Malawi has been one of the hardest hit countries by the HIV epidemic. Current estimates propose 1,100,000 Malawians are living with HIV in 2014, with over half a million (552,808) alive on ART. The adoption of the UNAIDS 90: 90: 90 targets in 2014 (90% of people living with HIV should know their status, 90% who know their status should be on ART, 90% of those on ART should be virologically suppressed) have been mirrored within the Malawian National Strategic plan (NSP) and concretely mean that 801,900 (73%) of all PLHIV should be virologically suppressed on ART.
Malawi has already embraced decentralisation, task shifting of HIV testing and counselling (HTC) and HIV care, and in most instances, is able to provide a 3 month drug supply. Service intensity however has not been systematically addressed. To achieve the 90-90-90 targets in a health system that has limited human resources and whose clinics are already overburdened, high impact interventions must be identified at each step of the HIV prevention, care and treatment cascade and linkages between the facility and community maximised.
Interventions defined as “community based” have included interventions by health care workers performed as outreach e.g. community based HTC campaigns, as well as interventions performed directly by community members either at the facility or in the community. Successful interventions have been documented across the cascade, supported by evidence from within Malawi and the wider region. To achieve the first “90” strategic community engagement to ensure acceptability of enhanced provider initiated testing alongside community based testing interventions should be combined. Maximizing testing coverage whilst ensuring maximum testing yield should be achieved through targeted outreach for key populations, families of index clients and in geographic and population based high prevalence areas.
To enhance retention and adherence, strategies that address psychosocial support and patient education, provide individual patient case management and services that place the patient firmly at the centre of ART delivery are described.
In many of the examples the critical work of lay counsellors, expert patients and community health workers underpin the intervention. These cadres support an activity at the facility but because they are community members, provide the essential link to the community to support tracing and home based interventions. Specific interventions for PMTCT such as providing a mother mentor and the organisation of teen clubs for adolescent care have also demonstrated significant impact on retention.
The mapping of these interventions has demonstrated that there are a range of interventions already implemented across the country but led by different implementing partners and with differing terminologies for cadres performing similar functions. Other promising interventions are only available in one or two districts (e.g. CAGs or ART fast track). What is clear is that to achieve the 90-90-90 targets by 2020, national programmes will need to employ innovative strategies in service delivery and identify system efficiencies and in order for any community based intervention to be successful an enabling environment is required. This will include mechanisms to strengthen the technical capacity of CBOs, engage community and faith based leaders in addressing stigma as well as ensuring robust and adaptable “differentiated” models of service delivery within the health system itself.
However to achieve these goals, the community and health system must act together as one with the patient placed firmly at the centre of any strategy. This report serves as a foundation for a multi-sectorial workshop that will consider which of these strategies could be taken to scale, led by the Ministry of Health.