A challenge against AIDS

S MA G G A A M

 AIDS is still a dramatic problem of public health, especially in SubSaharan Africa Project Malawi and the DREAM Programme have proven their effectiveness in tackling AIDS with an approach based on synergy and aimed at development
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AIDS is still a dramatic problem of public health

Global vision of HIV infection in 2008: 33.4 million people, 2/3 in Sub-Saharan Africa

Source: WHO/UNAIDS

AIDS is still the main cause of mortality in Africa

Rank 1 2 3 4 5 6 7 8 9 10 AIDS Acute lower respiratory tract infections Malaria Diarrhoeal diseases Perinatal conditions Measles Tuberculosis Cerebrovascular disease Ischaemic heart disease Maternal conditions
% of the total

20.6 10.3 9.1 7.3 5.9 4.9 3.4 3.2 3.0 2.4

Source: The World Health Report WHO, 2008

AIDS is still the main cause of mortality in Africa

Mortality rate in adults: breakdown by causes of death and geographic region
High income Western Pacific Americas Eastern Mediterranean South East Asia Europe Africa 0
Source: WHO Global Burden of Disease, 2004

Cardiovascular diseases Cancers Other noncommunicable diseases Injuries HIVAIDS Other infectious and parasitic diseases Maternal and nutritional conditions

4 6 8 10 Mortality rate per 1000 adults aged 1559 years 5

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AIDS brings along huge problems and economic and social damages

AIDS has killed one or both parents of 16 million children worldwide. 90% of these orphans live in Sub-Saharan Africa. The epidemic mainly strikes young adults with also economic effects: yearly loss of 1-2 percentage points of GDP in the countries mostly hit by the disease. AIDS hits everybody and deprives the countries of important categories of social operators: doctors, nurses, teachers, etc.

Malawi is one of the main victims of AIDS

At the top of the world ranking for the diffusion of the disease :

AIDS death cause number 1 12% of the population between 15 and 49 year old infected 17% of mothers HIV-positive yearly 85,000 births at risk of transmission of the virus

AIDS as an obstacle to development:

marginalization of the infected economic and social decline removal from normal activity of vital operators such as doctors, health workers, teachers, public officers 1 million orphans, of which half due to AIDS
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 AIDS is still a dramatic problem of public health, especially in SubSaharan Africa Project Malawi and the DREAM Programme have proven their effectiveness in tackling AIDS with an approach based on synergy and aimed at development
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Project Malawi: mission and target

Mission: improve the life conditions of the population of Malawi and ensure an overall perspective of development to one of the poorest countries in the world Target: create a barrier to AIDS starting from the prevention of mother-to-child transmission (DREAM Programme) and envisage, alongside the sanitary intervention, specific actions to restrain the impact of the disease on the population and to support the economic revitalization of the country.

Approach: it is caracterized since its beginning as an integrated project that tackles not only the battle against AIDS, but also health education and prevention, assistance to orphaned and vulnerable children and local development and microfinance. Financing: Project Malawi is a humanitarian initiative launched in 2005 by Intesa Sanpaolo e Fondazione Cariplo which have already committed 18 million euro. Another 2 million euro from other sources.
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Project Malawi: key words

Therapeutic quality: excellence of the structures and of the protocols for the treatment of AIDS

Strong autochthonous component: collaboration with the local Government in the local co-ordination of the project; involvement of local communities; investments in the training of local personnel; involvement of NGOs with offices in the country and with predominant Malawaian participation.

No simple financing but long-term direct involvement and assumption of responsibilities in the achievement of targets and results. Independent monitoring and audit.
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Project Malawi: the partners

For each area of action, a main operating partner has been identified: Health and AIDS care DREAM

Comunit di SantEgidio

Education and prevention

Scout Malawi
S MA G G A A M

Orphan assistance

Save The Children

Local development and microfinance

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Comitato Italiano per lo Sviluppo dei Popoli

Project Malawi: partners and areas of action

Health and AIDS care DREAM

Comunit di SantEgidio

Education and prevention

Scout Malawi
S MA G G A A M

Orphan assistance

Save The Children

Local development and microfinance

Comitato Italiano per lo Sviluppo dei Popoli

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Project Malawi DREAM Programme Change of approach in the cure of AIDS in Africa
From an esclusively preventive approach From sub-optimal therapies for the prevention of mother-tochild transmission From a late and limited treatment (only patients already seriously ill) From a prevention of mother-tochild transmission limited to the delivery From a diagnosis based only on clinical factors
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To an approach of prevention and treatment To the triple therapy for all pregnant women

To a more anticipated beginning of the treatment To the prevention of mother-tochild transmission extended also to all the feeding period To a diagnosis which includes also laboratory exams

Project Malawi DREAM Programme Reduction of mother-to-child transmission using different protocols 2000-2010: Trasmission rate 0-6 months

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Project Malawi DREAM Programme Maternal mortality rate

Malawi-HIV+ Mothers treated by DREAM-Project Malawi

Malawi-HIV+ Mothers with no therapy

Source: Palombi et al. IAS Capetown 2009; Von Letttow, Vienna, July 2010

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Project Malawi DREAM Programme Reduction of the average viral load (infectiousness)
in a population of patients treated by the DREAM Center at Francisco Palau Hospital, Dowa district, Malawi Central Region
160000 140000 120000 100000 c/ml 80000 60000 40000 20000 0

p< 0.001

2005

2006

2007

2008

2009

2010 First half

Number of viral loads

83 83 100%

663 609 91.8%

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1047 524 50.0%

1511 626 41.4%

1797 533 29.6%

1410 77 5.5%

Number of viral loads of new patients % of new patients

Project Malawi DREAM Programme Trend of HIV infection prevalence in pregnant women
treated at the Francisco Palau Hospital, Dowa District, Malawi Central Region
9 8 7 6 % HIV+ 5 4 3 2 1 0 2005 2006 2007
17 Govt start DREAM start

2008

2009

2010

The DREAM Programme has become a reference model

The approach promoted by the DREAM Programme since 2002 and included in Project Malawi from 2005 has been fully confirmed by the WHO 2009/2010 guidelines. On the basis of the good results recorded in Project Malawis DREAM centres, the Governement of Malawi intends to expand the HAART therapy to all HIV positive patients with less than 350 CD4 and to give the triple HAART therapy to all pregnant women from July 2011, thus including the DREAM protocol in the national guidelines.

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Project Malawi Investments

9 highly specialized clinical centres 7 maternity wards connected with the DREAM centres 3 of them have been renovated and equipped 4 laboratories, 3 of them with a molecular biological department Around 700 social-health workers trained Construction of information and communication webs in the country and connection with international centres.

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Project Malawi Country presence

Project Malawi presence

Dzoole

Mtendere

DREAM Centres Maternity wards connected with DREAM Centres Molecular biological laboratories Balaka Maternal and Neonatal Ward Polifunctional Centre Districts of synergetic action of Project Malawi

Kapire

Mulibwanj Namandanje

Kapeni

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Project Malawi DREAM Programme Performance 1/2

Patients Opened folders HIV+ patients Of whom: Pregnant women Of whom: Children (less than 15 year old) Children born in PMTCT* Patients accessed HAART**(cumulative) Patients living and in care Patients living, in care and on HAART* Children accessed HAART* (cumulative) Children living, in care and on HAART*
* Prevention Mother to Child Transmission ** Highly Active Artiretroviral Therapy

37,941 18,678 4,179 5,701 3,332 15,088 13,607 10,073 1,535 988

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Project Malawi DREAM Programme Performance 2/2

Laboratory Samples received CD4 Viral Load 154,348 97,340 69,278

Clinical activities Clinical examinations Blood samples Drug delivery Food integration 318,971 144,569 288,402 113,924

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Lilongwe - DREAM centre and molecular biology laboratory

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Blantyre - DREAM centre and molecular biology laboratory

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Project Malawi: partners and areas of action

Health and AIDS care DREAM
Comunit di SantEgidio

Education and prevention

Scout Malawi
S MA G G A A M

Orphan assistance

Save The Children

Local development and microfinance

Comitato Italiano per lo Sviluppo dei Popoli

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Education and Prevention

MA G G A S AM

The main results achieved by the Scouts of Malawi in the area of Education and Prevention till January 2011:

Opening of an operational base in Blantyre for educational activities for young people and HCT (HIV Counselling and Testing); 2,058 young people used the HCT service;

Girl Guides and Scout units established in 158 schools of the communities involved; today they reach 25,124 young people with information on sexual education and on the risk of transmitting HIV/AIDS;

80 young people have completed vocational skills training courses (carpentry, joinery, design and tailoring) and additional 29 have been selected to attend new courses in the current year.
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Education and Prevention

MA G G A S AM

14,809 young people report to have easy access to Sexual Reproductive Health services (SRH) and counselling on HIV/AIDS 36,610 young people and parents prove to have knowledge of where and how to access the above services and to have information and knowledge on SRH/HIV/AIDS and life skills 7,945 young people reported the use of condom during sexual intercourse with non regular partners

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Project Malawi: partners and areas of action

Health and AIDS care DREAM

Comunit di SantEgidio

Education and prevention

Scout Malawi
S MA G G A A M

Orphan assistance

Save The Children

Local development and microfinance

Comitato Italiano per lo Sviluppo dei Popoli

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Orphan assistance
The main results achieved by Save the Children in the area of orphan assistance till January 2011:

104 Community Based Child Care centres (CBCC) built or renovated that host every year around 4,000 orphans and vulnerable children; Early Childhood Development (ECD) training for 590 educators; Children Clubs established for prevention and recreational activities; every week an average of around 6,300 children from 7 to 13 years old take part in the activities;

Children Retreats organized for 2,721 children between 7 and 13 years old. These meetings enable children to raise problems like abuses and violence from adults, failed school enrolment, participation in traditional initiation dances.

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Orphan assistance

Psychological Support training (PSS) and promotion of information and prevention activities organized with the participation of 1,897 people among CBCC educators, primary school teachers, parents, traditional and religious leaders, midwives and traditional healers. 460 volunteers of the communities involved have been specifically trained in Community Home-Based Care (CHBC). 1,888 CHBC beneficiaries (cronically-ill adults and children and their families); Support Groups involving 1,826 people have been established to support People Living with HIV/AIDS.

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Project Malawi: partners and areas of action

Health and AIDS care DREAM
Comunit di SantEgidio

Education and prevention

Scout Malawi
S MA G G A A M

Orphan assistance

Save The Children

Local development and microfinance

Comitato Italiano per lo Sviluppo dei Popoli

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Local development and microfinance

The main results achieved by CISP in the area of local develpoment and microfinance till January 2011:

Establishment of 3 representative offices; 3 Business Information and Services Centre (BISC) open and operative;

Organization of Business Management and Refresher Courses; beneficiaries: 881 micro, small and medium entrepreneurs;

3 Memorandum of Understanding underwritten with Malawi Rural Finance Company, Malawi Saving Bank and INDEFUND that represent the mechanism through which the micro, small and medium entrepreneurs access credit.

306 entrepreneurs assisted in the preparation and presentation of Business Plans to local Microfinance Institutions (MFI); 180 loans disbursed;

Repayment rate of informal loans: around 90%.

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Local development and microfinance

76 Income Generating Activities (IGA) established in rural areas; 1,832 families directly involved; 72 Village Savings and Loans Associations - VSLA established; 1,283 beneficiaries directly involved.

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Project Malawi the team grows

Agreement with the Societ Italiana di Neonatologia (Italian Neonatology Society) and with the Societ Italiana di Pediatria (Italian Paediatrics Society) to select Italian neonatologists and paediatricians that offer training on a voluntary basis to local health workers through an alternating presence in Malawi. The activity is mainly carried out at the maternity ward of the Balaka Comfort Clinic, equipped with the funds raised through awareness campaigns organized by Project Malawi onlus. The Comfort Clinic paediatric ward is almost completed (construction and equipment). Also this intervention was made possible by the funds raised by Project Malawi onlus that currently co-operates with CHAM (Christian Health Association of Malawi) for the administration of the paediatric and the maternity wards.

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Next steps To continue with the fulfillment of the original project with an additional threeyear intervention To search and test all the best solutions to make the DREAM Programme more and more efficient and effective for the control of AIDS.

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The 3,300 children born AIDS free from HIV positive mothers and their mothers mainly still alive - demonstrate that the DREAM Programme can put a barrier to the AIDS epidemic in Africa

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