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The AIDS epidemic in Malawi has caused over 650,000 deaths and continues to be responsible for the deaths of around ten people every hour.^{1 2} Out of a population of 12.3 million, almost one million people in Malawi were living with HIV at the end of 2005.³ AIDS is the leading cause of death amongst adults in Malawi, and is a major factor in the country’s low life expectancy of just 38.5 years.⁴

History of the AIDS crisis in Malawi

Malawi's first AIDS case was reported in 1985. In response, the Government implemented a short-term AIDS strategy (including blood screening and HIV education programmes), and created the National AIDS Control Programme (NACP) in 1988 to co-ordinate the country’s AIDS education and HIV prevention efforts. Some have argued that these measures did little towards controlling AIDS in Malawi, and that it was not until 1989, when a five-year AIDS plan was announced, that the Government began to show any real commitment towards tackling the problem.

Malawi was under the rule of President Banda for thirty years starting in 1964, during which time little attention was paid to the escalating AIDS crisis. His puritanical beliefs made it very difficult for AIDS education and prevention schemes to be carried out, as public discussion of sexual matters was generally banned or censored, and HIV and AIDS were considered taboo subjects. Between 1985 and 1993, HIV prevalence amongst women tested at urban antenatal clinics increased from 2% to 30%.⁵

In 1994, following protests and international condemnation, Banda agreed to relinquish power and Malawi became a multi-party democracy. President Bakili Muluzi took office and made a speech in which he publicly acknowledged that the country was undergoing a severe AIDS epidemic and emphasised the need for a unified response to the crisis. Freedom of speech was re-established and political prisoners were released, creating a more liberal climate in which AIDS education could be carried out without fear of persecution.

However, by this point AIDS had already damaged Malawi’s social and economic infrastructure. Farmers could not provide food, children could not attend school and workers could not support their families, either because they were infected with HIV or because they were caring for someone who was. In 2002, Malawi suffered its worst food crisis for over fifty years, with HIV recognised as one of the factors that contributed most significantly to the famine. A report suggested that 70% of hospital deaths at the time were AIDS related.⁶

AIDS in Malawi in recent years

Malawi continues to suffer from the connecting problems of poverty, famine and AIDS. However, intensive efforts have been made in recent years to increase awareness about HIV and to prevent its spread, and these efforts appear to have had a positive effect.

In 2000, a five-year National Strategic Framework to combat AIDS was implemented. The policy was slow to take effect as financial and organisational difficulties within the NACP persisted. A more structured body was needed to co-ordinate Malawi’s response to AIDS, and the National AIDS Commission (NAC) was set up in 2001. The NAC has since overseen a number of AIDS prevention and care initiatives, including programmes to provide treatment, increase testing and prevent mother-to-child transmission of HIV.

The Government’s response to AIDS was further intensified in 2004 with the election of new President Bingu Wa Mutharika, who launched Malawi’s first National AIDS Policy. This policy set the goal of improving the provision of prevention, treatment, care and support services, and called for a multi-sectoral response to the epidemic. A Principal Secretary for HIV and AIDS was appointed within the Government, and treatment and prevention programmes were scaled up.

The national HIV prevalence has stabilised between 12% and 17% since the mid-Nineties,⁷ and prevalence amongst women attending antenatal clinics has fallen slightly. Several urban areas, such as the capital Lilongwe, have witnessed a decline in HIV prevalence, although some rural areas have seen prevalence increase.⁸

Who is affected by AIDS in Malawi?

The AIDS crisis has affected all sectors of society in Malawi, but certain patterns have emerged as the epidemic has progressed:

• The majority of HIV infections in Malawi occur through heterosexual sex. There is no available information about the number of infections transmitted through sex between men, as homosexuality is illegal, but the number is thought to be relatively low.
• There is a higher rate of HIV prevalence amongst women than amongst men: around 60% of adults living with HIV in Malawi are female.⁹
• The majority of HIV infections occur amongst young people, particularly those between the ages of 13 and 24.¹⁰
• The epidemic has heavily affected children. At the end of 2005, an estimated 91,000 children in Malawi were living with HIV, and over half a million children had been orphaned by AIDS.¹¹
• HIV prevalence is almost twice as high in urban areas as it is in rural areas.¹² However, studies suggest that prevalence is declining in many urban areas and rising in many rural ones.¹³
• There is a high prevalence of HIV amongst certain labour groups in Malawi, including sex workers, truck drivers, fishermen and other ‘mobile’ groups whose movement between areas can aid the spread of HIV infection.¹⁴

HIV Prevention

With help from international donors, the Government and other organisations within Malawi have taken a number of positive steps towards minimising the spread of HIV. Unfortunately, while awareness of HIV is generally high, behaviour change has been limited. Social and practical considerations often stop people from taking measures to prevent infection even when they know the risks involved. This coupled with a lack of human and financial resources means that prevention campaigns have so far failed to curtail the AIDS epidemic in Malawi.

It has been suggested that efforts to prevent the spread of HIV in Malawi need to be more flexible to cultural situations of different regions. There are six main languages spoken in Malawi, and within each language group there are different, culturally appropriate ways of conveying prevention messages.

It has also been recommended that since the majority of HIV infections in Malawi occur amongst young people, greater emphasis should be placed on HIV education in schools. Many Malawian schools currently lack the time, resources and training needed to carry out adequate sex education.¹⁵

Voluntary Counselling and Testing

Voluntary counselling and testing (VCT) combines HIV testing with counselling, information and support. VCT was introduced to Malawi at two sites in 1992, and became more widespread in 1995 when the Malawi AIDS Counselling Resource Organisation (MACRO, an NGO with the aim of strengthening and developing VCT initiatives) was founded. Rapid blood testing for HIV, which allows people to find out their HIV status the same day they are tested, was introduced in Malawi in 2000 and significantly increased the accessibility of VCT.

Despite these advances, the number of people accessing VCT is relatively low. It is estimated that between October 2002 and September 2003, only 1% of adults thought to be HIV positive in Malawi were tested and counselled.¹⁶ Many people are afraid to be seen accessing VCT services because of the stigma attached to HIV infection, or because they see knowledge of HIV infection as a burden and would prefer not to know their status.

For those who are willing to access VCT, the services available are limited; VCT programmes in Malawi are hindered by a severe shortage of resources. Dr. T. Thafatatha, the district health officer of Kasungu District Hospital, described some of the problems his department have faced in providing VCT:

“It’s difficult to meet the needs of the patients because we don’t have sufficient staff, training or equipment. Patients have to wait several hours to get their HIV test results. Many leave and have to come back the next day; a few never return for their results.” - ¹⁷

Prevention of Mother to Child Transmission of HIV (PMTCT)

In 2003 a national strategy was launched to prevent mother to child transmission of HIV (PMTCT). Under this strategy and the Government’s five-year AIDS treatment plan, access to the drug nevirapine (which significantly reduces the chances of a pregnant woman passing HIV on to her child) has been scaled up in Malawi. HIV testing is routinely offered to pregnant women at all antenatal clinics and at many hospitals, but there has been concern about the low numbers of women who choose to be tested. AVERT is calling for vast improvements in global PMTCT efforts in our Stop AIDS in Children campaign.

Pregnant women are often afraid that their HIV status will be revealed if they test positive, which they fear will lead to discrimination. Some women have reported that their husbands have discouraged them from testing for HIV, because they fear the implications of a positive result and would rather not know. Such issues are further discussed in our PMTCT worldwide page.

Condom distribution

Various NGOs have promoted the use of condoms in Malawi, including PSI and Banja La Mtsogolo, which have both carried out social marketing programmes to make condoms more accessible. Banja La Mtsogolo has distributed millions of condoms, and has also promoted use of the female condom. These campaigns have achieved successful results; between 1992 and 2004, the contraception prevalence rate (the percentage of married women using any form of modern contraception) in Malawi increased from around 7% to 28%.¹⁸

HIV and AIDS Treatment

Antiretroviral drugs (ARVs), which effectively delay the onset of AIDS in people living with HIV, were first made available through the public sector at three sites in Malawi in 2003. In 2004, following a grant from the Global Fund to Fight AIDS, TB and Malaria, the Government announced a five-year plan to make ARVs widely available in the public sector and began to distribute them to hospitals and clinics around the country.

The government has maintained a strong commitment to providing AIDS treatment, and substantial progress has been made in recent years. At the end of 2005, only 32,214 Malawians were receiving ARVs, out of a total in 169,000 in need.¹⁹ However, intensive efforts to improve treatment access saw this figure rise dramatically during 2006. The National AIDS commission reported that 70,000 people were receiving treatment by September 2006, and by December 81,000 were accessing ARVs, surpassing the government's target of treating 80,000 by the end of the year.^{20 21}

While the situation has improved significantly, there are still thousands in need who have no access to ARVs in Malawi. Alongside financial constraints, the distribution of ARVs in Malawi is hindered by the low number of health care workers available to administer the drugs. Malawian nurse Mary Ntata described how this problem has affected the provision of HIV treatment in one hospital in Lilongwe:

“There are enough antiretroviral drugs available for those who test positive and whose conditions are serious enough, but not enough staff to administer the drugs. So the patients have to leave their beds and queue for the drugs from 3am. The nurses dispense the drugs from 7am but many of those who have been waiting through the night are turned away.” - ²²

Access to treatment is particularly limited in rural areas, as problems such as a lack of transportation, prevent many people from reaching health services. These areas have been heavily affected by food shortages in recent years and malnutrition is rife, meaning that even in cases where treatment is available, people have been known to stop taking ARVs because they do not have enough food to eat alongside the drugs.

By 2010, the NAC aims to have 240,000 people on treatment.²³ To read more about international targets for the provision of ARVs and the 'all by 2010' campaign (which aims to achieve universal access to ARVs by 2010) visit our AIDS treatment targets and results page.

International support for Malawi

Malawi’s efforts to overcome poverty, AIDS and famine are heavily dependent on international donors, with international development assistance totalling around $400 million a year. In the past there have been concerns about political corruption and the mismanagement of funds in Malawi and this caused a number of donors to suspend support for the country in 2001. However, since President Mutharika took office in 2004 and vowed to take a zero-tolerance approach to corruption, these difficulties seem to have been reduced and international support for Malawi has increased.

A number of donor Governments provide direct aid to Malawi, such as the US, the UK, Canada, Norway and the European Union. In terms of assistance for HIV prevention and treatment, important donors and supporters include:

• The World Bank, which has lent around $35 million to Malawi as part of its Multi-Sector AIDS programme. This project runs from 2004 to 2008, and includes schemes to increase support for children affected by AIDS and improve AIDS education.
• The Global Fund to Fight AIDS, Tuberculosis and Malaria, which has so far approved grants of around $228 million to Malawi. Among other things this funding has allowed the Malawian Government to implement its ARV treatment programme.
• The World Health Organisation and UNAIDS, which have both supported the scale-up of ARVs in Malawi.
• The President’s Emergency Plan For AIDS Relief (PEPFAR), which provides Malawi with $15 million dollars annually. It has funded VCT, condom distribution and mother-to-child prevention programmes, amongst other initiatives. Perhaps surprisingly, Malawi is not currently one of the plan’s fifteen focus countries.

Major issues surrounding the AIDS epidemic in Malawi

Human resources

One of the biggest challenges currently facing Malawi is the lack of human resources available within the country. In terms of the AIDS epidemic in Malawi, this problem has been most significant in the healthcare sector, where attempts to increase access to HIV testing and treatment have been hindered by a severe shortage of staff. Malawi has just one doctor per 100,000 people – one of the lowest levels in the world. Around 60 nurses are trained every year, but at least 100 others leave the country annually to seek employment in other countries.²⁴ It has been estimated that 33% of healthcare posts available in Malawi are vacant, 64% of nursing posts are unfilled, and that the number of doctors practicing is only a sixth of the recommended total.²⁵ Although funding for healthcare has increased, there are simply not enough trained staff available.

While the shortage of medical staff in Malawi has partly been caused by factors such as immigration and a lack of access to education, it has also been directly aggravated by AIDS, as has been the case in all other sectors of Malawi’s workforce. Many people are either caring for someone with HIV or suffering from it themselves, leaving them unable to attend work. This has particularly affected farming communities, which are based in rural areas where access to HIV treatment and care is likely to be limited. As Toby Solomon, commissioner for the Nsanje district, describes:

“We don't have machinery for farming, we only have manpower… if we are sick, or spend our time looking after family members who are sick, we have no time to spend working in the fields." - ²⁶

It is not only the poorer sections of Malawian society that have been affected the human resources crisis. In 2000 parliamentary speaker Sam Mpasu revealed that 28 Members of Parliament in Malawi had died from AIDS in just four years. Two years later, cabinet minister Thengo Maloya stated that around 100 important officers in his ministry had died from AIDS in the previous six years, and that many of those still in employment were unable to attend work regularly because of the problem. At the same time, Mr Maloya disclosed that he had personally lost three of his children to AIDS in the past ten years.²⁷

Gender inequalities

As is the case in many nations, women in Malawi are socially and economically subordinate to men. This inequality fuels HIV infection, as traditional gender roles allow men to sleep with a number of sexual partners and put women in a position where they are powerless to encourage condom use. Many women are brought up to never refuse sex with their husbands, and sexual abuse and coerced sex are common. In some communities, traditional practices such as ‘wife inheritance’ – where a widow is married to (or required to have sex with) a relative of her husband upon his death – may also increase the risk of HIV transmission, particularly in cases where AIDS was the cause of death of the woman’s previous husband. Such rituals have been condemned by the Malawian Government and AIDS organisations working in the country.

HIV infection in Malawi is disproportionately female, and younger women are particularly affected. For instance, AIDS affects more than four times as many women as men amongst the 15-19 age group in Malawi, and about a third more women than men amongst the 20-25 age group. However, amongst those who are over 30 the trend reverses, as more men than women are affected.²⁸ This pattern reflects the fact that younger women are often married to older men, or coerced into having sex with them. An increasing number of young girls are being forced into marriage with older men in Malawi, which has been one of the main factors behind the Government’s recent plans to raise the age of consent from 15 to 18.²⁹

AVERT.org has more information about women, HIV and AIDS.

Stigmatisation

HIV is still a taboo subject in many communities within Malawi and discrimination is common. As a result, few people living with HIV make their status known, many have difficulty discussing the subject with their families, and some support groups do not meet openly.

In 2004, President Bakili Muluzi revealed that his brother had died of AIDS three years previously and urged Malawians to challenge the stigma associated with AIDS:

“I have no apologies in making this publicly known to Malawians. We should be open and break the silence about HIV/AIDS. The fight against the killer disease [can] only succeed if we break [the] barriers of silence, stigma and discrimination.” - ³⁰

In the same speech, Muluzi added that when he had attended other funerals of people who had died of AIDS, he had never known the relatives of the deceased to openly declare the cause of death.

Read more about HIV-related stigma and discrimination.

The way forward for Malawi

The AIDS crisis is one of a multitude of problems currently faced by Malawi, alongside poverty, food insecurity and other diseases such as malaria. These problems are interlinked in various ways, and the Government has acknowledged that a multifaceted approach is needed to tackle them. For instance, programmes to increase access to HIV treatment must run parallel with campaigns that address malnutrition, as ARVs should be accompanied by a good diet. Equally, efforts to strengthen the country’s economy need to be co-ordinated with the fight against AIDS, as one of the most significant economic problems faced is the lack of human resources caused by AIDS deaths.

The Malawian Government has mounted an impressive, comprehensive response to the AIDS epidemic in recent years. The Government and international donors have both made commendable efforts to increase access to treatment and to improve prevention initiatives. But factors such as the scale of the epidemic and the shortage of human and financial resources available have hindered progress; access to treatment remains severely limited, and prevention campaigns have largely failed to change sexual behaviour.

In April 2006, President Mutharika announced that Malawi’s HIV prevalence had fallen from 14.4% in the previous three years to 14% by the end of March. He also outlined Government plans to intensify nutrition, HIV and AIDS programmes at a community level, in particular in rural areas where HIV prevalence is rising. There is hope that these plans will have a positive impact on the situation, and that the falling HIV prevalence of areas such as Lilongwe will also be seen in other parts of the country.

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• AIDS in Africa
• HIV & AIDS in Nigeria
• The impact of HIV & AIDS on Africa
• AIDS and HIV statistics for Sub-Saharan Africa