Out of a population of 14 million, almost one million people in Malawi are living with HIV.¹ 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 43 years.²

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.

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 in 1988, created the National AIDS Control Programme (NACP) 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%.³

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.⁴

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 11% and 17% since the mid-Nineties,^5 6 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.⁷ Latest figures suggest a stabilisation of national prevalence at around 12 percent.⁸

Who is affected by HIV 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 indications from a small-scale study suggests prevalence may be much higher than previously thought.⁹
• There is a higher rate of HIV prevalence amongst women than amongst men: around 60% of adults living with HIV in Malawi are female.¹⁰
• The majority of HIV infections occur amongst young people, particularly those between the ages of 13 and 24.¹¹
• The epidemic has heavily affected children. In 2009 an estimated 111,510 children in Malawi were living with HIV, and around half a million children had been orphaned by AIDS.¹²
• HIV prevalence is around 17 percent in urban areas, compared to almost 11 percent in rural areas.¹³ However, studies suggest that prevalence is declining in many urban areas and rising in many rural ones.¹⁴
• There is a high HIV prevalence amongst certain labour groups in Malawi, including sex workers (70.7 percent), female police officers (32.1 percent) and male primary school teachers (24.2 percent).¹⁵

HIV prevention in Malawi

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. However, prevention efforts have been difficult to implement and while awareness of HIV has been generally high, change has been slow. 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.

Voluntary counselling and testing (VCT)

Voluntary counselling and testing (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 people in Malawi were initially slow to access VCT and only an estimated 1% of adults were tested and counselled up until 2003.¹⁶ Many choose not to find out their status as fear of being diagnosed as positive can have negative implications for married women or people fear being seen accessing VCT. This means reaching people infected with HIV can prove difficult.

Availability is also limited; VCT programmes in Malawi were 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

In 2006 President Bingu wa Mutharika began a national campaign to promote testing particularly in hard to reach rural areas, which accounts for over 70% of the population. Around 180,000 people were reached in a second ‘National HIV Testing and Counselling Week’, which for the first time was also extended to prisoners.^{18 19}

"The benefits of knowing ones HIV status are now greater than at any point in time since HIV and AIDS pandemic was first diagnosed in the country in 1985." - Minister of Health Khumbo Chirwa²⁰

By the end of 2009, 716 static testing sites were operational, an increase from 637 in mid-2008.²¹

Prevention of mother-to-child transmission of HIV (PMTCT)

In recent years, Malawi has increased efforts to prevent the transmission of HIV from mother-to-child. Since 2004 the country has rapidly expanded HIV testing for pregnant women. In 2008 around 68 percent of pregnant women received VCT, compared to only 8 percent in 2004.²² Although HIV testing is routinely offered to pregnant women at all antenatal clinics and hospitals, there are concerns that testing quality is being compromised, due to the high demand for tests and the lack of human resources.²³

In 2005 an estimated 5.4 percent of HIV positive pregnant women and their babies received a complete package of PMTCT services to reduce the risk of mother-to-child transmission.²⁴ By the end of 2007 this had risen to 26 percent,²⁵ with ambitious targets of 70 percent for 2012.²⁶ However, the scale up faces significant challenges due to drug stock-outs and logistical issues.²⁷

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%.²⁸ Approximately 38% of people surveyed in 2004 said they had used a condom the last time they had sex.

Often condom use can be seen as a ‘male domain’ so a 2008 UN funded project has been introduced to distribute female condoms through specially trained staff in beauty salons. The targeting of a traditionally female arena for HIV prevention messages, where women are used to open discussion, has proved successful. This has led to the possibility of similarly targeting men through barber shops.²⁹

HIV and AIDS treatment in Malawi

Antiretroviral drugs (ARVs), which 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 HIV treatment, and substantial progress has been made in recent years. In 2004 only 13,000 Malawians infected with HIV were receiving antiretroviral therapy.³⁰ This rose dramatically to  198,846 in 2009.³¹ However the government estimates that around 300,000 are eligible so there are still many people in need of treatment who are not receiving it. Malawi’s principle secretary for HIV and AIDS, Mary Shawa has said:

"We still need to do more, because those who did not make it may have died because they started the treatment late or did not have access to proper nutrition."³²

Reaching the targets for universal access is high on the government agenda due to a concerted effort by civil society organisations. However, there are practical concerns.³³ Malawi has begun to implement a new treatment regimen based upon the latest WHO guidance. This involves switching from a regime comprising d4t, 3tc and nevirapine, which costs US$33 per month, to a new regime costing US$100 per month. Whilst the new regime reduces the side effects associated with ARVs and enables people to live longer, less people will be able to access these essential medicines due to the increased costs.³⁴ 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.”³⁵

Access to treatment is particularly limited in rural areas, as problems such as a lack of transportation prevent many people from reaching health services. Even in areas where treatment is available, severe food shortages³⁶ have meant that the issue of HIV and nutrition is of particular concern. Another challenge is the common shortages of medicines to treat the opportunistic infections that arise at later stages of HIV infection.³⁷

International support for Malawi

Malawi’s efforts to overcome poverty, AIDS and famine are heavily dependent on international donors. In the past there were concerns about political corruption and the mismanagement of funds in Malawi, which 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 donors 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 US$407.9 million to Malawi, 45 percent of which are credits and the rest grants.³⁸
• The Global Fund, which has so far disbursed funds of almost $233 million to Malawi out of a total approved amount of $375 million.³⁹ In November 2009, Malawi's proposal for HIV/AIDS funding to the Global Fund was rejected with grave implications for the sustainability of prevention and treatment programmes in the country. Antiretroviral drugs and other treatment materials are largely sourced with support from the Global Fund while the National AIDS Commission, which supports grassroots prevention activities through the funding of community-based organisations, is fully funded by the Global Fund.⁴⁰
• 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 has committed over $25 million to Malawi for fiscal year 2009.⁴¹ PEPFAR funding has gone towards VCT, condom distribution and mother-to-child prevention programmes, amongst other initiatives. In May 2009, Malawi became the first country to establish a Partnership Framework with PEPFAR.⁴² Perhaps surprisingly, Malawi is not currently one of the plan’s fifteen focus countries.

Major issues 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 50,000 people⁴³ – one of the lowest levels in the world. 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 migration and a lack of access to education, it has also been directly aggravated by AIDS. The National Association of Nurses in Malawi (NONM) estimates that four nurses are lost to HIV and AIDS related illness every month.⁴⁴

AIDS impacts all sectors of Malawi’s workforce. Many people are either providing home based care for someone with HIV or are suffering from HIV or AIDS themselves, leaving them unable to attend work. This has particularly affected farming communities, which are based in rural areas where access to HIV treatment is likely to be limited. Drought, compounded by farmers and their families dying from AIDS, causes national food shortages. 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."⁴⁵

It is not only the poorer sections of Malawian society that have been affected by 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.⁴⁶

Gender inequalities

HIV infection in Malawi is disproportionately female, and younger women are particularly affected. HIV prevalence among women aged 15 to 24 is around 9 percent, compared to 2 percent among men. HIV prevalence is also higher in female adults aged 15 to 49 years (13.3 percent) compared to men (10.2 percent).⁴⁷

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 have sex with a number of partners and put women in a position where they are powerless to encourage condom use. Nearly one in five adolescent females (15-19yrs) reported force or coercion used in their first sexual experience.⁴⁸ Many women are taught never to 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.⁴⁹ However, changing a tradition that has persisted for generations is a slow process.

AVERT.org has more information about women and HIV.

HIV-related stigma

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.”⁵⁰

“We should be open and break the silence about HIV/AIDS.”

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.

Small steps in local communities can also have an impact. For example, support from community leaders in the Mchinji district has been effective in reducing discrimination locally. By co-ordinating between NGOs and other leaders in the area, chief Mudwa has been improving local attitudes and improving community efforts to help those affected by AIDS:⁵¹

“As chiefs have overall powers over our areas and we realised we should use our authority to protect people living with HIV and AIDS… We have made it policy that whoever discriminates against people living with HIV and AIDS shall be heavily fined or expelled from our kraals (villages)”

It is clear that if AIDS is going to be tackled in Malawi work needs to be done at all levels to address HIV stigma and discriminatory behaviour. Fear of AIDS prevents people going for testing, receiving treatment, and providing support and care for those affected in their community.

Conclusion

The HIV and 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.

Although prevalence of HIV in Malawi has remained relatively stable since 2004/2005,⁵² deaths from AIDS has increased slightly from 60,000 in 2001 to 68,000 in 2007, indicating that much needed improvements to nutrition, access to antiretroviral drugs and PMTCT have not yet taken effect on a national scale.⁵³

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