Below find National Aids Commission's Testing week postmortem
HIV TESTING WEEK: July 17-22 2006
What lessons has Malawi learnt?
Roy JR Hauya
- Director of policy and programming National Aids Commission
Introduction
With a prevalence rate of 14% of the adult population Malawi is still grappling with one of the most devastating HIV epidemics in this part of Africa. During the past decade Malawi has significantly diversified and accelerated its response, including treatment and prevention of vertical transmission of HIV. A robust policy has been formulated which defines four forms of testing-diagnostic, routine, voluntary and mandatory. And while good progress has been made to expand testing it is appreciated that a lot more needs to be done. Of its 11 million people, about 6 million are sexually active, only 15 percent have tested for HIV and know their status. At present prevalence levels it is estimated that 930,000 or nearly 1 million are living with HIV but the overwhelming majority of these remain unaware of their HIV status. And it is fully appreciated that this situation poses a great threat to prevention efforts and presents a case of missed opportunities by many HIV infected Malawians to access treatment, regular care and support services available through an ever growing number of providers.
Rationale for the testing week
In order to address this gap in the overall response, Malawi once again implemented an innovative strategy, an HIV Testing Week, to support efforts to scale up HIV testing and facilitate change of sexual and health seeking behavior. The testing week would raise the profile and role of testing in HIV prevention, access to care and support and become the basis for providing information on services available. It was also intended that people would be linked to various services available in districts and at national level and thereby generate confidence among Malawians to see testing as the ultimate decision for informed, healthier lives in the context of HIV and AIDS.
This innovation was a culmination of one year of discussion, consultation and advocacy with organizations in all sectors of the national response. Led by the Ministry of Health in collaboration with National AIDS Commission, the event involved a vast array of stakeholders in the public, private and civil society sectors in conceptualization, action planning and logistics for the week covering all 28 districts of Malawi. While the event was planned centrally most of the time, district health offices and local assemblies were responsible for field level implementation. It was projected that 50,000 people of all ages and gender would be reached through this innovation. This write up sums up my observations regarding successes, challenges and lessons learnt through this innovation.
Major successes
The major success is that Malawi was able to test over 90,000 (91,797) people in an open and public manner, attracting clients of all ages, sex, classes, faiths and cultural backgrounds. People of all ages, both male and female patronized the over 500 testing sites opened throughout the country, nearly half of them set up for the week. In fact while the trend all along suggested high patronage of testing services by young people 15-25of age the week attracted more adults and couples than envisaged except for sites located in school buildings, which tended to be dominated by young people. About 1000 counselors were mobilized and deployed for the event and in spite of some logistical hiccups and pressure from numbers of clients, the teams created (averaging 2-4 per site) worked with unprecedented commitment ensuring that that the week was a success. The use of field supervisors both at district and national level, including the role of ‘floating supervisors’ increased contact and communication with sites and gave both district personnel and site operators confidence in value of the work they were doing. There was equal success in logistics evidenced by timely mobilization, packaging and delivery of the HIV test kits to all sites and ushering in the week through a colorful launch in Lilongwe the Capital City led by Minister of Health. Collective planning and resource development for the event was a great demonstration of multi-sector partnership involving government institutions, private sector organizations, faith communities, donors and development partners. While social mobilization and communication fell short in a number of districts use of more traditional methods of publicizing the event, which including the church, the mosque, announcements at routine gatherings (even funerals), worked successfully. Leaders, notably district health officers, district commissioners and chiefs played their roles well in mobilizing communities and providing overall coordination and logistical support. There was very good working relationship and collaboration between the district health officers, district commissioners, chief executives and district AIDS coordinators from the assemblies and the health directorates in all districts.
Challenges
The major challenge was that more people turned up for HIV testing than the estimated target of 50,000, putting enormous pressure on test kits and other supplies and on counseling and testing services themselves. The majority of sites nationwide experienced stock-outs. Similarly because of high turn out counselors could not maintain the standard client-counselor ratio of 1:8 per day. The media while ready to participate was not adequately mobilized and supported to write stories about the progress especially from the districts. And while resources made available served the goal as planned, funding to districts was moved late and this affected timeliness in completion of preparatory activities and making logistics ready. Civil society organizations, which are key to community mobilization were engaged late and inadequately supported.
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Lessons learnt
The major lesson from the overwhelming public response is that ‘fear of testing’ for whatever reason has been rather ‘exaggerated’ by HIV and AIDS activists. From this event, not only is there demand for testing, people of Malawi are willing and ready to test if only services are brought close to their own communities and institutions and the environment is ‘free and non-threatening’. From testimonies given by clients in many sites, getting tested for HIV and knowing one’s own status removes the feeling of despair and hopelessness and provides a new start to life, particularly for ‘those who believed that they were already infected’. It was interesting that turn out was much higher away from district capitals and less busy health facilities and that many clients returned from busy health facilities that had more ‘patient-clients’ than clients coming for voluntary testing only.
The testing week has made it clearer that Malawi through the health sector as well as through civil society organizations should increase rapidly the number of appropriately trained counselors and supervisors focusing on district needs and plans. At the same time that the majority of sites were actually health facilities demonstrates that the Ministry of Health alone has enormous potential to contribute to voluntary testing if only the sector can use optimally the existing health infrastructure and demystify testing so that civil society organizations in the communities can increase provision of testing services. However, the health sector would have to review the counseling role of health surveillance assistants as experience during the testing week has shown that these are not able to offer HIV testing to the communities in their respective centers because they have to do a lot of other work demanded by their positions.
Planning for the testing week would work better if it were wholly decentralized to multi-sector district teams whose plans are then aggregated at the center for decentralized funding and support. At the same time, the need is now clear to engage civil society organizations early and more especially to assist with social mobilization, communication and pooling of key personnel such as counselors, laboratory assistants, supervisors and monitors.
The way forward
The Ministry of Health will organize a half-day meeting to de-brief the nation through the media on data gathered, successes, challenges and lessons learnt from this first ever HIV Testing Week. A technical and process report will be developed and disseminated widely among stakeholders, including individual districts to share lessons and sketch out blue prints for the next annual testing week. National AIDS Commission and Ministry of health will examine the practicality of a quick follow up public testing period preferably the week leading up to and a few days beyond December 1 2006 World AIDS Day Commemoration. This would provide an opportunity for people who had made up their minds but were not able to test and those who need to re-test to rule out the ‘window period’
