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2014: A pivotal year for the HIV response in Malawi

Categories: HIV/AIDS, Malawi

How we refined and refocused programs using a data-driven approach

Beth A. Tippett Barr, DrPH Chief of Health Services, CDC Malawi

Beth A. Tippett Barr, DrPH Chief of Health Services, CDC Malawi

The appointment of Dr. Deborah Birx as the new Global AIDS Coordinator in May 2014 heralded an enormous change in the PEPFAR world:  Within the span of a few weeks, the focus changed from the newly-cemented PEPFAR vocabulary around ‘sustainability’ and ‘country ownership’ to language more targeted at maximizing resources for ‘epidemic control’.  As Dr. Birx said at the PEPFAR Annual meeting in Durban in June 2014, “We cannot sustain an uncontrolled epidemic”.  Although there has been enormous success in globally scaling up access to HIV testing and counseling (HTC) and anti-retroviral therapy (ART), the point Dr. Birx has continually reiterated in her six months in office, is that we need to find those places and populations in which the epidemic is least-controlled and respond accordingly.

To successfully do this, data is required:  Data on locating those who have never been tested and those at highest risk of acquiring HIV, and data that identifies which programs work best at reducing new infections and caring for those already infected.  The wide variation in new and existing HIV infections between urban and rural, male and female, and between age groups has long been established;  however, the use of this and other data to maximize the entire spectrum of our HIV prevention, care and treatment interventions in a coordinated effort to control the epidemic, has not been maximized.  With this challenge ringing in our ears, and a mandate from the Office of the U.S. Global AIDS Coordinator (OGAC) to revise our 2014 annual plan (COP), CDC and the other US Government (USG) agencies utilizing PEPFAR funding in Malawi, sat down to plan how to better work with the Ministry of Health and gain control over the HIV epidemic. As a result of these meetings, the following has been endorsed or adopted.

Malawi has recently endorsed the UNAIDS ‘90-90-90’ goals for 2030, which include:

  • 90% of People Living with HIV (PLHIV) are tested and know their status
  • 90% of known PLHIV are initiated on Anti-retroviral Therapy (ART)
  • 90% of ART patients are retained in care at one year

To reach these ambitious goals we will actively pursue progress by matching the appropriate amount of funding with similar outputs of effort, targeted to the right places and the right populations.  The first 90% is the gateway to the subsequent 90’s for the 2030 goals; if we don’t find those already living with HIV, we won’t be able to start them on treatment or keep them in care.  To find 90% of people living with HIV (PLHIV), we have to know where to look, and although our national survey data isn’t current, there is enough available information to rethink our overall strategy.  Of immediate importance is ensuring we get the highest ‘yield’ for HIV Testing and Counseling (HTC); the highest likelihood of identifying an HIV-positive individual with every test used.  This is a recent departure from the last few years in which HTC had become a way to identify those who were negative and provide counseling on staying HIV-negative.  Fortunately, thinking has now come full circle, and the role of HIV testing is rapidly regaining its priority as the most important gateway to treatment, survival and epidemic control.  This has had the immediate effect of highlighting the importance of testing in health facilities, particularly in settings where HIV prevalence may be higher than the national average, including STI clinics, TB clinics and in-patient wards.

HIV prevention in the new millennium

The emphasis on reaching the 90-90-90 targets mandates that the targeted behaviors for change be HIV testing, accepting treatment, taking one’s medication, and keeping appointments.  Should these behavior change and treatment agendas truly align to support each other, the 90’s can be achieved in Malawi.  If this happened, then 73% of the approximately one million PLHIV would lower the amount of HIV in their blood so they essentially do not transmit the virus, reducing new infections nationally to 0.2 per 100 individuals per year.  This is a staggering 78,000 adult infections and 75,000 pediatric infections prevented in the next five years, a massive impact on HIV prevention in Malawi, the likes of which has never been seen before.


Reviewing our data from a new perspective

Districts in Malawi are made up of anywhere from 100,000 to 1,000,000 people, and HIV prevalence in antenatal (prenatal) clinics within a district can vary from 0.2% to 33%.  When reviewing variation in HIV prevalence in the Demographic and Health Survey (DHS) 2010 at the cluster level, it rapidly became clear that the epidemic needs a targeted response at the lowest possible geographic unit, certainly well below the typical approach of district level.  All health facilities in Malawi are assigned ‘catchment areas’, an uneven radius around each facility which provides an approximation for the population each health center is responsible for serving.  Because the entire population of the country can also be divided into these catchment areas, and because HIV service delivery data is available at the facility level and provides a proxy measure for community coverage, the use of facility and catchment areas to define our refocused response was the most appropriate choice for geographic refining of our programs.


Refining site-level focus

While funding cannot provide support to every ART site in Malawi, our data shows intensive HIV program support isn’t needed in every facility.  This has enabled us to rethink how every dollar invested in HIV can produce maximum impact.  Several measures for the prioritization of health facilities were considered, and after discussing the pros and cons of each measure with the Ministry of Health Department of HIV and AIDS, we utilized a combination of measures to identify those health facility catchment areas which altogether would provide 90% population coverage based on three priority criteria:

  1. Number of current ART patients of treatment
  2. Expected number of HIV-positive pregnancies registering at the ANC clinic
  3. Number of PLHIV in the health facility catchment area

The last measure was important, as it gives us an estimated program need outside of documented facility services.  In each of the measures, we sorted the health facilities in the country in order of size from largest to smallest, and identified which sites would enable us to reach 90% of the population.  We then displayed the results visually, via Venn diagram, to show the overlap between the criteria and the health centers.  venn_diagramMalawi_HIV

We found that we could reach 90% of the HIV-positive population by prioritizing support to 50% of the health facilities in the country. The majority of health centers which were to become ‘priority sites’ met two or more criteria, but 99 sites met only one of the three criteria, which emphasizes the importance of knowing priorities when targeting programs for impact.



We now have at hand all of the tools we need to fight the HIV epidemic – and win.  We have the program science, the ARVs, trained staff in the health centers, the experience at national, district and site levels, and organizations to support the program in every district in Malawi.  And now, we have the data.  We’ve mapped out the country’s population, reduced the programs at every site to numbers, and we have a logical approach to moving forward.  We have the ability to now intensively target our response within each facility, addressing challenges systematically, and monitoring results.  The data is complex and the road ahead still difficult, but for the first time in more than three decades, a clear end to the HIV epidemic is in sight.



A Life Dedicated to Public Health Service

Categories: Ebola, HIV/AIDS, infectious disease

Ellen Wan, Division of Healthcare Quality Promotion

Ellen Wan, Division of Healthcare Quality Promotion

In January 2010, Diane Caves was on a 3-week assignment from CDC to improve HIV/AIDS programs in Haiti when the massive 7.0 earthquake struck, killing her and 230,000 others on the island. She was 31 years old and the only CDC employee to die in the tragedy. Diane’s reasons for going to Haiti were typical of her deep commitment to helping others. Her sharp intellect, optimism, adventurous spirit, and infectious smile touched all who met her. I count myself lucky to have been her colleague and friend, and her spirit continues to influence my approach to life and work.


Diane Caves and friend in Haiti before the earthquake. Ellen Wan (Division of Healthcare Quality Promotion) and Diane Caves were colleagues in the Office of Public Health Preparedness and Response.

Diane Caves and friend in Haiti before the earthquake. Ellen Wan (Division of Healthcare Quality Promotion) and Diane Caves were colleagues in the Office of Public Health Preparedness and Response.

Diane left an enduring legacy of public health service for CDC and the community at large. Shortly after her passing, CDC established an award in Diane’s honor to recognize early career CDC employees who inspire others in the public health community through collaboration, resourcefulness, and perseverance. Rice University, Diane’s alma mater, supports undergraduate scholarships in her memory, and Georgia State University’s School of Public Health, where Diane was completing her second master’s degree, established an award to recognize students who best exemplify her selflessness and dedication to public health.

Today, I know Diane would be right there working alongside the many CDC staff who risk their personal safety and well-being to create healthier and safer communities throughout the world, from the ongoing CDC Ebola response in West Africa to public health efforts closer to home. Through their own dedication to public health service, CDC staff honor Diane’s memory and continue her legacy every day.

Fulfilling the Decade of Vaccines Vision

Categories: Ebola, HIV/AIDS, immunization, infectious disease, malaria

Dr Rebecca MartinAs 2014 draws to a close, one theme that has been continuously present is the importance of a strong public health infrastructure in a country to effectively protect against vaccine-preventable diseases (VPDs).  Universal access to immunization is the Decade of Vaccines vision, and in order to achieve this, more efforts are needed to build upon the existing infrastructure developed for immunization programmes and other health interventions, such as for HIV prevention and treatment and malaria control and elimination.  With the importation of Ebola virus disease into Nigeria, we saw the country use its Emergency Operations Centre built to support polio eradication to quickly respond to the outbreak supporting case investigation, contact tracing, and bringing government together with national and international partners to stop the outbreak.  The infrastructure built in Uganda to collect samples from individuals at the community level for HIV testing and get them to a laboratory for testing in minimal time, can be used to quickly identify cases of epidemic-prone VPDs.  We should continue to build upon and use the experiences to save more lives and achieve global goals that have been delayed.  The coming year, 2015, marks the halfway point of the Decade of Vaccines—let us use this moment to accelerate efforts by ensuring the public health infrastructure is there to reach every individual with lifesaving vaccines.


World AIDS Day 2014: Closer to an AIDS-Free Generation

Categories: HIV/AIDS

Shannon Hader, MD, MPH

Shannon Hader, MD, MPHDirector, CDC’s Division of Global HIV/AIDS

On December 1, people throughout the world observe World AIDS Day to raise awareness of the global impact of HIV/AIDS, to honor those affected by it, and—ever so importantly—to recommit to achieving more in the upcoming year. An estimated 35 million people are living with HIV/AIDS worldwide. The theme for World AIDS Day 2014 – “Focus, Partner, Achieve: An AIDS-Free Generation” – reflects the drive to focus on interventions proven to work and to partner with a broad range of stakeholders to achievecontrol of the HIV epidemic and, ultimately, an AIDS-free generation.

CDC plays a key role in fighting the epidemic. We provide scientific and technical support to more than 60 countries through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the largest commitment by any nation to combat a single disease. Daily, our teams are working to support Ministries of Health, community organizations, and other stakeholders to strengthen their systems to detect, manage, and respond to the epidemic; to deliver quality HIV services; and to be ready to shift as the epidemic shifts so as to ensure continued progress.


CDC activities are grounded in science and critical to saving lives and preventing new HIV infections. Core efforts include preventing mother-to-child HIV transmission, antiretroviral treatment, and voluntary medical male circumcision. We are also helping countries build and enhance the resources they need to achieve and sustain epidemic control, including accurate, reliable laboratories and a trained healthcare workforce. Innovative programs developed and led by CDC scientists are now being used by countries to collect more detailed data that allow them to target HIV treatment services to where they are needed most and to reduce the cost of delivering services. Besides reaching more people in need, these data-driven activities support greater accountability for the use of U.S. government funds.

No single entity can do it alone. We work closely with key partners such as the Global Fund to Fight AIDS, Tuberculosis and Malaria — to which the United States is the largest contributor—to ensure maximum impact for our investments.

Together, we are making great progress: AIDS-related deaths fell by 35% since the peak in 2005 to 1.5 million, and new HIV infections decreased 38% since 2001 to 2.1 million. But millions more around the globe are waiting for access to lifesaving antiretroviral drugs, including 40 percent of eligible adults and 75 percent of eligible children. We must continue to work to reach those affected by this devastating disease, including children, adolescent girls, and other neglected and hard-to-reach groups.

The United States has made an unwavering commitment to work with partner governments and other stakeholders to turn the tide on HIV/AIDS. Working together, I know we can achieve this.


Public Health Informatics in Action in Malawi: Making life easier for healthcare workers and patients while improving quality through an innovative national Electronic Medical Record System

Categories: child health, global health security, HIV/AIDS, women's/maternal health

Instituting an Electronic Medical Record System reduces the need to manage and store growing volumes of patient charts, a major challenge in resource-limited settings.

Instituting an Electronic Medical Record System reduces the need to manage and store growing volumes of patient charts, a major challenge in resource-limited settings.

Denise Giles, M.P.H., Health Scientist, CDC-Malawi

Denise Giles, M.P.H., Health Scientist, CDC-Malawi

Keeping track of even one patient undergoing treatment for HIV/AIDS can be complicated enough.

Doing it for over 472,865 patients when you’re a low income country coping with high demand and a sputtering economy magnifies the complexity.

Which is why Malawi’s story – and its solution – is attracting attention and praise. It’s a story of how Electronic Medical Record System (EMRS) technology is being used and the foresight needed to bring it to reality.

You don’t have to look far to see the positive results.

Preventing Maternal Deaths in Africa

Categories: HIV/AIDS, women's/maternal health

 Healthy mothers and babies

Maternal health has improved in most regions of the world, with far fewer women dying during pregnancy and childbirth than 20 years ago. 

Isabella Danel, MD, MS, CDC Division of Reproductive Health

Isabella Danel, MD, MS, CDC Division of Reproductive Health

Progress in sub-Saharan Africa, however, has been much slower. HIV and complications of childbirth are the leading causes of death among reproductive age women around the world, but above all in this region. Being pregnant in sub-Saharan Africa is often a dangerous medical condition. In Zambia, women who have given birth are often greeted with a Bemba expression of relief and surprise: “Mwapusukeni.” Translated it means, “You have survived!”

That greeting is becoming more commonplace these days, which is another way of illustrating a basic truth: positive change can happen quickly when the right actions are taken to improve maternal health.

Strengthening Global Health Security Protects Americans

Categories: flu, global health security, HIV/AIDS, infectious disease, malaria, parasitic diseases


This blog was originally posted on on February 13, 2014.


The 5 Ways Diseases in Other Countries Can Kill You

The world is smaller and people are more mobile than at any time in history. This makes it easier than ever for what’s happening anywhere on the globe to harm Americans’ health. 
Here are five ways diseases in other countries pose a threat:

1) The flu could threaten millions. Even in a mild year for flu, in the United States alone, there are thousands of deaths, hundreds of thousands of hospitalizations, and billions of dollars in productivity losses.
In a pandemic, millions of people worldwide could be killed. H7N9 influenza, also known as bird flu, is spreading in China, though fortunately it has not mutated to become an infectious disease outbreak that could threaten the health of people around the world.

CDC Director Dr. Tom Frieden

CDC Director Dr. Tom Frieden

2) Antibiotic resistance is on the rise. Antibiotic resistance just might be the most urgent health threat facing us now.

The nightmare strain of bacteria known as CRE, carbapenem-resistant Enterobacteriaceae, arose abroad and was introduced to one state in the United States. Now it’s in at least 44 states. It can resist all or almost all antibiotics, kills many of the people who get it in their blood, and spreads its resistance capabilities to other bacteria.

The World Health Organization estimates multidrug-resistant tuberculosis already has infected a half a. million people across the globe.

CDC Collaborations with the Ministry of Health in Dominican Republic Result in Measurable Public Health Gains

Categories: health systems strengthening, HIV/AIDS, malaria, tuberculosis (TB)

CDC Global Health Director Tom Kenyon (right), CDC Global AIDS Director Deborah Birx (second from right), and CDC-Dominican Republic Director Oliver Morgan (second from left) meet with Dr. Miguel A. Gerardino (left), Director of the Juan Pablo Pina Hospital in San Cristobal, Dominican Republic, January 2014.

CDC Global Health Director Tom Kenyon (right), CDC Global AIDS Director Deborah Birx (second from right), and CDC-Dominican Republic Director Oliver Morgan (second from left) meet with Dr. Miguel A. Gerardino (left), Director of the Juan Pablo Pina Hospital in San Cristobal, Dominican Republic, January 2014.

For a relatively small country where CDC established a full-time country office only five years ago, the Dominican Republic is suddenly drawing attention.

Oliver Morgan, MSc PhD FFPH, CDC Country Director for Dominican Republic

Oliver Morgan, MSc PhD FFPH, CDC Country Director for Dominican Republic

It’s easy to see why. The Dominican Republic is a popular vacation destination with 1.4 million Americans visiting each year. The country has a unique relationship with its neighbor, Haiti, the poorest country in the Western Hemisphere, where CDC also supports many programs. 

Earlier this month, Dr. Tom Kenyon, Director of CDC’s Center for Global Health and Dr. Debbi Birx, who leads CDC’s Division of Global HIV/AIDs visited the Dominican Republic to review, with Dominican authorities, CDC programs to protect public health. Kenyon and Birx are the highest level CDC officials to visit the DR since CDC’s country office officially opened in 2009.

Reflections on the Fight Against HIV in Malawi

Categories: child health, HIV/AIDS, women's/maternal health


CDC Malawi Laboratory Advisor Dr. Abdoulaye Sarr reviews a CDC supported HIV program during a site monitoring visit

CDC Malawi Laboratory Advisor Dr. Abdoulaye Sarr reviews a CDC supported HIV program during a site monitoring visit.

This year, my staff and I have had the opportunity to spend considerable time in health facilities that our HIV-funded partners support throughout this beautiful country. Some of these facilities are on back-country roads; others are on forest-covered hills, while others sit on the shores of Lake Malawi. For CDC-Malawi, making these trips every quarter has been critical to strengthening our partnership with the Malawi Ministry of Health, ensuring quality in our programming, keeping our technical discussions grounded and practical, and helping ensure each of us is aware of the challenging realities faced by health workers and patients on a daily basis.

Sundeep Gupta, MD, MPH, Director, CDC-Malawi

Sundeep Gupta, MD, MPH, Director, CDC-Malawi

It has also highlighted how, against enormous odds, Malawi has been a leader in achieving remarkable successes in the fight against HIV, despite being one of the poorest countries in the world, ranking 181 of 187 countries in GDP per capita. In Malawi, almost one in every four adult urban women are infected, child and maternal deaths remain elevated due to the epidemic, and almost every family in the country has a profound story to tell about how they have been personally affected by this disease.

I find it thrilling that in the next two months, Malawi is set to reach the milestone of 500,000 persons (one of every 30 Malawians) alive and on antiretroviral treatment, something that was simply inconceivable when the program started a decade ago.

Celebrating a Decade of Progress Fighting Global HIV/AIDS

Categories: child health, HIV/AIDS, women's/maternal health

Deborah Birx, MD, Director, Division of Global HIV/AIDS, CDC Center for Global Health

Deborah Birx, MD, Director, Division of Global HIV/AIDS, CDC Center for Global Health

This World AIDS Day, CDC and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) commemorate a decade of success in fighting global HIV/AIDS. Ten years ago, this modern-day plague was devastating the health and wellbeing of millions of individuals in communities across Africa and in other resource-poor countries around the world. Today, we celebrate the extraordinary progress we have made in reducing new HIV infections and providing life-saving care and treatment to those who are living with HIV/AIDS.

With resources available through PEPFAR, we have provided antiretroviral drug treatment (ART) to millions and increased life expectancy rates in much of Africa. HIV-infected patients have returned to the workforce, enabling them to provide for themselves, their families, and communities; and AIDS-related deaths are declining worldwide. In June, Secretary of State John Kerry announced the joyous news of the millionth baby born HIV-free thanks to life-saving PEPFAR-funded programs to prevent mother-to-child transmission (PMTCT) of HIV. New pediatric HIV infections have dropped by nearly 50% since PEPFAR began. 

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