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HIV & AIDS in Malawi
Malawi's population of 15.9 millon are greatly affected by HIV; as of 2011 an estimated 910,000 people were living with HIV. 1 2 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 54.8 years. 3
The Malawian government has mounted an impressive response to the HIV/AIDS epidemic in recent years. This has been reflected by a steady decline in HIV prevalence; from 14 percent in 2003 to 10 percent in 2011, and new annual HIV infections; from 100,000 new infections in 2003 to 46,000 in 2011. 4 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 greater progress. Gaps in Malawi's HIV response, such as the lack of data on high-risk groups, as well as legislation that criminalises them, means that greater effort is needed before Malawi can be said to be implementing a combined prevention approach.
Who is affected by HIV in Malawi?
- Heterosexual sex accounts for the majority of HIV infections in Malawi. 5
- Men who have sex with men. There is no available information about the number of infections transmitted through sex between men, as homosexuality is illegal, but indications from small-scale studies suggests prevalence may be as high as 21.4 percent among MSM. 6 7
- Women are disproportionately affected by HIV compared to men. Across all age groups, there is a higher rate of HIV prevalence amongst women than amongst men: around 60 percent of adults living with HIV in Malawi are female. 8 9
- Young people. HIV prevalence is increasing among young people aged 15-19 years. 10
- Children. The HIV and AIDS epidemic has heavily affected children in Malawi. In 2011 an estimated 170,000 children were living with HIV in Malawi, with new annual infections reaching 16,000. 11
- Orphans. The high rate of AIDS-related deaths has resulted in a huge population of AIDS orphans. Currently, more than half a million children have been orphaned by AIDS. 12 A quarter of all children aged 10-14 years are orphans and/or vulnerable children.
- Urban dwellers. HIV prevalence is around 17 percent in urban areas, compared to almost 9 percent in rural areas. 13
- 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). 14
HIV prevention in Malawi
Malawi has taken a number of positive steps towards minimising the spread of HIV. HIV prevention efforts are largely focused on preventing sexual transmission of HIV, due to the majority of HIV infections that occur through this route. 15 Some of the prevention initiatives being scaled up in Malawi include:
- Expanding voluntary HIV testing and counselling (HCT/ VCT)
- Prevention of mother-to-child transmission services
- Condom promotion and distribution
- Voluntary medical male circumcision (VMMC)
- Blood safety measures
- Mass media campaigns
- Life Skills Education (LSE) for young people
Malawi’s epidemic is driven by a number of key issues (largely structural) that hinder HIV prevention initiatives and contribute to new HIV infections. Among these is a lack of resources, stigma and discrimination, laws that criminalise high-risk groups, such as, men who have sex with men, low-socio economic status of women and gender inequality. Issues particularly associated with a high risk of HIV infection include widow inheritance, gender based violence (GBV) and the inability to negotiate condom use. 16
Malawi’s epidemic is diverse; with significant differences found between regions, urban compared to rural settings, between age groups and sexes, as well as the cultural diversity found across the country – Malawi has six main languages. If Malawi’s HIV prevention strategies are to have a significant impact on the rate of new HIV infections, it is vital they are comprehensive and tailored to the needs of individual groups and communities.
Voluntary counselling and testing (VCT)
Testing for HIV is essential to ensure early access to HIV treatment and related services, before progression to AIDS occurs. Getting tested for HIV enables protection of sexual partners and, for mothers, access to services that prevent HIV transmission during pregnancy and breastfeeding.
Knowing your status in Malawi is now easier than ever before. Voluntary HIV testing and counselling (HTC) services are becoming increasingly available as the number of testing sites increase. 17
- In 2011, 778 static and 614 outreach HTC sites provided testing and counselling services
- More than 1.7 million people (28 percent of sexually active population) received HIV testing and counselling last year (FY 2010)
- Women are nearly twice as likely to test for HIV compared to men. This is also the case among young men and women 18
People in Malawi have a number of concerns that are stopping them from testing for HIV. These include 19:
- Worried they will test positive
- Think they are already HIV positive, so no point testing
- Don’t know about HTC services
- Think they are not infected
- Against their religious beliefs
There are many good reasons for Malawians to get tested. Getting an HIV test is the only way to know you have HIV. This gives you access to life saving HIV treatment that is increasingly available in Malawi. Pregnant women who test positive for HIV will be placed on HIV treatment for life, to stay healthy and to protect current and future pregnancies from HIV.
Prevention of mother-to-child transmission of HIV (PMTCT)
Malawi has demonstrated an unprecedented commitment to preventing transmission from HIV-positive mothers to their infants in recent years. Major achievements include the expansion of sites providing PMTCT services and the implementation of the option B+ approach, in July 2011, meaning all pregnant women with HIV are offered antiretroviral treatment for life – irrespective of CD4 count. 20
- 63,000 pregnant women need effective antiretroviral treatment for PMTCT 21
- 33,557 (53 percent) pregnant women received effective antiretroviral treatment for PMTCT 22
- 544 facilities provided PMTCT services in 2011, compared with 152 facilities in 2006 23
However, a smaller scale study in Northern Malawi found that less than half of all HIV-positive mothers who were offered option B+ at their first antenatal appointment, had commenced their lifelong treatment by the time of delivery, increasing the risk of mother-to-child transmission of HIV. 24
Early testing of infants born to HIV-positive mothers is essential to lower infant mortality rates among children that have been infected. DNA PCR tests enable a conclusive diagnosis of infants exposed to HIV. Whilst the number of sites providing services for early infant diagnosis has been scaled up, to 200 sites in 2011, this remains low.
David Odali, Director of Umunthu Foundation, an AVERT overseas partner, discusses the benefits and challenges of option B+ in further detail below, see ‘Case Study: Option B+ in Malawi’.
Various NGOs have promoted the use of condoms in Malawi, including PSI and BLM, which have both carried out social marketing programmes to make condoms more accessible. BLM has distributed millions of condoms, and has also promoted use of the female condom. These campaigns have achieved successful results 25:
- 4.3 million condoms were distributed through PSI and BLM clinics, FY 2009-2010
- PSI sold more than 7 million condoms in 2010
- Half of young men and women (15-24 years), who have never married, report using a condom at last sexual intercourse.
Availability, accessibility and affordability issues continue to hinder condom use in Malawi. Bottlenecks in the condom supply chain leads to stockouts, whilst the low availability of condoms in rural areas, rest houses and places of entertainment can make consistent access to condoms difficult. Low condom use has also been associated with negative views and beliefs about condoms, such as, reduced sensitivity during sex, their efficacy, having a lack of mutual trust. In some cases, gender inequality can make it difficult for women to insist on condom use.
Condom use is the most reliable way to prevent HIV transmision during sexual intercourse. Despite previous objections to condom use by many faith based organisations, there is evidence that many are changing their position on condoms, and now encourage their use among individuals that fail to be abstinent, or faithful to one partner.
HIV and AIDS treatment in Malawi
- Greater numbers of people were alive and receiving treatment in 2011, (322,209) compared with 2004, (13,183)
- ART coverage increased from 54% to 67% between 2010-2011
- Nearly a third of children in need of HIV treatment in Malawi are receiving it
- 449 HIV treatment clinics
- Greatest access to treatment in Central East and Northern zone, lowest access in South East zone.
In recent years, Malawi has succeeded in improving the country’s HIV treatment response by implementing WHO treatment guidelines. 27 The introduction of a new treatment regimen in 2008, placed people with HIV on more effective drugs, with less side-effects; starting patients on treatment earlier (at a CD4 count of <350 cells/mm3 instead of <200 cells/mm3 28) improved patient health and life expectancy; introducing Option B+, in July 2011, reduced infections among children and improved the health of mothers. Between 2010 and 2011 a notably decline in AIDS deaths was recorded, from 49,000 to 44,000. 29
Access to treatment is particularly limited in rural areas with issues such as a lack of transportation preventing many people from reaching vital healthcare services. Even where treatment is available, transport costs and discrimination by healthcare workers leads to poor adherence and retention in care. 30 Moreover, famines and food shortages have highlighted the relationship between nutrition and HIV. 31
Additionally, due to a significant time lag of approximately six months between ordering ARVs and their delivery, some health facilities have experienced ARV drug stock outs. 32 This led to the rationing of ARVs in some health facilities in 2011. Improving the drug supply chain, such as having a buffer stock of ARVs, has been highlighted as a priority to prevent ARV stock outs. 33Another challenge is the common shortages of medicines to treat the opportunistic infections that arise at later stages of HIV infection. 34
HIV and AIDS funding in Malawi
Malawi’s efforts to overcome poverty, AIDS and famine are heavily dependent on international donors; more than 75 percent of the total HIV funding for HIV/AIDS was from international sources in 2011. 35 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. In 2004, President Mutharika took office and vowed to take a zero-tolerance approach to corruption. Whilst these difficulties were reduced and international support for Malawi increased, human rights and good governance concerns among international donors led to further declines in support throughout 2011. 36 In 2012, the election of Malawi's new President Joyce Banda improved Malawi's donor relations, with Britain releasing £30 million of, previously frozen, aid. 37 38
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. 39
- The Global Fund, which has so far disbursed funds of almost $294 million to Malawi out of a total approved amount of $390 million. 40 In November 2009 and December 2010, 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. 41
- 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. 42 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. 43 Perhaps surprisingly, Malawi is not currently one of the plan’s fifteen focus countries.
Malawi's annual budget for HIV and AIDS indicates that the majority of available funding goes towards HIV treatment and care, with HIV prevention and behaviour change accounting for 11 percent in 2011, less than in 2010. With 65.9 percent of the 2011 budget allocated to this area, compared with 46 percent in 2010, Malawi’s investment into HIV treatment and care has substantially increased over the last year. Malawi's financial sustainability has been an area of discussion for some time. The overall cost of the new treatment regime was expected to be three times more than the previous one, at around $105 million per year. 44 Following a succession of rejected funding proposals by the Global Fund, as well as the withdrawal of funding by the UK Department for International Development (DFID) in 2011, there were fears surrounding the sustainability of Malawi's new ARV regime. 45 As a result of the challenges Malawi faces in regards to phasing out stavudine certain sub-groups, for example pregnant women and those co-infected with TB, will be marked as a priority to receive stavudine-free treatment regimens. 46
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 people 47 – one of the lowest levels in the world. Although funding for healthcare has increased, there are simply not enough trained staff available.
Alongside financial constraints, the distribution of ARVs in Malawi is also 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.” 48
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. 49
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." 50
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. 51
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. Whilst there are issues that remain to be addressed, Malawi's response to HIV and AIDS in recent years demonstrates the scale of progress that can be made with greater investment and dedication.
Case Study: Option B+ in Malawi
Research findings show a dramatic increase (763%) on the number of HIV-infected pregnant women on ART undergoing Option B+ in Malawi. Officially reported at the 20th Conference on Retroviruses and Opportunistic Infections (CROI 2013) and published on 12th March 2013, this research is a very welcome development in PMTCT programming in Malawi.
Option B+, ART for life for all HIV infected, pregnant or breastfeeding women regardless of CD4 count is more ideal for HIV-infected women. Option B+ replaces the use of single –dose nevirapine, which was given to HIV-infected women during the labour pains and to the baby during 72 hours after its birth.
As one of the local NGOs that provide HIV counseling and testing and referral services for ART and PMTCT, in Bangwe and Limbe in Blantyre, Malawi, Umunthu Foundation finds the use of the Option B+ approach as commendable.
Option B+ has more advantages such as: simplification of PMTCT programme requirements-no need for CD4 count testing to determine ART eligibility (as required in Option A), it offers a strong and continuing prevention benefit against sexual transmission in sero-discordant couples and partners. Option B+ also sends a simple message to communities that, once ART is started, it is taken for life.
However, the unexpected finding that a quarter of HIV-infected women, involved in the study, only began taking ART during the breastfeeding period underscores some of the challenges the PMTCT programme faces in Malawi. These challenges include: limited availability and accessibility to ART by pregnant women more especially in semi-urban and rural areas, inadequate number of antenatal care (ANC) settings with integrated ART services, inadequate funding for sustainable universal access of PMTCT through B+ approach and low male involvement in maternal and PMTCT programmes, as male support is critically important for effective PMTCT.
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 Hastings 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%. 52
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 percent of hospital deaths at the time were AIDS related. 53
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.
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’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 stabilised between 11 percent and 17 percent between mid-1990 and 2007, 54 55 and prevalence amongst women attending antenatal clinics declined slightly. Several urban areas, such as the capital Lilongwe, witnessed a decline in HIV prevalence, although some rural areas saw an increase in prevalence. 56 Figures for 2009 indicated a stabilisation of national prevalence at around 11 percent. 57
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