (GFATM) At least 17.5% of public sector institutions had HIV/AIDS workplace policies and programmes in # and % of employees and spouses in all sectors that have been reached by interventions defined in their employers workplace policy Only 473 employees and spouses were reported to have been reached by work place interventions. More females, 296 (63%), were reached than males, 177 (37%). Out of 11 organizations which reported to have work place policies, 9 (82%) were NGO/FBO while 2 (18%) were from the public sector. Organizations with HIV/AIDS Workplace Policies Organization CADECOM- Mchinji Centre For AIDS Care Education and Training Concern Universal- Blantyre ESCOM-Clinic -Lilongwe GUILLEME Action for AIDS -GAGA Livingstonia Synod AIDS Control Program Malawi Police Headquarters- Lilongwe Medecines Sans Frontieres -Luxembourg SOS -Medical Centre Word Alive Ministries International YOPACO Type of organization NGO NGO NGO Public NGO FBO Public NGO NGO NGO NGO CAPACITY BUILDING AND PARTNERSHIPS Amount of funds that NAC granted to implementers A total of MWK was disbursed as grants by NAC in Funds for grants were from Pool donors, which consists of; CIDA, DFID, NORAD, Malawi Government, World Bank and discrete 1 Follow-up to the declaration of commitment on HIV/AIDS (UNGASS):Country report for Malawi

32 donors; UNDP and GFATM. The figures in table ## indicate that the private sector did not get a big share compared to the civil society and public sector. Amount of funds that NAC granted to implementers by type of organisation Number of Beneficially type grants Amount Approved Amount paid FBO 21 14,372, ,713, CBO 77 49,813,723 29,252,560 Private sector 17 9,943, ,009, Education Institutions 7 9,511,523 9,511,523 Public Sector ,660,802 68,068,342 NGO 29 52,947,230 36,240,678 Total ,248, ,796, # of CBO alliances created by the NAC or in which the NAC participates in order to increase demand for and supply services to target population (GFATM) data not available Average # of days for grant proposals received by NAC in the past 12 months to be processed (from when the grant proposal is received to when funding is provided) Data not available # of project staff and volunteers trained in HIV/AIDS related issues for the purposes of HIV interventions At least 2,405 persons were trained in HIV/AIDS related issues for the purposes of HIV interventions; 945 and 1,460 staff (39%) and volunteers (61%) respectively were trained in HIV/AIDS related issues. Training of staff and volunteers was reported for 15 districts. Project staff and volunteers trained in HIV/AIDS related issues District # of staff # of volunteers trained trained Blantyre Chikwawa 3-3 Dedza Dowa Kasungu Lilongwe Machinga Mangochi Mchinji Mzimba Mzuzu Nkhatabay Grand Total

33 Nsanje Ntchisi Salima Thyolo Total 945 1,460 2, MONITORING NATIONAL MANAGEMENT AND COMMITMENT Amount of funds spent on HIV/AIDS From July 2002 to March 2003 MWK 1, 166, 692, 451 was spent on HIV/AIDS. (UNGASS) Amount of funds spent on HIV/AIDS, July March 2003 Institution Amount Estimated MOHP expenditure on HIV/AIDS MWK 1,138,760, MWK allocation to NAC (actual expenditure) MWK 16,000, % sector ministry allocation to HIV/AIDS MWK 11,932, MWK total MWK 1,166,692, US$ equiv $ 12,963, National Composite Policy Index (NCPI) score The composite index covers the following four broad areas; strategic planning, HIV prevention, human rights, and care and support. A number of specific policy indicators have been identified for each of these policy areas. A separate index is calculated for each policy area by adding up the scores (yes=1, no=0) for the relevant specific policy indicators and calculating the overall percentage score. The composite index is calculated by taking the average of the scores for the four components. National Composite Policy index in 2003 was 80%, that is 16 out of required National Composite Policy index in 2003 Component Score (Number of accomplished processes) Required processes Strategic Planning 7 7 Human Rights 2 4 Prevention, 4 6 Care and Support UNGASS report, Malawi

34 # of times in which the NAC decision-making structures operate to review progress data or to decide program management issues in the past 12 months (GFATM) NAC management meets monthly to review progress. The NAC Board of Commissioners meet on quarterly basis to review progress. 4 RESEARCH a) HIV/AIDS Research Strategy The process to come up with an HIV/AIDS research strategy is under way. b) Research database A research database has been developed initially in excel platform. This will be imported into access database. It has data on Researchers: Type of Research:Geographical Coverage: Programme Area: Location Of Raw Data: Location of Report: Form of Dissemination of Results: Dissemination Date: Objective, Methodology, Results and Keywords. The data in this warehouse includes research abstracts submitted since c) The research database shows that research was done in the following fields: 1. Prevention IEC Promotion of safe sex VCT PMTCT STI Safe blood 2. Community Home based care 3. Impact mitigation 4. Basic science. 5. Social economic 6. HIV/AIDS Epidemiology Research abstracts captured on database Before submission of research abstracts for the 2004 Research Conference, the research database contained 123 abstracts. The majority of research abstracts fall under clinical studies (31%), social ecomomic studies (20%), prevention (20%) and epidemiological studies (19%). Very few abstracts were captured in the data base for the following areas; impact mitigation (2%), basic science (4%) and CHBC (5%)

35 Research field Prevention 24 (20%) IEC 2 (2%) Promotion of safe sex 2 (2%) VCT 7 (6%), PMTCT 5 (4%) STI 7 (6%). Safe blood and universal precautions 1 (1%) Community Home based care 6 (5%) Impact mitigation 2 (2%) Basic science. 5 (4%) Social economic 25 (20%) Clinical studies 38 (31%), HIV/AIDS Epidemiology 23 (19%) Number of abstracts # (%) Date of annual HIV/AIDS research seminar The research dissemination conference will be held from 5 th to 6 th May 2004 at MIM. The conference will be attended by at least 150 participants. % of research abstracts that have been submitted for annual research dissemination seminar, that have been accepted Out of 51 submitted abstracts, 44 were accepted. National HIV/AIDS research strategy that has not been included in completed or proposed research A research strategy is not yet in place % of organisations that have submitted the required number of completed NAC Activity Report Forms on time Only 5 organizations submitted the required number of completed NAC Activity Report Forms (100% reporting). Three organizations submitted reports for 5 months. Reporting was generally poor. Annual HIV ANC sentinel surveillance Annual HIV ANC sentinel surveillance was completed in time by a working group consisting of NAC, MOHP, WHO and CDC. Preparations for the 2004 sentinel surveillance survey are in progress. % of HIV/AIDS-related research studies in Malawi that are in line with national research strategy, and tracked annually in the national HIV/AIDS research database Not applicable as the strategy is not developed

36 5 STATUS OF NATIONAL M&E SYSTEM??? insert the section from the End of Mission report The national M&E system is in its infancy and needs more effort by NAC, M&E data source institutions and implementing agencies. The national HIV M&E Plan aims at tracking 59 indicators and has 20 official data sources. The 20 data sources belong to 10 different institutions. This is the first national annual M&E report on the multi-sectoral HIV/AIDS response in Malawi. Alternative data sources had to be used to complement information from formal data sources, due to under reporting and non-reporting by data source institutions and the majority of implementing agencies. 5.1 REPORTING ON M&E SYSTEM INDICATORS IN NATIONAL M&E PLAN MONTHLY ACTIVITY REPORTING Currently the NACARS is the only system that has potential to provide comprehensive HIV/AIDS response information at output/process level. An operational NACARS system would guarantee gathering of adequate information for evidence-based strategic planning. The NACARS can show neglected program intervention areas, as well as geographical areas. Conversely, the system would be instrumental in avoiding duplication of efforts. The success of the system depends on the cooperation of organisations implementing HIV intervention programmes by constantly sending verified and accurate monthly reports to NAC. Piloting of the monthly NACARS process was done between July and December 2003 whereby 131 organisations were oriented in the national HIV/AIDS M&E system. All organizations oriented in the national HIV/AIDS monitoring and evaluation system were expected to participate in the piloting of the NACARS. However, out of 131 oriented organizations, only 30 reported in the first quarter, July- September 2003 and only 62 reported in the second quarter, October to December A revised set of Guidelines to the NAC Activity Report System is being finalised. Plans to conduct a national launch are underway. Some remarkable achievements in this quarter include increased number of reporting organisations. In the second quarter, October to December 2003, 43% of oriented organisations reported as compared to 17% in the previous quarter ANNUAL REPORTS FROM DATA SOURCE INSTITUTIONS NAC held a series of meetings with Data Source Institutions between July and December in The major agenda in these meetings was to request institutions to provide information annually to NAC to inform one or a couple of indicators in the National HIV/AIDS M&E Plan. All data source institutions outlined in the M&E plan agreed to provide NAC with information annually, and to ensure that information would be sent by 31st January of the next year. Each of the organisations were given copies of the M&E plan and NACARS guide lines. In October 2003 official communications were sent to confirm what was agreed in the mentioned meetings SHORTCOMINGS

37 There was an increase in reporting rate for NACARS from quarter one to quarter 2 (October to December 2003), some of implementing organisations that reported for quarter 1 (July to September 2003) did not report for the second quarter. Reporting rate was very low. Major implementers MOH and CHAM have not been oriented in NACARS. However CHAM had 5 persons trained as trainers in NACARS.??? Need to list the organisation that have been able to provide any kind of data to NAC All data source institutions except, PSI international, submitted their reports very late to NAC. PSI provided all the information as required in the national M&E plan. Some of the data source institutions did not present their information in the requested format and did not manage to provide all the required information. Some data sources are newly established and could not provide information. Much needs to be done by NAC and Data Source Institutions to ensure timeliness and completeness of annual reports to NAC. Providentially, the information required by NAC is not much. 5.2 QUALITY OF DATA SOURCES Table 3: Quality and timeliness of M&E system data sources DATA SOURCE STATEMENT ABOUT QUALITY TIMELINESS OF INFORMATION SUBMISSION Abstract book from HIV/AIDS Research Conference Good quality Very late Condom distribution data from social marketing agencies (PSI) good quality Timely DHS / BSS / CWIQ Good quality though most of the required tabulations were not presented in the 2000 DHS report Drug Stock Supply Report System newly established N/A FMA Financial Management System report N/A Health facility survey N/A N/A HMIS Annual report MOEST Inspection Reports NAC database NAC meeting minutes NAC records Information on extra tabulations late N/A Out of the 8 indicators expected from HMIS only one had itsvery late information available for January to December 2003 Information given only for 3 MOEST Divisions and not givenvery late in the required format National HIV/AIDS M&E Report More detailed information lacking Late National HIV/AIDS research database Good quality NBTS report Newly established organization N/A timely NCPI questionnaire Good quality Timely Quarterly Service Coverage Report Good quality Late

38 DATA SOURCE STATEMENT ABOUT QUALITY TIMELINESS OF INFORMATION SUBMISSION Sentinel surveillance report Good quality timely Supply Chain Manager Minimal information given Very late UNAIDS/NCPI Financial resource flow survey N/A N/A Workplace survey N/A N/A 5.3 QUALITY AND FREQUENCY OF AD HOC INFORMATION REQUESTS Various institutions and implementing organizations send information requests to NAC by telephone, and in person. These are given the information accordingly. 5.4 STATUS OF NAC DATABASE AND NAC WEBSITE The National HIV/AIDS M&E plan of Malawi stated that???? 6 CONCLUSIONS Evidence based on information flowing to NAC indicates that the following districts are better saved: Thyolo, Lilongwe and Blantyre. It has to be noted that interventions in these districts do not cover whole districts. These districts for instance have at least VCT, PMTCT, ARV, Impact Mitigation and Capacity building programmes. The following are districts with least number of HIV/AIDS intervention programmes: Rumphi, Zomba, Chikwawa, Karonga, Chitipa, Likoma, Balaka, Dedza, Mulanje, Nkhatabay, Ntcheu, Ntchisi and Phalombe. In all these districts there is no evidence of basic HIV/AIDS programmes such as VCT and Life skills based HIV education to out of school youth. Most common intervention programmes are condom distribution to end users, capacity building, orphan care and support to PLWAs. These programmes need to be maintained and scaled up. However ARV programmes and life skills based education, especially to out of school youth are very rare programmes. Based on information flowing to NAC ARVs are currently dispensed only in 6 districts out of 28 districts while life skills education to out of school youth is only provided in 8 districts. Specific conclusions for each of the programme areas have been summarised below: Information, Education, and Communication

39 A lot was done in this area. Implementing organizations and NAC produced a substantial number of materials between July and December Lots of programmes were produced for TV and radio between July and December Promotion of Safer Sex Practices (ABCs) Much was done in this area. Roughly, 25 million condoms were distributed. Statistics indicate that all districts except Likoma got condoms from PSI. The Government nd BLM also played a very crucial role. Female condoms are however not widely used in the country. Life skills based education to out of school youth was not provided in many districts. Furthermore, due to unavailability of data the number of schools where life skills based education was taught is not known. Prevention of Mother-to-Child Transmission PMTCT was only implemented in 10 districts. There is an urgent need to expand PMTCT services to all districts by both public sector and civil society. MTCT is an important mode of HIV transmission accounting for about 10% of infections. Referral of HIV positive pregnant mothers was satisfactorily done by NGO implementing PMTC since only clients with AIDS symptoms need to be referred. This momentum should be maintained. Voluntary Counselling and Testing This is a fundamental programme as regards curbing the HIV epidemic. VCT needs to be accessible to as many persons as possible. There is evidence that VCT was provided in 11 districts. This is by far a low coverage for an epidemic which was detected in Extra support is vital to the MOH, MACRO and other implementing organisations to scale up VCT. A good percentage of youth (46%) accessed VCT. However fewer females (39%) accessed VCT compared to males. And more females tested positive than males. Implementing agencies should aim at increasing this percentage. Clinical Care (incl. ARV Therapy) Information on treatment of opportunistic infections was not available apart from that related to TB. Cotrimoxazole prophylaxis was provided to TB patients. No persons were reported to be prescribed isoniazid prophylaxis. Available information shows that cotrimoxazole prophylaxis is prescribed in 13 districts. There is an urgent need to expand this programme to all district hospitals and mission hospitals. Community and Home-based Care and Support Community and Home-based Care and Support is one of intervention programmes which are gaining ground in the country. A reasonable number of households received external assistance from July to December 2003 to care for chronically ill adults. The majority of households received psychosocial support with fewer nutritional and medical support. VCT scaling up will contribute the increase in number of registered PLWA with support organizations. These organisations need to expand to as many areas as possible with strong social mobilisation to have an increased number of clients

40 All kinds of support are equally important though psychosocial support may need to precede the other kinds of support. Considering the high prevalence of AIDS, very few PLWAs are registered with organizations. This justifies that stigma is still rampant. Support for Orphans and Vulnerable Children (OVC) Orphans were supported in at least 12 districts. They received psychosocial, nutrition and school fees support which are all very important requirements for orphans. Shelter is one of the major needs for orphans and should also be provided. Sectoral Mainstreaming Very little has been done in this programmes area. All sectors need to maistream HIV/AIDS programmes at least at the work place. Mainstreaming HIV/AIDS at the core function is even more robust. The few organizations which have mainstreamed HIV/AIDS at the workplace concentrate on IEC and condom distribution. Capacity building & Partnerships A total of MWK funded by Pool and Discrete Donors was disbursed as grants by NAC in This is indicative of the commitment and cooperation of international development partners. At least 2,405 persons were trained in HIV/AIDS related issues for the purposes of HIV interventions between July and December Though many people are undergoing training in HIV/AIDS related issues, the majority (61%) are volunteers. Malawi has inadequate trained staff and is losing staff to AIDS in the health sector and other sectors. 7 RECOMMENDATIONS Operationlisation of M&E system: Need to improve or simplify the way in which indicator data is disaggregated Need to follow up with data source providers to ensure that accurate and valid data is received from each organisation responsible for providing data sources. Implementing agencies should strongly consider expanding to other districts across Malawi ARV programmes should be scaled up to other districts considering high death rates Out of school youth and in-school youth should both be targeted equally with life skills based education. Out-of-school youth and in-school youth should be equally targeted for life skills based education Strategies should be put in place to improve HIV/AIDS information flow from Implementing organizations to NAC and vice-versa Monitoring, evaluation and research

41 All major HIV/AIDS implementers should contribute towards the National HIV M&E system. NAC should sign grant agreements with all data source institutions/departments within institutions. NAC grantees should use 5 to 10% of their budgets for M&E activities. Implementing agencies should send timely reports to NAC and the latter send timely feed back reports. Development partners should maintain support towards the CEHS and CWSHS annual surveys. NAC should also support these surveys while the national HIV M&E system is in its infancy. An HIV/AIDS national research strategy has to be developed. Promotion of Safer Sex Practices (ABCs) Mechanisms should be put in place to promote the female condom, for both family planning and STI prevention PMTCT Male involvement in PMTCT should be promoted to create demand for PMTCT. Research on male involvement critical. Couple counselling should be encouraged, (men decision makers in majority of Malawian households). STI Treatment and Prevention Distribution of STI drugs to health centres should be assessed. C. Infection Prevention and Health Care Waste Management The Health Care Waste Management Policy should be finalised and implemented throughout the country Voluntary Counselling and Testing Promote and advocate for couple counselling to increase the number of female VCT clients. Sites should be youth friendly to encourage youth participation Clinical Care The cotrimoxazole prophylaxis programme for TB patients should be evaluated and expanded to other district hospitals Plans are in the pipeline to scale up ARV therapy, VCT should scale up steadily (prerequisite to ARV therapy) Community and Home Based Care VCT should be scaled up to increase the number of PLWAs registered with support organizations The fight against stigma should be sustained and enhanced to encourage registration of PLWA

42 Support for Orphans and Vulnerable Children Organizations supporting OVC should also consider providing shelter apart from psychosocial support, school fees and nutritional support HIV/AIDS mainstreaming Organisations should mainstream HIV/AIDS programmes. Work place programmes should be diversified to include referral for PMTCT, VCT, clinical care and impact mitigation. Mainstreaming guidelines should be widely disseminated. Capacity building & Partnerships Information about umbrella organisation should be disseminated once their contracts are signed. Volunteers should be well motivated to avoid high attrition rates

43 8 POLICY IMPLICATIONS OF M&E FINDINGS AND RECOMMENDATIONS The findings documented in this report, and the subsequent recommendations that have been made, has the following policy implications: a) There is a need to ensure that in the future HIV/AIDS policy and strategy documents, compulsory reporting to NAC of all programme monitoring data, is clearly documented b) 9 NAC S M&E WORK PLAN 9.1 ACHIEVEMENTS In the financial year much has been done. The following activities were completed: NAC is represented in EP&D committees Implementing organizations from all sectors: public, private, umbrella organizations, faith based organizations, non governmental organizations were oriented in the national M&E system including the NACARS. Review workshops with implementing organizations as regards NACARS piloting. Field visits to a sample of organizations regarding piloting of the NACARS. Two quarterly service coverage reports have been produced and disseminanted. The annual M&E report for 2004 has been released The annual M&E dissemination workshop was held. MEIS TWG monthly meetings have been conducted. MASEDA meetings have been attended. DHS meetings have been attended and NAC was the secretariat for the sub committee on HIV/AIDS. An HIV/AIDS inventory database has been developed. The research database has been developed. A proposal data has been developed AIDS cases database updated Blood donors data base created A NACARS database has been developed. ANC based HIV sentinel surveillance survey for 2003 was conducted. A workshop was held to come up with HIV estimates for HIV estimates for 2003 were disseminated. Preparations for the BSS survey were completed. Quarterly Behaviour Surveillance Survey meetings were held. A firm was identified to abstract VCT, PMTCT and blood donors data from health facilities. NAC website was developed. The NAC data base was updated. The CBO M&E curriculum was drafted. Preparations for the Research Dissemination Conference were completed. NAC attended preparatory meetings for the 2004 sentinel surveillance survey

44 Adhoc requests for information were provided on daily basis by phone, , ordinaly mail and physically. A firm was identified to do the health facility survey. The following processes were started, and will continue during the 2004 financial year: o The research strategy o The 2004 MDHS HIV testing o Research dissemination conference o Abstraction of blood donors, VCT, PMTCT data from health facilities. 9.2 GAPS IN THE PLAN Grants agreements with data source institutions not done. 9.3 ACTIVITIES FOR (INCLUDING MAJOR SURVEYS) The work plan should include the following activities: Biannual visits to a sample of organizations Quaterly dissemination workshops Development of the National research strategy Support to the Coverage of Essential HIV/AIDS Services Survey and the Country Wide Survey on HIVAIDS Services Survey. 9.4 RESEARCH TO BE PUBLISHED IN 2004 BSS survey results 2004 sentinel surveillance survey Workplace survey Health facility survey Existing data projects report (Seroprevalence among PMTCT,VCT, Blood donors clients) PLACE Protocol (CDC study to determine high risk areas, and a methodology of how to determine these)

45 Malawi National Statistics Office, Malawi Demographic and Health Survey, 2000 Malawi Ministry of Health and Population, Sentinel Surveillance Report