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; Medecins Sans Frontieres-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. Of patients who had ever started, 82% (10 761/13 183) were alive and taking antiretrovirals; 8% (1026/13 183) were dead; 8% (1039/13 183) had been lost to follow up; < 1% (106/13 183) had stopped treatment; and 2% (251/13 183) had transferred to another facility. Of those alive and on antiretrovirals, 98% (7098/7258) were ambulatory; 85% (6174/7258) were fit to work; 10% (456/4687) had significant side effects; and, based on pill counts, 96% (6824/7114) had taken their treatment correctly. Mistakes in the registration and monitoring of patients were identified and corrected. Drug stocks were checked, and one potential drug stock-out was averted. As a result of the supervisory visits, by the end of March 2005 recruitment of patients to facilities scheduled to start delivering antiretroviral therapy had increased. Conclusion This report demonstrates the importance of early supervision for sites that are starting to deliver antiretroviral therapy, and it shows the value of combining data collection with supervision. Making regular supervisory and monitoring visits to delivery sites are essential for tracking the national scale-up of delivery of antiretrovirals.