The following are the guidelines for the “game changing” presentations
Theme II: Eliminating New Infections in Children & Keeping Mothers Alive: use of
innovation and technology for increased utilization and adherence
• Provide a brief context and overview of the country (1 slide);
Malawi is a landlocked country in southeast Africa that was formerly known as Nyasaland. It is bordered by
Zambia to the northwest, Tanzania to the northeast, and Mozambique on the east, south and west. The
country is separated from Tanzania and Mozambique by Lake Malawi. Malawi is over 118,000 km2 (45,560 sq
mi) with an estimated population of more than 14,844,822 (NSO Population projection 2012).
The economy of Malawi is dependent on agriculture. The sector remains the country’s main foreign exchange
earner with tobacco, sugar, tea, coffee and cotton as major export products followed by manufacturing and
tourism. In recent years, efforts have been made to diversify the economy to other sectors such as mining,
tourism and service sectors.
Consequently, the contribution of other sectors including mining to GDP has increased over the years with
agriculture declining from about 38 percent in 1994 to about 27 percent in 2010. During 2006 to 2010, the
economy performed remarkably well, with an average real GDP growth rate of 7.1 per cent compared to a
target of 6 percent.
There has been a decrease in maternal deaths from 984 per 100,000 live births in 2004 to 675 per 100,000 live
births in 2010 (DHS 2010) but maternal mortality still remains high as one out of 150 pregnant women dies
during pregnancy, delivery or shortly after giving birth. Many women still give birth at home and only 73 per
cent of births are assisted by health professionals (DHS 2010).
Malawi is on track to achieve MDG 4 on reducing child mortality. Under-five mortality stands at 112 per 1,000
live births in 2010, declining from 133 in 2004. Similarly, the infant mortality rate declined from 76 deaths per
1,000 live births to 66 over the same period. Behind this success lies the country’s commitment to providing
cost effective interventions, including immunization. BCG, DPT3 and measles coverage now stands at 93 per
cent and in 2009, vitamin A supplementation stood at 70.6 per cent. By 2009, 8.65 million insecticide-treated
bed nets had been distributed throughout the country and efforts to prevent MTCT and provide paediatric HIV
care and treatment have been dramatically scaled up. Despite these positive trends, malaria, pneumonia and
diarrhoea remain the leading causes of illness and death among children under five years and neonatal causes
still remain the major contributors to infant deaths.
Malnutrition, especially stunting, continues to pose serious challenges to Malawi’s development ambitions.
The percentage of stunted children declined from 49 per cent to 40.5 per cent, slightly below the sub-Saharan
average of 41 per cent. The rate of exclusive breastfeeding increased from 62.7 per cent in 2000 to 71.9 per
Malawi has attained an enrolment rate of 83 per cent with gender parity, particularly at the lower grades. The
education system however is characterized by insufficient learning and teaching materials, inadequate
infrastructure, a high teacher-to-pupil ratio of 1:92, weak school management systems, and a high repetition
and low completion rates (38 per cent up to standard 8).
In 2010, 67.2 per cent of schools had access to safe drinking water, while only 23 per cent had access to
adequate sanitary facilities. Appropriate sanitation plays a critical role in keeping girls in school. Current
efforts in the education sector are focused on improving the effectiveness and efficiency of the system.
• Situate the issue/theme in the context of the country’s policy and regulatory
Malawi continues to make steady progress in reducing the prevalence of HIV, with adult prevalence decreasing
from 14 per cent in 2005 to 10.6 per cent in 2010. There is however 70,000 new HIV infections annually, 88 per
cent of them attributed to heterosexual transmission. HIV contributes to at least one-third of all maternal
deaths and 20 per cent of all child deaths. In 2009, UNAIDS estimated that 920,000 Malawians were living with
HIV, among them 120,000 children under 14 years of age. Approximately 25 per cent of new annual infections
are due to mother-to-child transmission (MTCT). The HIV transmission rate among infants born to HIV positive
mothers declined from 16.5 per cent in 2008 to 13.8 per cent in 2009. As per MOH 4 quarter report, mMore Formatted: Superscript
than 330,000 people are currently on antiretroviral treatment, among them approximately 30,000 children Comment [N1]: Per Q4 ART report
which represents only 25 per cent of children eligible for treatment. There is a critical need to scale up
paediatric care and treatment.
The Government of Malawi has put in place a comprehensive framework of national policies, plans and
guidelines to broadly address the HIV and AIDS challenge, and to more specifically to deal with maternal and
child health within the context of the epidemic. The elimination of new HIV infections in children and keeping
their mothers alive is also a central commitment of the Government of Malawi as part of its efforts to achieve
MDGs 4, 5 and 6.
The Government of Malawi’s maternal and child health initiatives have been underpinned by a range of global
commitments and interventions for scaling up elimination of new HIV infections in children and keeping
mothers alive. More recently Malawi has aligned itself with the major initiative through WHO, UNAIDS and
their partners calling for the virtual elimination of mother to child HIV transmission by 2015.
Malawi has participated in the following global and regional initiatives and commitments to reduce MTCT have
been cumulative over the past decade:
• • 2000: Through MDG 4 (child health) and MDG 5 (maternal health) global leaders committed Formatted: Font: 10 pt, Bold
to a reduction by two thirds of child (under-5) and maternal mortality rates, and universal access Formatted: List Paragraph, Bulleted + Level:
to reproductive health by 2015; 1 + Aligned at: 0.25" + Indent at: 0.75"
• • 2001: The UNGASS declaration on HIV/AIDS committed countries to reduce new HIV Formatted: Font: 10 pt
infections in children by 20% by 2005 and 50% by 2010 by ensuring that 80% of women in need Formatted: Font: 10 pt, Bold
of services have access to them; Formatted: Font: 10 pt
• • 2005: At the G8 Gleneagles Summit member countries called for the development and Formatted: Font: 10 pt, Bold
implementation of a package of HIV prevention, treatment and care, with the goal of reaching Formatted: Font: 10 pt
universal access to treatment by 2010;
• • 2005: The PMTCT High level Global Partners Forum called for governments to commit Formatted: Font: 10 pt, Bold
themselves to working together to achieve an HIV and AIDS-free generation by 2015; and Formatted: Font: 10 pt
• • 2011: The MTCT High Level Global partners Forum and Face to Face Ministers Meeting on Formatted: Font: 10 pt, Bold
“Elimination of Pediatric New Infections by 2015 and Keeping their Mothers Alive”. The ministers Formatted: Font: 10 pt
of health from eight African countries agreed on a number of actions required at the political
level to address the identified challenges including actions needed at technical and
Malawi HIV/AIDS response has evolved progressively to accommodate and respond to the new developments
and initiatives within the country’s HIV epidemic context.
In 2001, the National AIDS Commission (NAC) was created. A national HIV/AIDS Policy developed in 2003,
laying down the guiding principles for all national HIV/AIDS programs and interventions. The National HIV/AIDS
Strategic Framework for 2000–2004 included prevention and behaviour change interventions, as well as
interventions to expand access to treatment and care and support services, including antiretroviral drugs
(ARVs). A National Action Framework for 2005–2009 guided the response to the epidemic and was followed by
the Extended National Action Framework 2009–2013. Policies and guidelines for voluntary counselling and
testing, prevention of mother-to-child transmission of HIV, ARV equity, and treatment of sexually transmitted
infections have also been developed and implemented.
After WHO provided the Rapid Advice on the use of antiretroviral drugs for treating pregnant women and
preventing HIV infections in infants, Malawi came up with an integrated clinical management of HIV in children
and adults which includes life-long ART for all HIV positive pregnant women with promotion of exclusive
breastfeeding for 6 months, introduction of complementary feeding at 6 months and continue breastfeeding.
In addition, Malawi has revised its HIV and AIDS policy framework with the new Malawi HIV and AIDS Policy
(2011) and the new National HIV and AIDS Strategic Plan for 2011-2015 is set.
• Outline what the problem was before the “game-changer was introduced and
how it impacted on women’s rights and access to quality health;
Maternal ART during pregnancy and breastfeeding is recognised as an effective and feasible PMTCT regimen,
allowing for safe breastfeeding and avoiding the need for extended infant prophylaxis using liquid
formulations, which are difficult to deliver safely in the Malawi context. In addition using pregnancy as an
entry point for life-long ART will result in a high cumulative coverage of HIV infected women of reproductive
age. This in turn will achieve optimal protection during delivery (about 28% of deliveries occur at home) and
for subsequent pregnancies (a high proportion of HIV infected women desire additional children). However
this comprehensive approach to prevent new HIV infections requires initiation of ART among pregnant women
during their antenatal care and retention of care for at least two years after delivery.
The new Malawi option B+ guidelines are an adaptation of the WHO 2010 guidelines that call for starting of
life-long ART early in pregnancy in all pregnant women living with HIV. This approach is not completely new,
but rather is a more feasible alternative to WHO’s proposed option B in the Malawi context where there is
limited access to CD4 tests to guide decision making. Universal, lifelong ART for HIV-infected pregnant women
has the potential to achieve maximum coverage and could potentially lead to elimination of paediatric
HIV/AIDS and significantly reduce HIV associated maternal mortality. The new guidelines also recommend that
all HIV infected children under two years of age start ART recognizing that without early intervention, the
majority of HIV children with HIV will die in early infancy or by their second birthdays.
While utilization of ART services tends to be fairly high, and antenatal attendance in the first visit is above 90%
(DHS 2004, 2010), Malawi sees significant drop-offs in attendance in the second, third and fourth antenatal
visits. This presents a significant challenge for Malawi to effectively provide effective ART services to pregnant
women, and later on for lactating mothers and their infants. In Malawi, less than half (46%) of pregnant
women visit antenatal clinics four times during pregnancy, only 12% of women had their first antenatal visit in
the first trimester of pregnancy, and almost half (48%) had their first ANC visit between 4 and 5 months after
pregnancy. Postnatal coverage is also low and the recent Malawi DHS (2010) indicates that 48% of women did
not receive any post natal check-up. Among women who did receive a postnatal check-up, 43% received their
post natal check -up within two days of delivery and 7% of women received their first postnatal check-up
between 3 and 41 days after delivery. It is therefore clear that retention remains a significant barrier to the
universal access to ART for HIV+ pregnant and lactating women, and children under the age of 2 years.
Loss to follow up and death have been major causes for attrition . Pose and colleagues recommended better
patient tracing procedures, better understanding of loss-to-follow up and early initiation of ART to improve
retention and increase survival. Retention across the cascade of care and treatment services is therefore a
critical lever of success in the elimination of mother-to-child transmission of HIV (eMTCT) and one of the most
challenging aspects of care delivery. In Malawi, national programs do not have clear follow-up and referral
systems for patients, leading to significant loss to follow-up. In Q2 2011, only 4,616 (54%) received efficacious
ARV regimens or ART. There is an even greater challenge with low retention in services for HIV-exposed
infants: only 32% of the estimated 18,210 HIV-exposed infants born in Q2 2011 received ARV prophylaxis at
maternity . Low retention across the PMTCT cascade poses particular barriers to successful implementation of
the integrated ART/PMTCT guidelines which require long-term follow-up of mother-infant pairs, to ensure that
mothers initiate and continue on ART, as intended under the Option B+ guidelines.
Loss to follow up for HIV exposed children after delivery is also a challenge particularly at the lower levels of
the health care system where health workers often fail to identify HIV exposed children. Early infant diagnosis
is further compromised by poor quality dry blood spot (DBS) samples, limited laboratory capacity, difficulty in
transportation of DBS samples from the health facilities to the central laboratories and un-reliable courier
system in delivering the results from the central laboratories back to the health facilities. On average the total
turnaround time from drawing of sample to receiving of results by clients is ten (10) weeks with most facilities
in rural remote areas receiving their results after eight (8) months. This lengthy wait for laboratory test results
have been a significant bottleneck to effective scale-up of treatment programs, delaying a client from initiating
treatment and complicating care-givers ability to effectively conduct follow-up activities. In addition the
distance between health centers and clients throughout rural communities in Malawi prohibit clients from
accessing test results, counselling and treatment services in a timely and efficacious manner. The average
distance between health centers and patients` homes is about 15 km. These factors lead to children
diagnosed to be HIV positive being started on antiretroviral treatment late; or even dying before
commencement of treatment.
• Explain systematically exactly what was done to address the problem
In many rural areas in Africa including Malawi the coverage of the mobile networks often exceeds the reach of
regular infrastructure such as roads, electricity and water. Mobile technology therefore provides a real
opportunity to improve communication systems to reach rural areas and is proving to be a powerful tool for
reaching these remote areas, as well as coordinating and monitoring the scaling-up of services.
The Ministry of Health in collaboration with UNICEF and the Clinton Health Access Initiative (CHAI) have joined
together to leverage technology to address the retention/lost to follow-up challenges experienced at different
points in the PMTCT cascade.
In December 2010 Malawi introduced a number of mobile technology-based projects to strengthen services in
rural areas. Among them is a service called Results160, which delivers laboratory HIV results of infants from
central laboratories to remote clinics via secure short message service (SMS) delivery. The project was first
piloted in twenty-one health facilities in the two (2) districts on the southern part of Malawi, Chiradzulu and
Chikwawa. The specific objectives were to (1) reduce the turnaround time for the delivery of laboratory results
to mothers and children by a faster and more reliable means (rapid SMS), (2) reduce loss of laboratory results
along the cycle. Community health workers (CHWs) were trained in receiving of results on their mobile phones
and recording results into the facility registers. Using the same model, health facilities in Machinga district with
higher volumes of patients benefited from the use of SMS printers which following the same principle as
Results160, provided printed results making following up with the larger volume of patients more manageable
for health workers.
Tracing Interventions to address loss to follow-up targeting, pregnant women, lactating mothers and their
infants, were initiated in Machinga, Neno, Mwanza and Chitipa. Through a program called “Frontline SMSSMS
Frontline”, community health workers were able to follow-up HIV positive pregnant women (and their
spouses) and mother-infant pairs in their communities to ensure that they were accessing life-saving ART
services regularly, as well as immunization and other maternal and child health services. The system works as
follows; Follow-Up Focal Person at the health facility use the Frontline SMSSMS Frontline software installed on
a laptop with a modem to send a SMS message from the health facility directly to the Heath Surveillence
Assistants,SA (NOT SURE WHAT THIS ABBREVIATION STANDS FOR YOU NEED TO WRITE IT OUT IN FULL THE
FIRST TIME YOU USE IT) close to village where the patient lives. The HSA liaises with CHWs to help trace the
client. The CHW locates the patient and then sends the outcome back to the HSA who then sends an SMS to
the health facility Frontline SMSSMS Frontline laptop.
SMS technology is also used to remind clients to attend critical visits in order to improve on adherence and
avoid drug resistance; to relay results of EID to the facility and also to inform mothers whenever EID results
for their infants are available.
As part of the project MOH, UNICEF and CHAI also strengthened the capacity of all three central laboratories in
establishment of laboratory information management system and integration of rapid SMS data transmission
which allows all facilities which have access to the cell phone network to use mobile phone technology for data
transmission, reporting and follow up.
In addition Malawi is now piloting the use of mobile technology in the continuum of care model to register
antenatal visits and send automatic reminders to pregnant women or their spouses for next scheduled visits to
enhance retention efforts, and even to track drug stock-outs to ensure that when women and their children
show up for care, ready stocks of ARVs and other essential medicines are available to them.
• Explain the results in terms of positive impacts on women and girls and
analyze why these actions that were taken have resulted in success and what positive
impacts the actions have had on women and girls;
Evaluation of the pilot projects revealed that in 2011, nearly 9,000 infant HIV results were delivered to the
twenty-one (21) health facilities using the Results 160 (secure rapid SMS) and the results showed that on
average the delivery of laboratory results to clients was faster by thirty –two (32%) and loss of results was
reduced by up to twenty percent (20%). With introduction of smsSMS technology, the total number of EID
tests in one pilot site has increased three times from 800 tests baseline in 2010 to 2400 tests in 2011. The
delivery of results was more reliable when sent via Results 160 than via paper based systems and that
significant savings could be recognized in the transportation of results back to facilities. With the SMS Printers
situated in the facilities, Machinga DHO observed that the turnaround time reduced from 2-3 months before
to about 25 days after the intervention.
With SMS Frontline, those who were successfully traced showed remarkably high reintegration rates. Of the
1,522 patients who were successfully traced across all site, 1,217 (80%) returned for services. Among the 305
patients who did not return, 85 (7%) had transferred to another site for care and 44 (4%) were deceased.
Thus, only 176 (12%) of the successfully traced patients opted not to return to the facility for care (or perhaps
could not return due to transportation issues or other barriers). The high proportion of patients returning to
care after follow-up demonstrates the value of outreach in reminding and motivating patients to return to the
facility for critical services: even in the absence of any other incentives, the experience of having a home visit
from a CHW resulted in most patients returning to care supported by this technology intervention.
Use of innovation and technology, leadership from the Ministry, technical assistance provided from partners,
commitment and support from both national and district level and involvement of community health workers
have brought things together to demonstrate that the use of innovation and technology can overcome the
challenges in follow up and scaling up early infant diagnosis.
With introduction of new technology the turn-around time and reliability of EID test results have improved and
also the total number of EID test results has increased. The programme is now developing a monitoring tool to
keep track of children being referred from EID programme are enrolled in ART. , leading to increased number
of HIV positive infants and children initiated early ART and brought more women back into care. (WHERE ARE
THE DATA THAT SUPPORT THIS STATEMENT ON EARLY INITIATION OF TREATMENT?) YOU HAVE ONLY
PRESENTED INFORMATION ON TURN AROUND TIME, IMPROVED MANAGEMENT OF RESULTS AND
REINTEGRATION OF PATIENTS BUT NOTHING ON THE ACTUAL NUMBERS OF INFANTS BEING STARTED ON
State what lessons have been learnt and what other countries should consider Formatted: Normal, No bullets or numbering
in implementing similar actions
1. Government leadership is critical. Involvement of MoH and integrating the project into long-term planning
will help to leverage the existing national health systems and tools and integrate data into district reporting
system such as DHIS.
2. Creation of government-led working groups and strengthening of the MOH central department by
appointing a permanent project manager to coordinate and monitor the projects ensures well-coordinated
3. Capacity building component of local institutions should be part of the project to ensure there is a capacity
at national level for sustainability of project.
4. Government and partners need to work together in an organized and coordinated fashion to leverage one
another’s comparative strengths to optimize patient outcomes.
5. The need for strong partnerships and coordination is further emphasized as stakeholders need to consider
the additional costs required as a result of scale-up of innovations and technologies to address lost to follow-
up and enabling more patients to access services (i.e. improving patient flow, enhancing infrastructure)
6. While technology can be used to accelerate message delivery, significantly reducing turn-around time, it is
important that government and partners put mechanisms in place to ensure that results coming back are
actionable and are translating into patients being initiated on treatment (need for health systems
strengthening and cCommunity system strengtheningSS (???) – sms SMS technology works within a system).
Miller et al.( 2010), in their qualitative study assessing the reasons for lost-to-follow up found that these
included transport costs, logistical challenges, stigma and side effects associated with ART . In view of these
challenges, service integration clinics (like Malawi’s Mother-Infant Pair Clinics (MIPs) or HIV Care Clinics (HCC)
help reduce logistical challenges such as patient referral and transfers, community sensitization and
mobilization against stigma and strengthening sample transport networks are all necessary interventions in
pulling together a comprehensive solution to retention and HSS/CSS challenges..
• Outline the potential for the actions that were adopted to be taken to scale (i.e.
not just limited to a few districts but adopted nationally);
In 2012, MOH has developed a national scale up plan for early infant diagnosis using mobile technology in all
28 districts of Malawi. The EID scale up plan includes capacity building of health workers to improve technical
competencies on identification of HIV exposed children, dry blood spot sample collection and processing, and
use of SMS technology in information and data transmission. The EID scale up plan will be used to mobilize
additional funds from other partners to implement at national scale up. Furthermore, in the future, MOH plans
to engage private sector such as DHL to assist in sample transportation as part of their corporate social
responsibility efforts. Further, CHAI has been able to procure over eighty (80) SMS printers through its
UNITAID donation to distribute SMS printers for health centres with higher patient volumes where a
standalone cell phone for receiving results would not suffice.
Innovations such as SMS Frontline can prove to be an effective and comprehensive solution lost to follow up
system. The foundation of a successful lost to follow up system for a pregnant mother requires a national pre-
ART program that registers patients from the time they are tested to the time they are eligible for treatment.
This provides an essential platform for a national SMS database that can track patients and bring them into
care. Encouragingly, Malawi has begun national roll-out of its pre-ART program that will enable the national
scale of innovative programs like SMS Frontline for follow-up of pregnant mothers and mother-infant pairs.
Rosen S, Fox P.M & Gill C.J (2007). Retention in Antiretroviral Therapy Programs in Sub-Sahara: A systematic review
MoH HIV Program report, quarter 2 2011.
Miller et al. (2010). Why are antiretroviral treatment patients lost to follow-up?
A qualitative study from South Africa