- Malawi has one of the highest HIV prevalences in the world despite the impressive progress the country has made in controlling its HIV epidemic in recent years.
- Young people are particularly at risk, due to early sexual activity and marriage, with 50% of new HIV infections affecting those aged 15 to 17 in Malawi.
- Stigma remains a key barrier to progress, particularly among men who have sex with men and sex workers.
- Malawi is on track to achieve the UNAIDS 90-90-90 targets by 2020, which include 90% of people with HIV knowing their status, 90% of these accessing ARVS and 90% of those on treatment being virally suppressed.
Malawi’s HIV prevalence is one of the highest in the world, with 9.2% of the adult population (aged 15-49) living with HIV.1 An estimated one million Malawians were living with HIV in 2018 and 13,000 Malawians died from AIDS-related illnesses in the same year.2 The Malawian HIV epidemic plays a critical role in the country’s low life expectancy of just 57 years for men and 60 for women.3
Over the last decade, impressive efforts to reduce the HIV epidemic have been made at both national and local levels. In 2018, 90% of people living with HIV in Malawi were aware of their status, of which 87% were on treatment, of which 89% were virally suppressed. This equates to 78% of all people living with HIV in Malawi on treatment and 69% of all people living with HIV being virally suppressed.4
New infections have dramatically declined from 55,000 new infections in 2010, to 38,000 in 2018.5 Malawi has also witnessed a reduction in HIV infections among children. There were 3,500 new paediatric infections in 2018, compared with 15,000 in 2010.6
Malawi’s HIV epidemic is generalised, which means it affects the general population as well as certain high-risk groups. Unprotected heterosexual sex between married or co-habiting partners accounts for 67% of all new HIV infections, while unprotected casual heterosexual sex accounts for 12%.7 Beyond this, several populations groups such as adolescent girls and young women, sex workers and men who have sex with men are particularly vulnerable to HIV.
The Malawian HIV epidemic varies greatly across the country. HIV prevalence and density is high in the urban districts of Lilongwe, Blantyre and Zomba and in the southern region of the country.8
HIV disproportionately affects women in Malawi. A national assessment of the impact of HIV on the population, carried out by the Malawian Ministry of Health in 2015-2016, found HIV prevalence among adult women (aged 15-64) to be 12.8%, compared with 8.2% among adult men.9 This disparity is especially prominent among 25- to 29-year-olds, as HIV prevalence is three times higher among women than men in this age group (14.1% vs 4.8%).10
HIV disproportionately affects women in Malawi. This disparity is especially prominent among 25 to 29-year-olds, as prevalence is three times higher among women (14.1% vs 4.8%).
Sexual violence is also an issue with 22% of women and 15% of men experiencing sexual violence before the age of 18. Most of the perpetrators of sexual violence against women are spouses, boyfriends or romantic partners (sexual violence is also known as ‘intimate partner violence’).11
Roughly a third of all new HIV infections (12,500 out of 36,000) in Malawi in 2016 occurred among young people (aged 15-24) Of these, 70% were among young women.12
Early sexual activity is high in Malawi with around 15% of young women and 18% of young men (aged 15-24) reporting having sex before the age of 15.15 Furthermore, girls aged 15-19 are 10 times more likely to be married than their male counterparts, with 45.9% of women having their first marriage before they turn 18, nearly one in two.16 To attempt to deal with this issue, in 2017 Malawi increased the minimum age of marriage from 15 to 18, criminalising child marriage.17
With young people engaging in sex at an early age, addressing the sexual and reproductive health needs of this population is critical. Indeed, knowledge of HIV prevention among young people is improving, with 78% of young women and 82% of young men demonstrating sufficient knowledge of HIV prevention in 2016.18 For both genders, comprehensive knowledge about HIV generally increases with age, educational attainment, and wealth. Urban young people are more likely than rural young people to have knowledge of HIV prevention.19
Despite increasing knowledge about HIV, condom use remains low among sexually active 15-to-19-year-olds, with only 25% of married females and 30% of sexually active unmarried females from this age group using any form of modern contraception.20 Young people often face obstacles to accessing contraceptives and health services, which increases their risk of acquiring HIV and other sexually transmitted diseases.21
Sexual violence is also an issue for young people. Around 23% of females and 13% of males aged 13-17 surveyed by UNICEF in 2013 reported experiencing sexual violence in the past 12 months.22
Sex work is criminalised in Malawi, limiting the amount of available data on this key population, as well as the support and services sex workers are able to access.
The evidence that is available suggests a major decrease in HIV prevalence among female sex workers, from 77% in 2006 to 24.9% in 2016, although it remains unacceptably high.23
There is also evidence of growing positive trends in the adoption of safer behaviours by female sex workers that may help to further reduce HIV transmission in the coming years. For example, the proportion of female sex workers reporting using a condom with their most recent client was high at 85%.24
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.25
Men who have sex with men (MSM)
Men who have sex with men (sometimes referred to as MSM) have been identified as a key affected population within the Malawian HIV epidemic.
Nearly one in five men who have sex with men are living with HIV. At 17.3%, prevalence remains two times higher than the rest of the adult male population.26
Although prevalence tends to be higher in older men, data from 2017 suggests 11.8% of 18-19-year-old men who have sex with men are already living with HIV. This highlights the importance of targeting young people for HIV prevention and testing services, regardless of their gender or sexual orientation.27
Worryingly, 80% of men who have sex with men questioned in a 2014 study incorrectly reported that anal sex carries a lower risk of HIV transmission than vaginal sex and only 23% reported receiving targeted HIV prevention information.28.Also of concern is the fact that, in seven of the 28 districts surveyed, 30% to 45% of men who have sex with men did not know their HIV status. High-risk behaviours were common, including multiple sexual partners, inconsistent condom use and exchanging sex for money.29
Homosexuality is illegal in Malawi, punishable by up to 14 years in prison, although prosecutions were suspended in 201230 Nevertheless, men who have sex with men still face varying levels of punishment - for example a police officer may still prosecute someone involved in same sex acts under the provision that they are ‘breaching the peace’.
Furthermore, many men who have sex with men face increased levels of stigma and violence in Malawi. A 2016 survey of around 200 men who have sex with men found that 39% had experienced a human rights abuse in some form, including 12% who had been raped.31
All of these factors create a hostile environment that increases men who have sex with men’s vulnerability to HIV while lessening their ability to access HIV prevention and treatment services.
Children and orphans
An estimated 110,000 children (aged 0-14) were living with HIV in 2015 of whom 49% (53,400) were receiving antiretroviral treatment.32
Children and vulnerable children are identified as a key target group by Malawi’s 2015-2020 HIV strategy.33Indeed, the country has shown immense progress in reducing child HIV infection rates. In 2013, the country had achieved a 67% reduction in children acquiring HIV, the largest country decline across sub-Saharan Africa.34
There is estimated to be 670,000 orphans in Malawi as a result of AIDS.35 Supporting the needs of orphans and other children made vulnerable by AIDS is identified as a main element of the national Malawian HIV response.36 Factors such as poverty are preventing the roll-out of adequate support and services for these children.
HIV testing and Counselling (HTC) services have increased over the last few years in Malawi, surpassing national targets.
HTC services are provided in two ways: through client-initiated HTC (also known as ‘voluntary counselling and testing’), and provider-initiated HTC. Provider-initiated testing, which is when a healthworker offers an HIV test to a patient, occurs in a wide variety of settings including healthcare facilities; mobile testing units; people’s homes and at national health events.37
Within the first three months of 2017, 982 560 people were tested for HIV, suggesting that testing services have significantly expanded in recent years.38 In comparison, 1.8 million people accessed HTC services in total during 2014.39
Although HIV self-testing kits are not widely available, UNITAID’s 4-year Self-Testing Africa (STAR) project is trialling self-testing in the country. Initial results from 2016 suggest that, when HIV self-testing is provided as part of a community-based approach, it can increase uptake of testing services, particularly among men and adolescents, and connect people to HIV treatment, particularly among individuals who are at high risk of HIV infection. For example, 26% of those using the self-testing kits in 2016 were first-time testers, 26% were aged 16–24, and 49% were men (aged 16-65). Overall, testing coverage among men in areas where STAR operated increased by 24%.42
There were 36,000 new HIV infections in Malawi in 2016.43
Malawi’s National HIV and AIDS Strategic Plan 2015-2020 has various prevention policies and strategies for reducing new HIV infections. Some of these strategies are outlined below.
Condom availability and use
The provision of free condoms has been a major element of Malawi’s National HIV Prevention Strategy.
In 2013-2014, more than 40.4 million condoms were distributed. However, only 24.1 million of these were free of charge. The remaining 16.3 million condoms were for sale (sometimes referred to as ‘socially marketed’). Despite the total number of condoms distributed being double the amount distributed the year before, this figure was 40% short of Malawi’s yearly target. However, the yearly target for commercial condoms was surpassed by 64%.44
In 2016, despite a challenging environment, about 53,000 condoms and 47,000 lubricant tubes were distributed to people within the lesbian, gay, bisexual, transgender and intersex (LGBTI) community.45
Malawian men demonstrate one of the highest rates of condom use at last high-risk sex (with a non-marital, non-cohabiting partner) in Eastern and Southern Africa, at 76% (in 2015).46 However, condom use among Malawian women engaging in high-risk sex is significantly lower at 50%.47
HIV education and approach to sex education
Raising awareness about how to prevent HIV is a key part of Malawi’s prevention strategy. This is covered in life skills education (LSE) for young people who are both in-school and out-of school. LSE subjects include the promotion of mutual faithfulness and the use of male and female condoms.
Before 2010, LSE for young people in school was irregular. By 2014, the most recent data available, all students in primary and secondary schools were exposed to LSE. However, only 53,600 of a target of 150,000 young people out-of school had received LSE.48
In 2016, a major push on prevention efforts targeted at adolescents and young adults was carried out. For example, Action 4 Adolescents and Youth reached as many as 200,000 adolescents with HIV, sexual and reproductive health information and treatment services.[49
Radio shows are also used to raise awareness of HIV prevention in Malawi. In 2014, just over 220 hours of radio time was used to air programmes, slots and jingles on HIV and AIDS. This missed the 2014 target of 300 hours and is a reduction on preceding years. 50
Prevention of mother-to-child transmission (PMTCT)
Malawi has demonstrated an unprecedented commitment to preventing transmission from mothers living with HIV to their infants in recent years. Major achievements include the expansion of sites providing prevention of mother-to-child transmission (PMTCT) services. In July 2011 Malawi became the first country to implement the Option B+ approach, which means that all pregnant women living with HIV are offered antiretroviral treatment for life – irrespective of CD4 count.
The impact of this has been huge. Between 2011 and 2016, the proportion of women with HIV who were diagnosed went from 49% to 84%,51. Between 2011 and 2015, the proportion of pregnant women with HIV who were virally suppressed jumped from 2% to 48%.52 In 2014, of the more than 520,700 women receiving HIV test results, 7.7% were living with HIV.
PMTCT sites have increased across Malawi since the implementation of the Option B+ approach, with 638 PMTCT sites available as of September 2014, although this is still short of the target of 700.53
Around 73% of women offered treatment as part of Option B+ were receiving treatment after 12 months and around 71% after 24 months. This treatment gap is mostly due to the fact that up to 15% of pregnant women who are diagnosed with HIV do not then go on to start treatment. This could be due to poor counselling of newly-diagnosed HIV-positive pregnant women in healthcare facilities, poor male involvement in PMTCT issues and a lack of disclosure to spouses and family.54
Clara was 25 when she noticed she had the same symptoms as her parents. But despite knowing she was living with HIV, guidelines at the time only allowed access to antiretroviral treatment if her CD4 count had fallen below 200 (guidelines now recommend people start treatment as soon as they are diagnosed). She had to travel 400km just to get a CD4 count test, which confirmed she had advanced stage HIV infection and a CD4 count of only 32.
Today, with the right treatment, her viral load has been rendered undetectable and her oldest daughter, who also lives with HIV, is in good health. Her youngest daughter was born HIV-negative, as a result of improved access to PMTCT services. Clara now co-ordinates national activities for women living with HIV, offers advice, encourages testing and works to combat stigma and discrimination.55
The 2015 Malawi Progress Report identifies early infant diagnosis as a priority for the national HIV and AIDS response. In 2016, around 31% of infants were diagnosed within the first two months of birth.56 However, this is a decline from 2014 levels when 37% received early infant diagnosis.57 Addressing the delay between birth and diagnosis is crucial for reducing infant mortality as a result of HIV infection.
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.
The availability of VMMC has increased since 2012, with 129,975 circumcisions performed in 2016 although this is far below the country’s stated target of 250,000.58
Overall, the proportion of circumcised men in Malawi has increased marginally, from 21.5% in 2010 to 27.8% in 2016.59
A number of barriers limit the uptake of VMMC. Misconceptions about the efficacy and unintended consequences of this intervention are high. Malawi’s National AIDS Commission (NAC) reports how some men perceive VMMC as a guaranteed protection against HIV, which may promote high-risk sexual behaviour, while others have expressed concerns about its adverse effects on sexual pleasure and performance. Infections and gangrene have also been reported in some districts following VMMC, which are likely to have negatively affected demand.60
Pre-exposure prophylaxis (PrEP)
Pre-exposure prophylaxis (PrEP) is not available in Malawi, though a feasibility study was planned to start in late 2017 by the International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) Network. The study is looking at adherence among HIV-uninfected pregnant adolescents and young women (aged 16-24) and is expected to complete in 2019/2020.
Malawi has a ‘test and treat’ strategy, which calls for all people living with HIV to begin antiretroviral treatment (ART) as soon as possible, irrespective of their CD4 count.61
Malawi’s ART rollout has significantly expanded, with 68% of adults living with HIV receiving ART in 2016, an increase of 18% from 2013.62
In 2016, of the 900,000 adults (aged 15-64) living with HIV, 70% were aware of their status. Of these, 89% were on ART and 89% were virally suppressed.63 Viral suppression is when levels of HIV are so low in the body that a person is likely to be in good health and unable to transmit HIV to others.
In 2016, the percentage of men living with HIV who were on ART and virally suppressed was found to be significantly lower than that of women (58.6% vs 72.9%). This is a direct result of the majority of Malawian men living with HIV being unaware of their HIV status.
Just under half of all children (aged 0-14) living with HIV are on ART. To increase the number of children on ART, Malawi began piloting easier-to-take ARV formulations (known as ritonavir-boosted lopinavir – or LPV/r – pellets) for infants and young children in 2016.64
As a result of expanded access to treatment, AIDS-related deaths decreased by almost two thirds between 2004 and 2016 with more Malawians living healthy lives on ART than ever before.65 However, as far fewer men living with HIV are on ART than women, they are 1.3 times more likely to die from AIDS-related illnesses. In 2016, 11,200 men died of AIDS-related illnesses compared with 8,800 women. This is despite prevalence being significantly higher among women than men.66
A further important element of any treatment programme is ensuring effective follow-up. Yet recent studies have found ART follow-up procedures in Malawi to be inconsistent, with many patients missing treatment sessions.67
This is reflected by the fact that adherence levels in Malawi are lower than the rate of 85% recommended by the World Health Organization (WHO).In 2014, 78% of people living with HIV who had begun ART were still on it after 12 months. At 24 and 60 months, the proportion of people living with HIV who remained in care was 73% and 59%, respectively. 68
Adherence levels are lower among adolescents than adults. Recent research found that 45% of adolescents living with HIV reported missing ART in the past month. The most commonly reported reason was forgetting (more than 90%), travel from home (14%) and busy doing other things (11%). Alcohol use, violence in the home and low treatment self- efficacy were all associated with worse adherence.69
Data on HIV drug resistance (HIVDR) in Malawi is very limited, but globally prevalence of HIV drug resistance is now estimated to be 9%. In 2016, the WHO estimated that pre-treatment resistance to NNRTIs (a type of antiretroviral treatment drug) had reached 11% in Southern Africa. Weak health systems, limited viral load monitoring, and low levels of adherence are key issues for Malawi in addressing drug resistance.
In Malawi, the law protects civil society, although government intimidation and policing sometimes impede activism and the work of civil society organisations (CSOs). Fears exist that the independence of CSOs will be further eroded by the restrictive 2017 NGO (Amendment) Bill.70
Non-government organisations (NGOs) play a vital role in representing the most vulnerable in society in a number of areas, including health. NGOs have made strides in furthering human rights by raising awareness against negative cultural traditions and beliefs such as child marriage. However, NGOs working on issues relating to men who have sex with men and other people who are LGBTI have had less of an impact.71
I wish for the day Malawians will accept us as we are. Being gay or lesbian in this country, you risk being excommunicated from church, fired from work, banished from home and even getting arrested.
- James, a gay man from Malawi72
HIV remains the most important risk factor for developing active TB in Malawi: 52% of people with TB are also living with HIV.73 In addition, TB is the leading cause of death among people living with HIV and AIDS, accounting for around 40% of AIDS-related deaths in Malawi each year.74
In 2015, around 95% of registered TB patients know their HIV status and 92% of those were on ART during their TB treatment period.75
Despite high levels of TB/HIV co-infection, until the mid 2010s TB and HIV were traditionally treated under separate programmes. However, Malawi’s National TB Control Program (NTP) and the Malawian Ministry of Health are increasingly working together to integrate TB and HIV services.76
Malawi’s National HIV and AIDS Strategic Plan 2015-2020 recognises that certain cultural norms are a barrier to HIV prevention. 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.77
Multiple and concurrent sexual partners, which can increase the transmission of HIV, is a feature of Malawian culture. The 2015-2016 health survey found that 13% of men had two or more partners during the 12 months prior to the survey, compared to 1% of women.78 For married men, this figure increases to 16%.79
A 2013 study based on in-depth interviews with around 70 women found marriages in Malawi to be characterised by such stark gender inequalities that marriage itself is a risk factor for HIV infection in women. Respondents generally reported they had remained faithful while their husbands had girlfriends or had taken an additional wife within a polygamous marriage, which is legal in Malawi.80
Malawi has no legal restrictions that discriminate against people living with HIV entering and residing in the country. In December 2017, the long-deliberated HIV Bill, which had the potential to be a major legal barrier to an effective HIV response in the country, was rejected by parliament. The bill included provisions to make HIV testing and treatment mandatory for certain populations and sought to criminalise HIV exposure and transmission.81
However, punitive laws are hindering an effective response for key affected populations, particularly sex workers and men who have sex with men.
Stigma and violence experienced by key populations, linked closely to their criminal status under Malawian law, often prevents these groups from accessing HIV testing, prevention and treatment services. For example, in a 2016 survey of Malawian men who have sex with men, 17.5% reported being afraid to seek healthcare of any kind.82
While Malawi’s current national HIV reporting system is robust, there is limited age-and sex-disaggregated data available. This impedes the country’s response as it means there is a lack of information about which population groups are being reached with services effectively and which populations are currently under-served. This is a significant issue, particularly given the need for HIV programmes that are targeted at young people. Use of electronic medical records system (EMRS) can facilitate reporting on age and gender, but currently EMRS is only available in a limited number of sites.83
Structural and resource barriers
Gains made in addressing the HIV epidemic in Malawi are threatened by key weaknesses in the country’s overall health system. Malawi has one of the most severe health workforce crises in Africa, with the lowest physician-to-population ratio at 2:100,000 and second lowest nurse to population ratio at 28:100,000.
Of the 719 functioning health facilities across the country, 81% are in rural areas. These are unevenly distributed, forcing many people to walk more than 10km to access services. In addition, 40% of public health facilities have no regular electricity supply, only half have running water, and two thirds do not have toilet facilities.
Another key issue is a lack of adequate infrastructure to meet the needs of HIV testing services as well other HIV treatment services. In 2016, 11% of facilities reported a stock-out of HIV testing kits. Laboratory systems are also weak and cannot efficiently support viral load testing.84
In 2016, Malawi received 74% of funding for its HIV response from the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Presidents Emergency Plan For AIDS Relief (PEPFAR) and a further 12% from other donors, with the remaining 14% coming from domestic funding.85 Significant progress has been made on the proportion of domestic funds being made available for the HIV response, however, as this stood at only 1.7% in 2010-2011.86
The majority of funding (47%) is spent on treatment and care, leaving gaps in financial support for non-biomedical interventions. Only 5% of 2014 expenditure went on PMTCT and 23% went on prevention.87 Additionally, funding gaps are present that limit opportunities to effectively provide HIV services and fully implement the National HIV and AIDS Strategic Plan.88
Issues of corruption within the government have severely affected overseas development aid provision. Sometimes, funds are not available or inconsistently disbursed, impeding the roll-out of HIV prevention programmes and the provision of treatment.
Malawi has made impressive progress in responding to its HIV epidemic, particularly PMTCT which has dramatically reduced infections in new-born babies.
In its 2015-2020 HIV strategy, NAC states that Malawi will aim to meet the UNAIDS 90-90-90 treatment targets. However, a number of gaps in the country’s response may lessen its ability to reach these goals. In particular, reaching the first target on testing, especially among men and young people, represents the country’s greatest challenge.89 In addition, more effective behaviour change programmes for young people are needed to increase condom use.
Malawi also faces challenges with regard to ensuring adequate funding for both its HIV response and its healthcare system in general, a challenge shared by many countries across sub-Saharan Africa. A severe shortage of healthworkers, poorly-equipped healthcare facilities and laboratories unable to carry out viral load testing continue to restrict progress.
Greater effort is also required to support sex workers, LGBTI people and men who have sex with men via comprehensive prevention programmes and campaigns that challenge stigma and discrimination. Unless these groups’ needs are properly addressed, significant gaps in Malawi’s HIV response will remain.
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- 31. Zahn R, Grosso A, Scheibe A, Bekker L-G, Ketende S, Dausab F, et al. (2016) ‘Human Rights Violations among Men Who Have Sex with Men in Southern Africa: Comparisons between Legal Contexts’ PLoS ONE 11(1): e0147156. doi:10.1371/journal.pone.0147156
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