AIDS Epidemic in Malawi: This is of such a magnitude and such a threat to economic and social stability that the country is proposing to continue with a bold and ambitious scale up and expansion plan for delivery of antiretroviral (ARV) therapy. Malawi’s “aspirational” goal is to establish “Universal Access to ARV”. A five-year vision is presented, along with a 2-year detailed and costed operational plan.

Numbers started on ART: Based on the reality under which the health sector functions, it is estimated that numbers of patients ever started on ARV therapy will be 35,000 by January 2006. Scaling up at the rate of 35,000 new patients in 2006, 40,000 new patients in 2007, and 45,000 each year in 2008, 2009 and 2010, the number ever started on ARV therapy will be 245,000 by the end of 2010.

ART Scale up strategy: These numbers will be achieved by continuing current scale up in the 60 sites in Round 1, by bringing 38 new sites in Round 2 into service delivery by April 2006, possibly having more sites in Round 3 delivering therapy by 2007, and by involving the private sector. Plans to reduce the burden of work in established clinics include less frequent follow-up, use of a lower cadre of health worker to follow-up patients, and decentralising to health centres.

Constraints to ART scale up: There are 5 possible constraints to such rapid scale up:

• Capacity of the health sector to deliver ARV therapy to people in need

• Uninterrupted drug supplies

• Adequate financial support

• Quarterly supervision monitoring and evaluation of ARV therapy

• HIV drug resistance and unacceptable side effects with first line ARV therapy

Risks of ART scale up: The risks to this large expansion of ARV therapy are similar to the risks outlined in the first scale up plan (2004-2005) and include:-a) drug security issues, b) drug adherence and risk of ARV drug resistance, c) impact on the health sector, d) equitable access to ARV therapy, e) overdue attention to care at the expense of prevention. 2-year operational plan (2006-2007): the plan includes the following activities:

• To review /revise/print/disseminate National Guidelines

• To build capacity for ART and HIV disease management

• To procure drugs for treating HIV and HIV-related diseases

• To implement ARV therapy in the public sector

• To implement Cotrimoxazole Preventive therapy

• To increase health worker and public education on ART and HIV

• To conduct enhanced monitoring and evaluation of ART and HIV-disease

• To assess new ART sites and supervise established ART sites

• To conduct ARV and HIV-operational research

• To manage ARV and HIV-disease at MOH Headquarters

• To implement ARV therapy in the private sector

• To link this scale up plan to other scale up plans (eg CT and PMTCT)

Budget: The total budget for the 2-year period is estimated at USD$47,273,500