Supervision, Monitoring and Evaluation of Nationwide Scale-up of Antiretroviral Therapy in Malawi*

Abstract

Malawi is facing a severe human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) epidemic. There are an estimated 900 000 adults and children living with HIV/AIDS; there are more than 85 000 AIDS deaths per year, and up to 170 000 people are thought to need antiretroviral therapy. At the beginning of 2004, only 4000 patients in nine public health facilities had access to antiretroviral drugs.2 With so few patients on antiretroviral therapy, scaling up treatment became an urgent national priority, and a two-year national plan for scaling-up delivery services in 2004–05 was developed and finalized in February 2004.

The main elements of the plan for the public health sector included: (a) the selection of 60 hospitals and clinics to scale-up the delivery of antiretrovirals therapy to provide broad geographical coverage throughout Malawi; (b) the provision of antiretrovirals free of charge; (c) the use of the first-line antiretroviral treatment regimen only for scale-up activities involving new facilities, with alternative first-line and second-line therapy provided when health facilities had shown the ability to properly deliver antiretroviral therapy; and (d) the provision of antiretrovirals to facilities only if they had been formally assessed by the clinical HIV Unit of the Ministry of Health as being ready to deliver treatment.

This document describes the supervision, monitoring and evaluation strategies used to assess the delivery of antiretroviral therapy during nationwide scale-up of treatment in Malawi.

In findings, data monitoring showed that by the end of 2004, there were 13 183 patients male, 12 527 who had ever started antiretroviral therapy. Of patients who had ever started: (a) 82% were alive and taking antiretrovirals; (b) 8% were dead; (c) 8% had been lost to follow up; (d) < 1% had stopped treatment; and (e) 2% had transferred to another facility. Of those alive and on antiretrovirals, (a) 98% were ambulatory; (b) 85% were fit to work; (c) 10% had significant side effects; and, (d) based on pill counts, 96% had taken their treatment correctly. Mistakes in the registration and monitoring of patients were identified and corrected. Drug stocks were checked, and one potential drug stock-out was averted. As a result of the supervisory visits, by the end of March 2005 recruitment of patients to facilities scheduled to start delivering antiretroviral therapy had increased.

In conclusion, this report demonstrates the importance of early supervision for sites that are starting to deliver antiretroviral therapy, and it shows the value of combining data collection with supervision. Making regular supervisory and monitoring visits to delivery sites are essential for tracking the national scale-up of delivery of antiretrovirals.