Malawi’s HIV prevalence is one of the highest in the world, with 10.3% of the population living with HIV.1 Malawi accounts for 4% of the total number of people living with HIV in sub-Saharan Africa.1 An estimated 1,000,000 Malawians were living with HIV in 2013 and 48,000 Malawians died from HIV-related illnesses in the same year.1 The Malawian HIV epidemic plays a critical role in the country’s low life expectancy of just 54.8 years.2
Over the last decade, impressive efforts to reduce the HIV epidemic have been made at both national and local levels. New infections have dramatically declined from 98,000 new infections in 2005, to 34,000 new infections in 2013.1 Malawi has also witnessed a 67% reduction in children acquiring HIV, the largest country decline across sub-Saharan Africa.1
The Malawian HIV epidemic varies greatly across the country, with HIV prevalence in Southern regions of Malawi twice as high as Northern and Central regions, at 14.5%. Additionally, HIV is found to be more prevalent in urban areas (17.4%) than rural areas of Malawi (9%).3
Key affected populations in Malawi
Unprotected heterosexual sex is the main mode of HIV transmission in Malawi, accounting for 88% of new HIV infections.3 Despite this, there are several key populations that are increasingly vulnerable to HIV infection.
Women and HIV in Malawi
HIV disproportionately affects women in comparison to men in Malawi. The 2010 Malawi Demographic and Health Survey found that HIV prevalence among women was 12.9% compared to 8.1% HIV prevalence among Malawian men.3 This disparity is especially prominent among young people, with 3.7% of 15-17 year old women living with HIV in comparison to 0.4% of 15-17 year old men.3
This difference could be reflected in young men having more comprehensive knowledge of HIV than females, with 44.7% of young men showing understanding of preventative measures and rejecting misconceptions of HIV. This knowledge appears lower among females at 41.8%.3
Young people and HIV in Malawi
Young people account for 50% of new HIV infections in Malawi, with HIV prevalence higher among some young populations, such as 15-17 year olds.4 4.5% of young females aged and 2.7% of young men aged 15-24 years old are living with HIV in Malawi.5 Early sexual activity is high in Malawi, especially among young men, with one in five sexually active before age 15.6 With young people engaging in sex at an early age, addressing the sexual and reproductive health needs of this population is critical.
Socio-cultural factors such as initiation ceremonies and rituals have been found to lead to unprotected sex, increasing young people’s vulnerability to HIV, especially among girls. One study found that the transition period from childhood to adulthood in Malawi within many communities is defined by initiation ceremonies and rituals that can often encourage unprotected sex.7
Men who have sex with men (MSM) and HIV in Malawi
Men who have sex with men (MSM) have been identified as a key affected population within the Malawian HIV epidemic. Data on this group remains very limited, although some studies have found HIV prevalence as high as 21%.3 Efforts to address this increased vulnerability were, until very recently, limited by laws that rendered homosexuality an illegal behaviour. Homosexuality was decriminalised in 2012 and it is hoped that this legal change will bring more support for this underserved, high-risk population.8
Many MSM in Malawi face increased levels of stigma and violence. One 2013 study found that over 20% of MSM had experienced some form of stigma and 11.4% of MSM had experienced homophobic violence.8 Stigma and violence experienced amongst MSM can be responsible for difficulties in going for an HIV test, seeking HIV services and disclosure of HIV status.8
Sex workers and HIV in Malawi
Sex work is criminalised in Malawi, limiting the amount of available data on this key population. It has been found that HIV prevalence among sex workers is as high as 71%.3 Sex workers in Malawi face high levels of discrimination and stigma when seeking HIV services further increasing their vulnerability to HIV, especially from police when seeking victim support services.9
Children, orphans and HIV in Malawi
An estimated 170,000 children are living with HIV in Malawi.5 Malawi has shown immense progress in reducing child HIV infection rates with a 67% reduction in children acquiring HIV, the largest country decline across sub-Saharan Africa.1 However, only 23% of children living with HIV were on treatment in 2013.1 The 2014 Malawi Progress Report further identified early infant diagnosis as a priority for the national HIV and AIDS response.3
There is estimated to be 530,000 orphans in Malawi as a result of AIDS.10 Supporting the needs of orphans and other children made vulnerable by AIDS is identified as a main element of the national Malawian HIV response.3 Factors such as poverty are preventing the roll-out of adequate support and services for these children.
HIV testing and counselling (HTC) in Malawi
HIV testing and Counselling (HTC) services have increased over last few years in Malawi, surpassing national targets. During 2012-2013 over 2.1 million HIV tests were conducted, exceeding the national target by 20%.3 Despite this, the number of new people being tested was lower than previous years3, suggesting that engaging people who have never had an HIV test is crucial for future HIV testing campaigns.
HTC services are provided in two ways in Malawi, client initiated HTC, which is Voluntary Counselling and Testing (VCT), and provider initiated HTC, which encompasses a variety of methods including static sites; mobile testing units; home-based testing and national HTC events.11
Despite progress in the availability of HTC services, addressing the many factors that limit people accessing HIV testing services is crucial in order to ensure more people go for HIV tests. People in Malawi have a number of concerns that are stopping them from testing for HIV. These include:
- worried they will test positive
- think they are already HIV-positive, so no point testing
- unaware of HTC services available
- against religious beliefs
- some believe they don’t have the virus.12
Greater awareness and knowledge of the importance of HIV testing and HTC services available is crucial for these barriers to be overcome.
HIV prevention programmes in Malawi
The National HIV and AIDS Strategic Plan has developed various prevention policies and strategies for reducing HIV incidence. Some of these strategies are outlined below.
Preventing mother-to-child transmission (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 living with HIV are offered antiretroviral treatment for life – irrespective of CD4 count. PMTCT sites have increased across Malawi since the implementation of the Option B+ approach, with 588 PMTCT sites available, yet Malawi is still short of the target amount of 650.3
Despite this, the percentage of mothers receiving antiretroviral treatment to prevent MTCT has dramatically increased from 17% in 2009 to 79% in 2013.1 A similar increase is shown for mothers and infants receiving antiretroviral treatment during breastfeeding, with 79% receiving antiretroviral drugs in 2013, compared to just 4% in 2009. As a result of the impressive national efforts to reduce mother to child transmission and the scale up of antiretroviral therapy for pregnant mothers, the transmission rate from mother to child has reduced from 32% in 2009 to 13% in 2013.1
The 2014 Malawi Progress Report identified early infant diagnosis as a priority for the national HIV and AIDS response. Currently, only 30% of infants receive their diagnosis within the first two months of birth.1 Addressing the delay between birth and diagnosis is crucial for reducing infant mortality as a result of HIV.
Voluntary medical male circumcision (VMMC)
Another effective prevention strategy that has been scaled-up across Malawi is voluntary medical male circumcision (VMMC), which is now a key national prevention strategy.
VMMC availability and access has increased since 2012 and exceeded targets, with 45,441 circumcisions being performed in 2012/2013, surpassing the target of 10,000. A large proportion of these circumcisions were due to a national VMMC campaign, promoting the benefits of VMMC for HIV prevention.12 The Malawian 2014 Progress Report highlights that despite progress, the targets are still too low to increase prevalence of VMMC amongst the general male population of Malawi.
Many barriers remain that are limiting the uptake of VMMC in many areas. These include:
- low understanding of the benefits of VMMC
- fear of pain related to procedure
- cultural and religious factors
- little knowledge regarding differences between traditional circumcision and VMMC.13
Some concerns have arisen that the impressive scale-up of VMMC has led to a reduction in condom use among men.13 It is therefore important that VMMC is provided as part of a comprehensive package of HIV prevention.
Condom provision and programming
The provision of free condoms has been a major element of Malawi’s National HIV Prevention Strategy. Nearly 21 million condoms were provided across Malawi in 2012/20133, a big increase on previous years. However, there has been a decrease in the provision of female condoms.
Condom use remains low across Malawi, with only 27.3% of females and 24.5% of males with more than one sexual partner in the last 12 months reporting using a condom the last time they had sex.3 Furthermore, disparities in condom use among young people are evident across Malawi, at only 40.5% among young men, and 31.4% among young women.3
Chronic shortages of condoms have been reported as a major barrier to increasing the availability and accessibility of condoms across Malawi, impeding HIV prevention programmes.3
Antiretroviral treatment (ART) in Malawi
Malawi’s antiretroviral treatment (ART) rollout has significantly expanded, with 51% of people living with HIV receiving antiretroviral treatment in 2013. As a result of the expanded access to treatment, there has been a decline in AIDS-related deaths by 51%1, with more Malawians living healthy lives on antiretroviral treatment than ever before. However, only 30% of children living with HIV are receiving ART.5
The 2013 WHO guidelines on HIV treatment have been encompassed into the Malawian treatment, care and support plans, with new CD4 count thresholds for antiretroviral treatment initiation. This has meant that more people living with HIV are eligible for antiretroviral therapy. To cope with this, there is now greater access to treatment services at a local level, with many antiretroviral treatment sites becoming decentralized to primary care facilities.3 Between 2011-2013, the number of static antiretroviral sites increased significantly from 300 sites in 2011 to 689 in 2012.3
Malawi is making great progress in the provision of treatment, however coverage for children and young people is still low.3 Focusing on treatment programmes and coverage for children and young people is crucial if the future generations of Malawi are to lead long and healthy lives.
A further important element of the antiretroviral programme in Malawi is ensuring effective follow-up procedures. In 2012, only 79% of adults and children initiated on antiretroviral therapy were still taking antiretroviral drugs 12 months later1, suggesting a large percentage of people fail to consistently take their antiretroviral drugs. Recent studies have found that antiretroviral therapy follow-up procedures are inconsistent, with patients exhibiting late and missing treatment sessions.14Issues surrounding follow-up procedures can have implications for adherence to antiretroviral therapy, emphasising the importance of monitoring and follow-up.14
Barriers to HIV prevention programmes
A number of barriers to HIV prevention that range from cultural, social and structural factors to legal and financial barriers further exacerbate Malawi’s HIV epidemic.
- Cultural practices
The National HIV & AIDS Strategic Plan recognises that harmful cultural practices are a barrier to HIV prevention. Initiation ceremonies are one example in Malawi that has been linked to increased vulnerability to HIV for young girls. The ceremonies typically involve a young girl having unprotected sex with an older man.15 These cultural practices act as a barrier to effective HIV prevention, instead promoting unprotected sex.
- Multiple and concurrent sexual partners
Multiple and concurrent sexual partners is a feature of Malawian culture. The 2010 Malawian Demographic and Health survey found that 6.5% of males had two or more partners during the 12 months prior to the survey, compared to 0.4% of women.16 For married men, this figure increases to 10.1%.12 Multiple and concurrent partners can increase the transmission of HIV and behaviour change programmes that advocate faithfulness as well as educating people on safer sex are needed.15
- Gender inequality
The low socioeconomic status of women and gender inequalities also drive the epidemic. Power relations between men and women are reinforced through sex, with males usually dominating and initiating sex.7 One study found that males were also more likely to make decisions regarding contraceptive use during sex, making it difficult for a woman to negotiate condom use.17
The cost of the Malawian national response to HIV increased in 2011, to over $77.3 million.5 The majority of funding is spent on treatment and care, leaving gaps in financial support for non-biomedical interventions. Additionally, funding gaps are present that limit opportunities to effectively provide HIV services and fully implement the National HIV and AIDS Strategic Plan.3
Malawi’s HIV response is largely donor dependent, with 75% of funding coming from international donors in 2011.18 However, issues of corruption within the government have severely affected overseas development aid provisions. Sometimes, funds are not available or inconsistently disbursed, impeding the roll-out of HIV prevention programmes and the provision of treatment.
Malawi has no legal restrictions that discriminate against people living with HIV entering and residing in the country. However, punitive laws are hindering an effective response for key affected populations, particularly sex workers and MSM.
Although considerable progress has been made for decriminalizing homosexuality in Malawi, formal recognition of MSM rights remains limited. This can result in increased levels of stigma and discrimination towards these vulnerable populations. Sex work remains an illegal occupation in Malawi, limiting the support and services to these vulnerable populations.
The way forward
Malawi has made impressive progress in responding to their HIV epidemic, particularly in HIV prevention with regards to MTCT as child transmission rates have dramatically reduced. HIV prevention in regards to behaviour change programs however, is failing to address the rising infection rates among young people.
Malawi faces challenges with regards to ensuring adequate funding, a challenge shared by many countries across sub-Saharan Africa. Furthermore, to combat the high HIV prevalence rates among young people, more young-person oriented programmes are needed to increased prevention and knowledge of HIV and AIDS.
A number of key affected groups exist in Malawi and greater effort is required to support them, via comprehensive prevention programmes and campaigning to challenge the high levels of stigma and discrimination facing these populations.
- 1. a. b. c. d. e. f. g. h. i. j. k. l. UNAIDS (2014) 'The Gap Report'
- 2. UNDP (2013) 'Human Development Report 2013: The Rise of the South-Human Progress in a Diverse World'
- 3. a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. q. r. s. t. Malawi Ministry of Health (2014) ‘Malawi Progress Report for 2013’
- 4. Small, E. and Weller, B. (2013) ‘Profiles of Malawian adolescents at risk for HIV infections: Implications for targeted prevention policy, and practices’ AIDS Care 25(3):289-295
- 5. a. b. c. d. UNAIDS (2013) ‘Global Report 2013’
- 6. Population Reference Bureau (PRB) (2014) ‘A Vision for the Health and Wellbeing of Malawi’s Young People’
- 7. a. b. Jimmy-Gama, D B. (2009) ‘An assessment of the capacity of faculty-based youth friendly reproductive health services to promote sexual and reproductive health among unmarried adolescents: evidence from rural Malawi’
- 8. a. b. c. Wirtz, A.L. et al (2013) ‘HIV among men who have sex with men in Malawi: elucidating HIV prevalence and correlates of infection to inform HIV prevention’ Journal of the International AIDS Society 16(Supplement 3)
- 9. Theatre for a Change (2014) ‘Building Advocacy Capacities of Sex Workers in Malawi’
- 10. UNAIDS ‘Malawi’ [accessed May 2015]
- 11. Malawi Ministry of Health ‘Scaling up HIV Testing and Counselling in Malawi’ [accessed May 2015]
- 12. a. b. c. Malawi Ministry of Health (2012) ‘Malawi Country Report for 2010 and 2011’
- 13. a. b. Clearing House on Male Circumcision for HIV Prevention (2012) ‘Malawi Voluntary Medical Male Circumcision Communication Strategy 2012-2016’
- 14. a. b. Rachlis, B. et al (2014) ‘Follow-Up Visit Patterns in an Antiretroviral Therapy (ART) Programme in Zomba, Malawi’ PLOS One
- 15. a. b. Malawi College of Medicine (2007) ‘Policy Review – The Malawi HIV Prevention Policy’
- 16. Malawi Ministry of Health (2012) ‘Malawi Country Report for 2010 and 2011’
- 17. Munthali, A and Zakeyo, B (2011) ‘Do they match? Adolescents’ Realities and Needs Relating to Sexuality and Youth Friendly Service Provision in Dowa District, Central Malawi’
- 18. UNAIDS (2012) ‘Global Report 2012’