Institutional maternal and perinatal deaths: a review of 40 low and middle income countries.

Background: Understanding the magnitude and clinical causes of maternal and perinatal mortality are basic requirements for positive change. Facility-based information offers a contextualized resource for clinical and organizational quality improvement. We describe the magnitude of institutional maternal mortality, causes of death and cause-specific case fatality rates, as well as stillbirth and pre-discharge neonatal death rates.

Scaling-up antiretroviral therapy in Malawi.

Problem: In Malawi, health-system constraints meant that only a fraction of people infected with human immunodeficiency virus (HIV) and in immediate need of antiretroviral treatment (ART) received treatment.

Approach: In 2004, the Malawian Ministry of Health launched plans to scale-up ART nationwide, adhering to the principle of equity to ensure fair geographical access to therapy. A public health approach was used with standardized training and treatment and regular supervision and monitoring of the programme.

Act local, think global: how the Malawi experience of scaling up antiretroviral treatment has informed global policy.

The scale-up of antiretroviral therapy (ART) in Malawi was based on a public health approach adapted to its resource-poor setting, with principles and practices borrowed from the successful tuberculosis control framework. From 2004 to 2015, the number of new patients started on ART increased from about 3000 to over 820,000. Despite being a small country, Malawi has made a significant contribution to the 15 million people globally on ART and has also contributed policy and service delivery innovations that have supported international guidelines and scale up in other countries.

How operational research influenced the scale up of antiretroviral therapy in Malawi.

The national scale up of antiretroviral therapy in Malawi is based on a public health approach, with principles and practices borrowed from the successful World Health Organization "DOTS" tuberculosis control framework. The scale up of antiretroviral therapy was under-pinned by a very strong monitoring and evaluation system, which was used to audit the scale up approach and conduct operational research to answer relevant questions. Examples of research included:- i) access to antiretroviral therapy, populations and social groups served, and how the different groups fared with regard to outcomes; ii) determining whether the quality of data at antiretroviral therapy sites was adequate and whether external supervision was needed; iii) finding feasible ways of reducing the high early mortality in patients starting treatment in both Malawi and the sub-Saharan African region; iv) the causes of loss-to-follow-up, what happened to patients who transferred out of sites and whether transfer-out patients had outcomes comparable to those who did not transfer; and v) the important question of whether antiretroviral therapy scale up reduced population mortality.

Why did the scale-up of HIV treatment work? A case example from Malawi.

The national scale-up of antiretroviral therapy (ART) in Malawi is based on a public health approach, with principles and practices borrowed from the successful DOTS (directly observed treatment short course-the system used to successfully deliver antituberculosis treatment to people in some of the poorest countries of the world) tuberculosis control framework. During the first 6 years, the number of patients registered on treatment increased from 3000 to >350,000 in both the public and private sectors. The most important reasons for this success have been strong international and national leadership combined with adequate funds, a standardized approach to ART with practical guidelines, an approved national scale-up plan with clear, time-bound milestones; investment in an intensive program of training and accreditation of ART sites, quarterly supervision and monitoring of ART and operational research, rational drug forecasting and no stock-outs of drugs during the first few years, and involvement of the private sector.

A public health approach to rapid scale-up of antiretroviral treatment in Malawi during 2004-2006.

Background: Approximately 1 million people are infected with HIV in Malawi, where AIDS is the leading cause of death in adults. By December 31, 2007, more than 141,000 patients were initiated on antiretroviral treatment (ART) by use of a public health approach to scale up HIV services.

Methods: We analyzed national quarterly and longitudinal cohort data from October 2004 to December 2006 to examine trends in characteristics of patients initiating ART, end-of-quarter clinical outcomes, and 6- and 12-month survival probability.

Outcomes of patients with Kaposi's sarcoma who start antiretroviral therapy under routine programme conditions in Malawi.

AIDS-associated Kaposi's sarcoma (KS) is the most common AIDS-related malignancy in sub-Saharan Africa, with a generally unfavourable prognosis. We report on six-month and 12-month cohort treatment outcomes of human immunodeficiency virus (HIV)-positive KS patients and HIV-positive non-KS patients treated with antiretroviral therapy (ART) in public sector facilities in Malawi. Data were collected from standardized antiretroviral (ARV) patient master cards and ARV patient registers.

Lower early mortality rates among patients receiving antiretroviral treatment at clinics offering cotrimoxazole prophylaxis in Malawi.

Objective: To determine whether Malawi antiretroviral treatment (ART) clinics providing cotrimoxazole (CTX) prophylaxis had lower early mortality rates compared with clinics not providing CTX.

Methods: Retrospective cohort study of eleven ART clinics in Malawi that were or were not providing CTX. Medical record abstraction was performed for all patients (N = 1295) initiating ART between July 1 and December 15, 2005.

Outcomes of tuberculosis patients who start antiretroviral therapy under routine programme conditions in Malawi.

Setting: Public sector facilities in Malawi providing antiretroviral therapy (ART) to human immunodeficiency virus (HIV) positive patients, including those with tuberculosis (TB).

Objectives: To compare 6-month and 12-month cohort treatment outcomes of HIV-positive TB patients and HIV-positive non-TB patients treated with ART.

Design: Retrospective data collection using ART patient master cards and ART patient registers.

Assessment of a national monitoring and evaluation system for rapid expansion of antiretroviral treatment in Malawi.

Objectives: Monitoring and evaluation of national antiretroviral therapy (ART) programs is vital, but routine, standardized assessment of national ART patient monitoring systems has not been established. Malawi has undertaken an ambitious ART scale-up effort, with over 57,000 patients initiated on ART by June 2006. We assessed the national ART monitoring and evaluation system in Malawi to ensure that the response to the epidemic was being monitored efficiently and effectively, and that data collected were useful.

Malawi's contribution to "3 by 5": achievements and challenges.

Problem: Many resource-poor countries have started scaling up antiretroviral therapy (ART). While reports from individual clinics point to successful implementation, there is limited information about progress in government institutions at a national level.

Approach: Malawi started national ART scale-up in 2004 using a structured approach.

Ensuring uninterrupted supplies of antiretroviral drugs in resource-poor settings: an example from Malawi.

Problem: Drug procurement and distribution practices are weak in many resource-poor countries, and are a major reason for lack of access to medicines. With many countries scaling up antiretroviral therapy (ART), it is vital to avoid interrupted drug supplies, which would lead to drug resistance and treatment failure.

Approach: Malawi has adapted a model, based on that adopted by the country's Tuberculosis Control Programme, to allow rational ART drug forecasting.

Supervision, monitoring and evaluation of nationwide scale-up of antiretroviral therapy in Malawi.

Objective: To describe the supervision, monitoring and evaluation strategies used to assess the delivery of antiretroviral therapy during nationwide scale-up of treatment in Malawi.

Methods: In the first quarter of 2005, the HIV Unit of the Ministry of Health and its partners (the Lighthouse Clinic; Médecins Sans Frontières-Belgium, Thyolo district; and WHO's Country Office) undertook structured supervision and monitoring of all public sector health facilities in Malawi delivering antiretroviral therapy.

Findings: Data monitoring showed that by the end of 2004, there were 13,183 patients (5274 (40%) male, 12 527 (95%) adults) who had ever started antiretroviral therapy.

Who is accessing antiretroviral therapy during national scale-up in Malawi?

Malawi is scaling-up provision of free antiretroviral therapy (ART) in the public sector. In the fourth quarter of 2004 and the first quarter of 2005, 3261 and 4530 new patients, respectively, were started on ART. Of these patients, approximately 40% were male and 95% were adults aged > or =13 years.

Scaling up antiretroviral therapy in Africa: learning from tuberculosis control programmes--the case of Malawi.

The rapid and massive scale-up of antiretroviral drug therapy (ART) so needed in sub-Saharan Africa will not be possible using a 'medicalised' model. A more simple approach is required. DOTS has been used now for many years to provide successful anti-tuberculosis treatment to millions of patients in poor countries of the world, and many of the established concepts can be used for the delivery of ART.

Scaling up HIV/AIDS and joint HIV-TB services in Malawi.

Two country-wide surveys were undertaken to assess progress in scaling up human immunodeficiency virus/ acquired immune-deficiency syndrome (HIV/AIDS) and HIV-tuberculosis (TB) services in the public health sector in Malawi between 2002 and 2003. In 2003, 118 sites were performing counselling and HIV testing compared with 70 in 2002. There were 215 269 HIV tests carried out in 2003 compared with 149 540 in 2002, the largest increases being in pregnant women (from 5059 to 26791), patients with TB (from 2130 to 3983) and patients/clients attending health facilities (from 35 407 to 79 584).

Expanding antiretroviral therapy in Malawi: drawing on the country's experience with tuberculosis.

The DOTS (“directly observed treatment, short course”) strategy has been successfully used in developing countries to provide effective control of tuberculosis. Field workers in Malawi are promoting the same approach for HIV infection through the expansion of highly active antiretroviral therapy

Monitoring the response to antiretroviral therapy in resource-poor settings: the Malawi model.

With assistance from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), Malawi is scaling-up the delivery of antiretroviral (ARV) therapy to HIV-positive eligible patients. The country has developed National ARV Treatment Guidelines, which emphasize a structured and standardized approach for all aspects of ARV delivery, including monitoring and evaluation. Using the successful DOTS model adapted by National TB Control Programmes throughout the world, Malawi has developed a system of quarterly ARV cohort and cumulative ARV quarterly analyses.