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Alice Dong
Student ID: 1328466
June 10
th
, 2014
Assessing the HIV/AIDS Crisis in Malawi
Introduction
HIV/AIDS is a global epidemic that affects over 40 million people nationwide. Most of
the people living with this infection are concentrated in developing countries, with South African
countries experiencing the most severe epidemic. Located in the Sub-Saharan region of Africa,
Malawi is a developing nation with an estimated population size of 17,377,468.
20
Malawi is not
only one of the most densely populated countries, but it is also one of the poorest, ranking 160
th

out of 189 on the Human Developmental Index.
20
Over 52.4% of the population lives below the
rural poverty line and the national GDP per capita is only $900 dollars according to 2003
estimates.
20
With a struggling economy and limited resources, Malawi is poorly equipped to
respond to the rising issue of the HIV/AIDs epidemic. Currently, there 1,129,800 people living
with HIV/AIDS in Malawi and 45,600 AIDS related deaths each year.
20
However, healthcare
expenditures only account for 6.2% of national GDP in 2000, and the average number of
physicians per 1000 people is a low 0.02.
20
The shortcomings of the Malawi healthcare system
are evident as the average life expectancy in this country is a mere 59.99 and infant mortality
rates are at 48%.
20

Despite these limitations and obstacles, Malawi has launched a series of strategies and
campaigns over the years that has successfully reduced HIV/AIDS incidence and prevalence.
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The HIV/AIDS epidemic is severe in the country as Malawi has the 9
th
highest HIV prevalence
in the world and the annual incidence rate is 14.4%.
20
However, Malawi has made great strides in
alleviating the HIV/AIDS epidemic in the country.
In 2003, Malawi developed the National HIV and AIDS Policy, which was a major
milestone in the national responds to the HIV/AIDS epidemic. The policy was the foundation of
all the administrative and legal framework for the HIV interventions in the country. The goal was
to to reduce infections and vulnerability; to improve provision of treatment, care and support for
PLHIV; and to mitigate the socio-economic impact of the epidemic.
8
Between 2005 and 2009,
the National HIV and AIDS Action Framework (NAF) also guided the development and
implementation of HIV and AIDS interventions in the country. The focus of the framework was
prevention and behavior change, treatment care/support, mainstreaming and decentralization, and
research/evaluation of HIV/AIDS in the country.
8
In 2009, National HIV Prevention Strategy
was also developed to address key gaps in Malawis prevention programs. The strategy called for
a focus on the main drivers of the HIV/AIDS epidemic to reduce transmissions. Efforts included
reducing concurrency levels, reducing HIV transmissions among discordant couples, male
circumcision, prevent initiatives for young people, condom programming, and HIV prevention
for most at risk populations (MARPS).
8
National efforts, along with support from numerous
donors and development partners, have led to a significant scaling up of HIV prevention, care
and treatment programs in Malawi.
Then in 2011, the National HIV AIDS policy was renewed based on the three ones
principle and the three zeros (zero new HIV infections, zero discrimination and zero AIDS
related deaths).
8
By 2012, a new national strategic plan (NSP) 2011-2016 replaced the NAF with
the goal of reducing new infections by 20%, AIDS deaths by 8% and childrens death by 50%
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over the next 5 years.
8
As a result of these policies and campaigns, HIV prevalence in Malawi
decreased from 14% of the total population in 2003 to 10% of the population in 2011.
11
Annual
new infections per year (incidence) also decreased from 100,000 to 2003 to 46,000 in 2011.
11

With drastic improvement in HIV incidence and prevalence over the last decade, Malawi
is known to have one of the most innovative and effective strategies towards combating
HIV/AIDS. However, it is unclear if Malawi will be able to reach the WHO UNAIDS goal of
zero HIV transmissions by 2015. The effectiveness of these strategies and campaigns will be
evaluated throughout this paper to determine if Malawi is able to this zero transmissions goal.
Although Malawi has made many improvements in the response against HIV/AIDS since the
first outbreak of HIV/AIDS in 1985, in order to determine if Malawi is able to reach the WHO
UNAIDS goal of zero transmission by 2015, it is important to analyze the main drivers of the
HIV/AIDS epidemic in Malawi. Current HIV prevention and treatment strategies that target high
risk groups and behaviors will be evaluated in depth in terms of effectiveness and trajectory. This
is necessary to determine the future of HIV/AIDS in Malawi.

Current Vulnerable Groups and Behaviors
Although new HIV infections each year have been reduced drastically, the spread of HIV
to vulnerable populations continues to drive the HIV/AIDS epidemic. In Malawi, heterosexual
sex accounts for 88% of HIV transmission and mother-to-child accounts for 10%.
14
Other
modes of transmission includes MSMs, FSWs, and blood transfusions.
14
In addition, some
studies cite that transmission by blood accounts for 1% of new infections each year.
11
These
statistics demonstrate who main drivers of the HIV/AIDS epidemic in Malawi are; however, the
numbers may not accurate reflect the situation because homosexuality is illegal in Malawi and is
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punishable by up to 14 years in prison.
1
Male to male sexual transmission may account for a
significant portion of new infections each year but many of these cases go unreported due to the
criminalization of homosexuality. Another particular area of concern for HIV transmissions
include female sex workers, as recent estimates predict that 70% of all sex workers are HIV
positive in Malawi.
11
Women and girls are more likely to be affected, as the female demographic
constitutes for 58% of the infected in Sub-Saharan Africa.
14
The figure below predicts the
percent incidence by risk category, showing some of the main target risk groups.









Although the % incidence by risk category less than 3.7% for risk categories that involve
heterosexual sex, it is important to realize that the population that engages in heterosexual sex is
very large in Malawi and hence constitutes for the majority of new HIV infections each year.
Among the heterosexual population, the main drivers of the epidemic are multiple and
concurrent sexual partnerships, discordancy in long-term couples (one partner HIV-negative and
one positive) where protection is not being used, low prevalence of male circumcision, and low
and inconsistent condom use.
8
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Furthermore, studies show that 50% of all new infections in the heterosexual sex
population are in the age group 15-24.
14
This shows that the HIV/AIDS epidemic
disproportionally affect the younger population. Young children are also a major group of
concern because of the high incidence of mother-to-child HIV transmission and also because
children who have lost parents due to HIV/AIDS are highly vulnerable and susceptible to the
disease. In addition, tuberculosis and HIV/AIDS co-infection is reported to have a large role in
the HIV/AIDS epidemic in Malawi. The analysis of these main modes of HIV transmission, high
risk behaviors, and vulnerable groups in Malawi is key to understanding the trajectory of the
HIV/AIDS epidemic in Malawi.

MSMs:
Overview
Although there is little HIV/AIDS data collected on MSMs in Malawi due to cultural
stigma and the illegality of homosexuality, small scale studies suggest that HIV prevalence is
around 21.4% in MSMs.
11
Even though rates of new HIV infections are decreasing, the
prevalence among MSMs remains alarming high. There are no estimates of the number of MSMs
currently living in Malawi as a result of the cultural stigma. However, studies predict that 56% of
MSMs in Malawi are bisexual and often transmit the HIV virus that they contracted from sex
with other men to women.
5
Hence, the MSM population is an underrated driver of the
HIV/AIDS epidemic in Malawi.



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Major Risk Factors
Males who have sex with males (MSMs) are a high risk group for HIV/AIDS
transmission in Malawi due to both biological and socio-cultural factors. The main biological
risk factor is that MSMs are more likely to engage in anal sex and studies have shown that HIV
transmission through anal intercourse is 10 times higher than transmission through vaginal
intercourse.
2
This is because rectal tissue is more prone to tearing during intercourse and the
larger surface area of the rectum increases the opportunity for viral penetration and infection.
2

Another biological risk factor is the presence of genital ulcer disease (GUD) that is likely to
occur in MSMs, such as primary syphilis and chancroid.
2
MSMS are susceptible to these STIS
because chancroid is transmitted through breaks in the skin during intercourse, and primary
stage of anorectal syphilis appears within 2 to 10 weeks of exposure via anal intercourse.
27
As
STIs contribute to an increased risk of HIV acquisition, there is an increased risk of HIV
transmission among MSMs.
Moreover, because homosexuality is criminalized in Malawi, many MSMS are unaware
of their HIV status and/or unable to obtain proper healthcare services. In a study done by John
Hopkins School of Public Health, it was estimated that only 4.7% of MSMs are aware of their
HIV status.
4
Over 17.59% of MSMs surveyed said that they were afraid to seek health services
for HIV/AIDS in the fear of being denied basic health services, 15.5% were afraid to walk in the
community as a homosexual, 6.5% were denied housing due to sexuality, and 18% were
blackmailed because of their homosexuality.
4
Due to the high prevalence of HIV/AIDS in
MSMs networks and the low amount of testing and treatment for MSMs, MSMS are at high risk
for HIV transmission. The fear of seeking proper testing and HIV treatment that stems from
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cultural stigma and discrimination greatly limits the ability for the Malawi to reach MSMs and
decrease HIV incidence and prevalence in this group.

Current Strategies
Currently, there no HIV/AIDS governmental programs in Malawi that specifically target
MSMs. The Center for the Development of People (CEDEP), which provides HIV testing,
counseling, and outreach to MSMs is facing numerous challenges in HIV/AIDS related
interventions for MSMs due to the mass-spread of homophobia.
21
However, in 2003, MSMs
were acknowledged and included in the Malawi HIV Policy.
26
MSMS were also integrated into
Malawis National HIV Prevention Strategy 2009-2013, which detailed interventions including
targeted prevention messages and access to health services for the general population.
26
Even
though MSMs were included both policies, there were no specific campaigns and programs that
targeted the MSM population exclusively. However, efforts to acknowledge stigma and
discrimination within government health care facilities have recently been put into action in
Malawi.
1
In 2011, the Foundation of AIDS Research (amFAR) encouraged Fenway Health,
The John Hopkins Bloomberg School of Public Health, and the CEDEP to complete training for
health care providers to increase their cultural and clinical competence in addressing the needs of
MSMs.
1
While these programs aim to improve prevention and treatment for MSMs, these
programs are relatively new, disorganized, and has not shown significant effects in the reduction
of MSM HIV prevalence thus far. The MSM population in Malawi is mainly being helped
indirectly through programs that focus on increasing condom use, male circumcision, and STI
management.
For instance, many NGOS including Population Services International (PSI) and Banja
La Mtsogolo (BLM) have implemented social marketing programs to increase the accessibility
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of condoms.
11
This is important because with a higher percentage of condom use, there is a
lower risk of HIV transmission among individuals. Over the last few years, PSI and BLM clinics
have successfully distributed 4.3 million condoms throughout Malawi.
11
With more condoms
reaching the general population, it is likely that condom use has increased among MSM
populations. Studies have shown there in 11 districts across Malawi, there is about a 6% increase
in male condom use.
5
Even though there are no statistics to show that increased condom
distribution in Malawi has directly benefitted MSM populations, it can be inferred that MSMs
have been positively impacted by these programs.
In addition, Malawi also has made recent efforts to increase Voluntary Male Medical
Circumcision (VVMC). This is helpful because male circumcision decreases the likelihood of
HIV transmission. The removal of the foreskin decreases the surface area exposure of inner
membrane that is highly susceptible to infections and reduces the likelihood of tears in the
foreskin.
11
In an Australian study, it was shown that circumcisions were associated with a
significant reduction in HIV incidence among MSMs who reported a preference for the insertion
rather than reception in anal intercourse.
11
Although Malawi has attempted to provide stand-
alone clinics, routine facility-based services, and outreach or mobile services over the years,
Malawi has largely been criticized for slowly introducing free male circumcision in state clinics.
27
The current prevalence rate of male circumcision in Malawi is 21%.
23
However, recently,
Malawi has launched a large scale campaign to promote VMMC with the goal of performing
60,000 male circumcisions over a time span of 30 days.
17
The campaign was relatively
successful as 45,000 adult males were effectively circumcised long before the 30 days were up.
17
The unique campaign by Malawi successfully increased the number of males circumcised and is
likely to have a profound impact on the reduction of HIV/AIDS prevalence over the years.
17
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Another way Malawi is decreasing MSM HIV prevalence is through the streamlining of
STI management. Malawi has recently been putting in effort to help STI patients that are at risk
of HIV infection. In 2008, a total of 11,079 STI clients were treated and referred for HIV and
AIDS services.
1
Organizations such as Project Hope, AIDSCAP Project, and many others such
as have launched missions to support increased distribution of condoms to prevent STIs, training
in syndrome management of STIs, and operations research to combat HIV/AIDS and other
STIs.
18
These programs all positively benefit the MSM population in Malawi since MSMs are at
a high risk for STI and HIV infections.

Evaluation
Overall, MSM populations will continue to be a major driver in the perpetuation of
HIV/AIDS epidemic in Malawi over the years as this group will most likely not reach zero
transmissions by 2015. Due to the lack of data on MSMs, it is difficult to predict the trend of
HIV infections over the years. However, with a high prevalence of 21.4% among MSM, this is a
segment of population that deserves more attention and aid. However, due to cultural stigma,
discrimination, and ignorance, MSMs are not getting the help that they need. In fact, Malawis
proposal to dedicate $2,610,623 for MSM-specific activities over a five-year period was rejected
by the Global Fund.
1
The exclusion of MSMs was rationalized by the misconception that high-
risk practices such as men having sex with men are not common in Malawi.
5
This is alarming
because MSM populations are hugely impacted by the lack of MSM specific programs. MSMs
often do not receive proper testing and treatment services, as a 2009 U.S. Department of State
Human Rights report on Malawi found that approximately 34 percent of gay men in the country
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had been blackmailed or denied services such as housing or healthcare due to their sexual
orientation.
1

Furthermore, there are limitations to programs in Malawi that target condom distribution,
male circumcision, and STI management. Adherence to condom usage is a big problem, as it was
found that only a third of men consistently used condoms in casual sex with other men in
Malawi.
5
Another problem is that Malawis monetary resources are very limited while the cost
for male circumcision and STI treatment drugs are very high. Estimated costs of male
circumcision are between 25-500 dollars a person in Africa.
11
As a result, the limited outreach
and range of these programs in Malawi is not enough to successfully reduce the number of new
HIV transmissions among MSMs to zero by 2015.

Recommendations
The biggest problem that MSMs face is the criminalization of homosexuality in Malawi.
Ideally, Malawi should overturn the countrys ban on same-sex practices in order to improve
testing and treatment services for MSMs. Although President Banda has indicated that she would
like to repeal the countrys anti-gay laws, this is unlikely because it would require the approval
of parliament and most Malawians seem to oppose decriminalization.
1
Hence, the best thing that
Malawi can do is to create HIV/AIDS prevention and treatment programs that target MSMs
specifically. To eliminate the problem of discrimination within health care facilities, the
government should launch awareness programs among health personnel on the issues affecting
MSMs, making it known that HIV transmission among MSMs is a huge problem in Malawi.
Furthermore, educational campaigns should be initiated to inform the population about the
importance of adherence to condom use and getting tested for HIV and STIs. In general, Malawi
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needs to increase the accessibility of HIV prevention and treatment services to MSMs through
educational and treatment campaigns that specifically combat the major biological and socio-
cultural HIV transmission risk factors that MSMs face.

Children:
Overview
In 2012, it was found that over 260,000 children aged 0-14 in Malawi were newly infected
with HIV and 650,000 children were orphaned by the epidemic.
19
Children aged 0-14 constitute
for 46.9% of Malawis population and birth rates in Malawi are the 7
th
highest in the world at
41.8 births/1,000 population.
20
Malawi is a very young and rapidly growing population; hence, it
is important to focus on preventing and treating HIV/AIDS in children.

Major Risk Factors
There are two main factors that make children vulnerable to HIV transmission in Malawi.
One factor is the high incidence of mother-to-child transmission. Mother-to-child transmission
(MTCT) is when a child is infected with the virus by an HIV positive mother through pregnancy,
labor, delivery, or breastfeeding. MTCT is a huge problem in Malawi because HIV prevalence in
pregnant women is 8.8% (1.5 million) and the transmission rate from mother to child is around
13.8%.
19
Another large factor is the lack of treatment and support systems for young children
and orphans. Children below 15 account for nearly 15% of the population that needs ART in
Malawi.
19
Furthermore, an estimated 1.8 orphaned children currently live in Malawi.
19
Without
parents, resources, and a sense of stability, these orphans are particularly vulnerable to the
HIV/AIDS epidemic.
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Current Strategies
To help reduce the risk of children contracting HIV/AIDs, Malawi has launched several
programs to eliminate new HIV infections among children and to keep more mothers alive. In
fact, Malawis National AIDS policy outlines broad efforts to improve maternal and child health.
19
One specific program that has had a large impact on MTCT is Option B+. Option B+ is a
simplified health approach introduced in 2011 to prevent mother-to-child-transmission (PMTCT)
by offering all pregnant women a lifelong triple-antiretroviral drug regimen regardless of CD4
count.
24
The treatment is given in a single-pill fixed dose combination, has less side effects, and
is more effective than previous ART treatments that were implemented in Malawi.
11
By starting
an HIV-positive pregnant women early on treatment, the risk of MTCT is greatly reduced and
the mothers own health is also protected.
So far, this program has shown great success, with 87 per cent of known HIV-infected
pregnant women starting lifelong ART and a 763% overall increase of pregnant women on ART
treatment.
24
Of the 63,000 pregnant that are in need of antiretroviral treatment for PMTCT,
33,557 (53%) received the treatment that they needed.
11
Compared to 2006 in which there were
only 152 facilities in Malawi that provided PMTCT services, there are now 544 facilities.
11
The
government has successfully scaled up PMTCT programs and has increased accessibility of HIV
treatment for pregnant women. At the district level, Malawi planned to increase the number of
women on Option B+ through the increase of access to HIV testing and counseling, promotion of
early and four focused antenatal clinic visits, and social mobilization.
19
Furthermore, Malawi has
successfully scaled up the number of sites providing early infant diagnosis services to 200 sites
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in 2011.
11
The early testing of infants born to HIV-positive mothers is crucial for lowering
mortality rates among infected children.
In addition, there are many HIV/AIDS programs in Malawi that are currently directed at
children and orphans. For instance, Project Concern International (PCI) has organized and
maintained care groups of orphans and young children through the USAID/CRS-funded
IMPACT project.
16
In 2012, these Care Groups successfully educated 1,339 caregivers in
maternal and child health, with a focus on hygiene, primary school retention, and HIV/AIDS
prevention.
16
This helped improve the living conditions of orphans and children in Malawi and
helped decrease their vulnerability to the HIV virus. Moreover, the Hilton foundation promoted
healthy childhood development through assisting parents/caregivers, enhancing community-
based programs and services, and encouraging country and global level stakeholders to leverage
investments and resources in order to change the lives of children in Malawi affected by
HIV/AIDS.
6
Finally, there was also a pediatric HIV care training program that was launched in
Malawi to scale-up care and treatment services to HIV-infected children. In 2007, the program
successfully trained 813 health care professionals.
12
This greatly improved accessibility of
testing and treatment services for children in Malawi.

Evaluation
As a whole, children in Malawi will not reach zero HIV transmissions by the end of
2015. This is largely due to the fact that there is a large population of children and that Malawi
treatment and prevention programs cannot possibly reach such a widespread demographic. It is
estimated that fewer than 25% of children that are in need of ART are currently receiving
treatment in Malawi.
19
Limited resources and outreach to children and orphans in Malawi makes
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it impossible for programs to drastically lower HIV transmissions to zero. However, there is a
chance that MTCT may reach close to zero HIV transmissions by 2015 or in the near future. The
decreases in MTCT have been largely successful due to the push to improve maternal health and
PMTCT programs such as Option B+. Between 2009 and 2011, over 409,000 new infections
were averted among children due to PMTCT.
11
The countrys target projections for the mother-
to-child transmission rate is shown below, demonstrating that Malawi aims to have a less than
5% MTCT rate by 2015.
19



While these targets appear feasible, there are some limitations that may prevent these
goals from being reached. These limitations include limited availability and access to ART for
pregnant women, especially in rural areas due to lack of transportation and resources.
11
This
results in lower levels of follow-up visits to antenatal clinics and lower adherence of ART
treatment by HIV-positive pregnant women. Also, many pregnant women do not get proper HIV
testing and are not aware of their HIV status. This hinders Malawis initiative to increase the
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number of HIV positive pregnant women put on Option B+. Finally, a lack of substantial funding
for sustainable universal access of PMTCT B+ approach is a vital problem as this program
increases the yearly cost per person from 65 US dollars to $176.
13


Recommendations
To reach the target of zero HIV transmissions by 2015 via MTCT, several measures can
be taken. One action that can be taken is to increase access to clinics and treatment for pregnant
women. It is estimated that between 2005 and 2011, a third of pregnant women in the African
region did not attend an antenatal clinic.
11
Traveling services to clinics should be improved to
improve clinic attendance and increase the accessibility of PMTCT services to a larger
population of women. For instance, mobile clinics could be established to reach women that live
in areas far away from health care facilities.
Another way to improve PMTCT is to increase male involvement. A study in Kenya has
shown that women are more likely to consistently visit antenatal clinics when they are supported
and accompanied by their male partners.
11
One way to accomplish this through couple
counseling at clinics or mandates for males to get routine testing at the clinics along with their
women. Increasing the continuity of antenatal clinic visits by pregnant women would thus
increase the adherence of HIV-positive pregnant women to ART treatment.
Finally, the traditional form of HIV testing in antenatal clinics is currently voluntary
counselling and testing (VCT), where women are simply offered an HIV test.
11
An alternative
solution is to establish HIV testing as a standard art of antenatal care, with the option of opting
out. Behavioral studies have shown that removing the special status that is often given to HIV
testing helps to make it more acceptable and that the uptake of HIV testing among pregnant
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woman was 94% when the test was opt-out, compared to 58% when the service was opt-in.
11
Increasing HIV testing among pregnant women helps identify more women that need to be put
on ART treatment and is thus crucial in helping improve PMTCT services in Malawi.

Female Sex Workers (FSW)
Overview
It is estimated that there are currently over 19,295 female sex workers (FSW) living in
Malawi.
15
Of this population, there is a 70.7% prevalence of HIV/AIDS.
11
This is concerning
because high HIV prevalence among commercial sex workers pose a huge risk of HIV
transmission to the general population. Clients of sex workers act as a link between sex workers
and the general population, making FSWs an important driver of the HIV/AIDS epidemic in
Malawi. Studies have shown that new HIV infections occur in 6.3% of clients partners each
year.
23

Major Risk Factors
Female sex workers are particular vulnerable to HIV/AIDS infection due to the fact they
have multiple sex partners and are exposed to violence and stigma. This is because laws in
Malawi governing commercial sex promote the isolation of sex workers, which sets them apart
from society, placing them in a legal or social status that facilitates their exploitation.
15
Some
problems for sex workers include the lack of access to condoms, knowledge of condom use, and
discrimination from health care services.
11
The basic civil rights of FSWs are often not protected
and the reality is that sex workers and clients do not always use condoms.
11
Studies suggests that
clients may refuse to pay for sex with a condom and may use intimidation, violence, or rape to
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force unprotected sex.
11
Because male to female HIV transmission rates are higher than female
to male transmission since women have a larger surface (vagina) in which HIV infections can
occur, female sex workers are at a high risk of STI and HIV infection from unprotected sex.
FSWS are at high risk because contracting STIs increases the risk of HIV infection.

Current Strategies
According to the Malawi HIV and AIDS Extended National Action Framework 2010-
2012 plan, 2.6 million dollars of resources was allocated to FSWs HIV prevention programs in
2012.
9
Currently, it is estimated that coverage of prevention services is at 25% for commercial
sex workers.
15
In addition, the government also drafted provisions that mandated compulsory
HIV testing among sex workers in Malawi.
15
This increased the number of FSWs that were
aware of this HIV status and the number of HIV-positive FSWs that was put on the ART
treatment they need.
Moreover, there are many programs and interventions in Malawi that specifically target
commercial sex workers. Two well-known interventions targeted at FSWs are the ones by the
Banja La Mtsogolo (BLM) and the Family Planning Association of Malawi (FPAM). Because
poverty is the main source of motivation behind the choice of commercial sex work, these
programs aim to create stability and economic opportunity for commercial sex workers. Through
its TV program the BLM talk show the BLM interviews commercial sex workers and provides
them with the resources needed to start small scale businesses.
15
On the other hand, FPAM has
worked with CSWs in Lilongwe district to build business skills in mushroom growing, hair
dressing and tailoring, provide civic education on prevention, treatment, care and on safe sex
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negotiation skills, and distribute prevention measures to CSWs in their bars or pubs in
Lilongwe.
15
Furthermore, a project called the Interactive Theatre and Legislative Theatre for Sex
Workers and Their Clients in Malawi was implemented by Theatre for Change to ensure that
sex workers and their clients have the knowledge, attitudes, and skills to reduce the risk of HIV
transmission.
7
The program also worked to advocate safer environments for FSWS free from
gender-based violence and to provide FSWs with the skills to generate professional income or
return to school.
7
The results showed that FSWs in Malawi improved knowledge and
understanding in most areas including around condom use, STIs, gender rights, and self-
confidence and efficacy.
7
Finally, Equity in Health in East and Southern Africa (EQUINET)
launched an intervention program for FSWs that detailed door-to-door talks, groups meetings,
and face-to-face talks with commercial sex workers.
15
As a result of this intervention, over 60
CSWs underwent HIV testing and counseling, 9 CSWs were referred for ART treatment, and 34
sex workers were screened, diagnosed and treated for STIs.
15
These programs and interventions
greatly helped improved the social and economic conditions of FSWs.

Evaluation
In general, FSWs in Malawi will not reach zero HIV transmissions by 2015 even though
HIV infections among FSWs are facing a downwards trend. The HIV prevalence among female
sex workers has dropped from 70.7% to an estimated 69% over the recent years; however, this
number is still very high.
9
HIV infections among FSWs will continue to persist and contribute to
the HIV/AIDS epidemic in Malawi in the near future. Although there are many programs in
Malawi aimed at improving the lives of FSWs through education and financial support, these
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programs can only target a small portion of FSWs. In fact, the intervention conducted by
EQUINET focused on improving the lives of only 45 commercial sex workers.
15
Programs
targeting FSWs are greatly limited by resource and range. Furthermore, FSWs still face many
barriers to accessing healthcare. In a baseline survey conducted by EQUINET, it was found that
around 70% of health care workers and commercial sex workers reported extremely high
barriers that commercial sex workers face to using healthcare.
15
This is largely due to
discrimination, stigma, and a general attitude of disapproval that many health care personnel
harbor towards female sex workers.
15
Another problem that FSWs face is the low adherence to
condom use, as condom use was reported to be very low by 73% of the CSWs in the EQUINET
baseline survey.
15
Moreover, the sexual rights of FSWs are often unprotected, making them
subjective to rape and other high risk behaviors that increase their vulnerability to HIV infection.

Recommendations
As resources are limited in Malawi, programs targeted at improving the working and
social conditions of FSWs cannot possibly be expanded to reach the entire FSW population.
Hence, the best way to decrease HIV prevalence among FSWs is to establish stricter laws and
policies to protect FSWs from discrimination (particularly from health care provides), violence,
and violation of their basic sexual rights. Also, a centralized national peer-education and gender
based violence project could be launched to empower female sex workers to realize and defend
their rights. In addition, programs can be established to increase adherence to condom use. A
good example of such an effective program is the 100% Condom Use Program established in
Thailand that required brothels and massage parlors to distribute free condoms and mandated the
use of condoms among clients in these establishments.
11
The program successfully raised
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condom usage from 14% in 1989 to over 90% in 1992.
11
Such a program would be largely
beneficial in Malawi and would help reduce the number of HIV infections among FSWs.

Young People (15-24)
Overview
While the HIV/AIDs epidemic in Malawi is widespread and affects individuals across all
age groups, young people are an important population to focus on because young people are the
future and reducing HIV incidence in this demographic will help decrease HIV prevalence over
the years. Since Malawi is a very young population, young people ages 15-24 constitutes about
50% of new HIV infections each year.
11

Major Risk Factors
As 88% of HIV transmissions occur through heterosexual sex in Malawi, the largest
driver of the HIV/AIDS epidemic is concurrency and low condom use.
23
Reports have shown
that 27% of men and 8% of women have multiple and concurrent sexual partners multiple and
concurrent sexual partners.
23
Furthermore, most HIV infections occur within stable, discordant
relationships, where condom use is only 30%.
23
Young people are particularly vulnerable to HIV
infection because it was found that adolescents who start having sex early are more likely to have
sex with high-risk partners or multiple partners, and are less likely to use condoms.
28
In
particular, women in the younger age group (15-19) have less knowledge around key PMTCT
practices including the benets of ARVs taken in pregnancy, intra partum, and during breast-
feeding.
19
Due to a lack of education, knowledge, and basic skills to protect themselves from
Dong 21

HIV infections, young people are a high risk group in Malawi that is highly vulnerable to the
HIV/AIDS epidemic.

Current Strategies
Several strategies and plans have been developed to address this issue, including the
National HIV Prevention Strategy, which outlines technical strategies for abstinence, mutual
faithfulness, and HIV prevention for young people.
23
Life skills education has been scaled up
drastically in Malawi, reaching over 3 million primary and over 250 thousand secondary school
students.
23
In addition, Malawi has also been targeting in school youth as well as out of school
youth. Peer education sessions, guidance and counselling and mentoring have been implemented
countrywide to teach young people about methods of HIV prevention.
23
Moreover, there has also
been an increase in the number of resource centers and outreach HIV awareness activities.
Nancholi Youth Organization and Plan Malawi are also a few examples of the many programs
developed in Malawi targeted at HIV prevention among youth.
28

In addition, the Malawi government, through the National AIDS Commission, plans to
provide youth-friendly services that include high-quality, cost-effective, confidential and
accessible voluntary counselling.
28
Between 2009 and 2010, a total of 541,084 youths were able
to access services from 1,609 youth friend sexual and reproductive health service sites in the
country.
8

Evaluation
HIV prevalence among young people aged 15-24 is decreasing as the estimated HIV
prevalence dropped from 6% in 2004 to 3.6% in 2010.
28
However, it is unlikely that young
Dong 22

people will reach zero HIV transmissions by 2015. There are many issues that contribute to
continued high numbers of new HIV infections among young people each year. One major
problem is the cultural stigma surrounding the use of condoms. It is a common perception in
Malawi that condoms are not highly effective and reduce sexual pleasure.
28
Moreover, among
couples, condoms were consistently found to interfere with feelings of mutual trust.
28
As a
result, despite high levels of the HIV prevention knowledge, there are still low levels of condom
use.
11
Another major issues is that concurrency levels continue to remain high in the young
people population in Malawi.
28
The problem stems from young people having a low perceived
risk of themselves contracting the HIV virus. In fact, a study in Malawi found that 90% of girls
perceived little risk in contracting HIV/AIDS in having sexual relations with a boy.
28
In
addition, 72% of females 15-24 know of a place to get tested, but reports show that only 9% have
actually gotten tested.
28
This is alarming, as it demonstrates that these education programs
promoting HIV/AIDS education and abstinence are not significantly impacting the behaviors and
attitudes of young people in Malawi. The average age of first sex in Malawi is getting lower and
20% of the population is sexually active by age 15.
28

Recommendations
To reach the goal of zero HIV transmissions in young people in the future, Malawi
should launch a social marketing campaign to reduce the stigma towards condom use. It is
important to overturn the perception that using condoms detracts from trust in a relationship and
reduces sexual pleasure. Condom usage should be established as a cultural and social norm in
Dong 23

Malawi in order to increase adherence to condoms among young people and reduce the number
of new HIV infections in this demographic.
Furthermore, instead of focusing on teaching abstinence and faithfulness to young people
to encourage them to engage in less high risk behaviors, education campaigns should focus on
sexual education. A 2010 study commissioned by UNFPA found that there was a general lack
of teaching and learning resources, inadequate training on the part of teachers, lack of knowledge
by teachers on sexual reproductive issues including HIV transmission, and that there was a
feeling that mentioning private parts in public was a taboo.
8
In fact, it was found that in
Malawi, at least 40% of adults felt that children aged 12-14 should not be taught to use
condoms.
28
However, in a review of more than 50 sex education programs around the world, it
was found that young people are more likely to delay starting their sexual activity when they are
provided with correct information about sexual and reproductive health; and that when they do
start having sex, they are more likely to protect themselves against STIs including HIV.
28
By
teaching young people about their sexual and reproductive health rather than attempting to
convince them abstain from sex completely, young people are empowered to make safer choices
regarding condom use and concurrency. This would help reduce the number of new infections
among young people each year in Malawi.

People with Tuberculosis
Overview/Risk Factors
Another factor that contributes to severe HIV/AIDS epidemic in Malawi is the
tuberculosis (TB). Tuberculosis is a disease caused by a bacterial infection called
Mycobacterium tuberculosis and can cause infections in the lungs, kidneys, and other organs.
9
Dong 24

Nearly 80% of the people with pulmonary tuberculosis in Malawi are also HIV positive.
9
TB is
a huge problem in Malawi as nationwide studies have shown that 77% of people identified with
TB are HIV sero-positive and more than 60% of hospitalized TB patients had one or more other
HIV-related disease.
23
There are 25,000 new cases of TB reported on average each year; and
over the last 20 years, the number of reported TB cases per 100,000 people in Malawi has
increased from 95 in 1987 to 275 in 2015.
23
Tuberculosis is the leading cause of death for those
infected with HIV/AIDs in the country. Hence, focusing on preventing and treating TB is
important to improving the living conditions of those living with HIV/AIDS in the country.

Current Strategies
In response to the growing issue, Malawi was one of 3 African countries to launch the
WHO Protest initiative (1999-2002), which increased HIV testing and counselling among TB
patients as an entry point to HIV prevention, treatment and care services.
10
Furthermore, a 3-
year TB/HIV plan was created and integrated into a 5 year national TB control plan (2001-2005).
The objectives of this plan were to scale up HIV testing among TB patients, increase HIV-
positive TB patients access to ARVs, and to provide more co-trimoxazole preventive therapy,
which is known to reduce morbidity and mortality in HIV infected TB patients.
10

Furthermore, the availability of Isoniazid prevention therapy to help prevent the development of
TB was scaled up and many social interventions such as the Directly Observed Treatment
Short Course (DOTS) strategy was implemented to control the TB epidemic in Malawi.
10
Overall, the National TB Control Program (NTP) works very closely with the Department of
HIV in Malawi.

Dong 25

Evaluation/Recommendations
The efforts of the Malawi government lead to huge success, as the proportion of TB
patients tested for HIV increased from 15% to 47% from 2003 to 2005.
10
In this time period,
over 90% of HIV positive TB patients were put on co-trimoxazole preventive therapy and over
54 % of these patients were put on ART treatment.
10
The TB/HIV co-infection rate is estimated
to have greatly decreased to 63% in 2007, in comparison to 77% in 2000.
15
Projections predict
that by 2015, there will be a 50% reduction of TB deaths in people living with HIV/AIDS.
28

Despite the improvements in the TB-HIV/AIDS co-epidemic, there are still many
improvements that can be made to help reach the UNAIDS 2015 goal of zero HIV transmissions.
By scaling up TB testing and treatment in Malawi, more individuals were able to be aware of
their HIV-positive status and be put on the ART treatment. This helped reduce the likelihood of
HIV transmissions because ART treatment drastically decreases the HIV viral load in
individuals.
However, there are still many limitations to TB programs in Malawi as only half of TB
patients were tested for HIV. The main obstacles to this issue include irregular supplies of HIV-
testing reagents and health care staff forgetting to refer patients to HIV testing or patients
themselves not undergoing HIV testing/counseling after being placed on TB treatment.
10
Hence, a recommendation would be to be to find ways to improve the uptake of HIV-testing in
Malawi, perhaps by integrating mandatory HIV testing into the TB registration process. Another
problem is the low percentage of HIV-positive TB patients being put on ART (54%). This is due
to the fact that TB patients are only able to start on ART therapy after they have completed the
initial phase of anti-TB treatment and because anti-TB treatment is decentralized to health
centers while ART is administered by central, district hospitals.
10
Hence, it is difficult for
Dong 26

patients receiving anti-TB treatment at health centers to access ART treatment. Malawi should
therefore establish health care policies that offer earlier ART to TB patients and expand the
availability of ART to health centers. That way, more HIV-positive TB patients are able to
undergo HIV testing and receive the ART treatment that they need.

People Vulnerable to Transmission by Blood
Overview/Risks
There are two main modes of HIV transmission by blood. One way is through blood
transfusions, when HIV-infected blood becomes integrated into blood transfusion patients.
Reports estimate that in 2007, 0.03% of new HIV infections each year in Malawi occur from
blood transfusions.
23
Another mode of transmission is through IDUs. HIV can be transmitted
when people who inject drugs share needles and one person is HIV-positive. Although there is
not much data on the incidence of HIV transmission via injecting drug use in Malawi, recent
reports show that HIV transmissions among injecting drug users (IDUs) is becoming a more
prominent problem. It was found that in 2006, 0.2% of adults in Sub-Saharan Africa were using
heroin.
11
In Malawi, HIV transmissions among IDUs are concentrated in prisons, where it is
estimated that up to 30% of inmates inject drugs.
11


Current Strategies/Evaluation/Recommendations
To combat HIV transmission via blood transfusions, Malawi launched its national blood
transfusion service (MBTS) in 2003. Before 2003, Malawi had a hospital-based system for
blood collection where stocks of blood were insufficient and where safety could not always be
guaranteed.
11
However, after the 2003 MBTS initiative, which had received 7.8 million dollars
Dong 27

of funding, tight administrative management of blood transfusion services were established.
3
There are now established blood centers in Blantrye and Lilongwe that supply four central
hospitals and 80% of district hospitals in Malawi.
3
Blood safety increased drastically as all blood
used for transfusions had to be screened in accordance to national guidelines.
8
In fact, a Ministry
of Healths Depart of HIV routine supervision found that 99.6% of the blood collected in these
health facilities were properly screened for HIV in 2010.
8
As a result, HIV transmission via
blood transfusions are becoming lower and lower over the years as the outreach of these blood
centers increase. Malawi is considered a success story for its MBTS initiative and reduction of
HIV transmissions through blood transfusions. It is likely that HIV transmissions through blood
transfusions will hit the UNAIDS target of zero transmission by 2015.

On the other hand, Malawi has not established the extent of injecting drug use in the
country. Hence, HIV transmissions among IDUs will not reach zero by 2015. There are little to
no programs in Malawi directed at HIV prevention/treatment of IDUs. In fact, the Malawi HIV
and AIDS Extended National Action Framework (NAF), 2010-2012 had no estimate of the
amount of resources needed to establish HIV prevention and treatment programs for IDUs.
9
As
the prevalence of IDUs are a rising concern in Sub-Saharan Africa, Malawi should dedicate more
money and time into investing the problem of HIV transmission via injecting drug use and
should invest in programs that target this high risk behavior. This will help Malawi reach its goal
of zero HIV transmissions in the future.

General Prevention/Treatment Programs
While there are a lot of HIV prevention/treatment strategies that targeted at specific high
risk groups and behaviors in Malawi, the HIV/AIDs epidemic in the country that is widespread
Dong 28

and greatly affects the general population. Malawi has also dedicated a lot of effort towards
preventing new HIV infections among the general population and increasing accessibility HIV
treatment programs for all. Looking the figure below it can be seen that a large majority of the
annual expenditure for HIV/AIDS in Malawi is directed towards treatment, care, and support.
The second largest proportion of the annual is allocated towards prevention and behavior change.









To decrease the number of new HIV infections each year, Malawi has established both
behavioral and biomedical prevention programs. One of Malawis goals was to induce
behavioral change through mass media campaigns that cover HIV prevention, treatment, care
and support, and issues including gender, human rights and culture.
8
As the current drivers of
the HIV/AIDS epidemic are multiple and concurrent sexual partnerships, discordancy in long-
term couples (one partner HIV-negative and one positive) where protection is not being used,
low prevalence of male circumcision, and low and inconsistent condom use, these media
campaigns aim to combat these issues by teaching individuals to avoid these risky behaviors.
8
Radio and television are the primary modes of media used to target the general population.
Dong 29

Between 2010 and 2011, a total 1,477 radio and 429 television (TV) programs were aired to
enhance behavior change and prevention of HIV/AIDS transmissions.
8
However, despite high levels of HIV/AIDS awareness in Malawi, the levels of behavior
change are low. National surveys have shown that knowledge about HIV/AIDS is universal, as
99.4% of the women and 99.3% of the men aged 15-49 reported that they have heard about
AIDS.
8
However, although most people have heard about HIV/AIDS, studies show that
comprehensive knowledge about HIV/AIDS remains low and unchanged since 2004.
8
It is
estimated that only 41% of women and 44.8% of have a comprehensive knowledge of
HIV/AIDS.
8
Hence, it is recommended that Malawi shifts its focus from broad community based
campaigns that spread awareness of HIV/AIDS issues and risk behaviors and focus on more on
educating groups and individuals more comprehensively about HIV/AIDS. That way, as more
individuals gain a more comprehensive knowledge about HIV/AIDS, they are more likely to
understand the implications of high risk behaviors and respond better to mass media campaigns
that encourage low risk behaviors.
Furthermore, another focus of Malawi is to increase condom distribution. In particular, a
priority of the national response in 2003 was the make female condoms available to the general
population.
8
Two NGOs called PSI and BLM were able to distribute over 6.6 million condoms
through their clinics in 2008.
8
Since 2003, the number of condoms distributed per capita has been
steadily increasing, and the universal access target for male condoms is estimated at 34,000,000
for 2011.
8
However, there are still problems with condom distribution in Malawi as distributions
of both male and female condoms are below target each year, demonstrating that condom
accessibility and availability to the general population is limited.
Dong 30

On the other hand, Malawi has also established many biomedical prevention programs.
Some of these strategies include prevention of co-factors that encourage infection through
increases in sexually transmitted disease treatment (STI management), male circumcision, Post-
exposure prophylaxis (PEP), and HIV counseling and testing. Strategies for STI management
and male circumcision in Malawi have already been outlined in the MSM section of this paper.
However, the other methods of biomedical prevention have not yet been discussed.
Antiretroviral post-exposure prophylaxis (PEP) is short-term ARV therapy that is
initiated when exposure to HIV is expected.
25
Despite being a low income country, Malawi has
successfully established PEP guidelines, which includes identifying people at the risk of
exposure, counseling PEP candidates of implications, HIV testing of PEP candidate before and
after completion, and initiating of an appropriate PEP regime within 72 hours of exposure.
25
The
availability of PEP contributes to Malawis effectiveness in combating the HIV/AIDS epidemic.
Furthermore, HIV counseling and testing services (HTC) in Malawi have been dramatically
increasing throughout the years. In 2010, there were 600 sites providing HTC services and by
2011, there were a total of 778 static and 614 outreach sites, which greatly improved the
accessibility/availability of HTC testing services.
8
In addition, many NGOs in Malawi have
launched mobile and door-to-door HTC initiatives. As a result, over 1,700,000 people were
tested for HIV/AIDS between 2010 and 2011.
8

Finally, Malawi has also improved the outreach and availability of its HIV treatment
programs. In the early 2000s, Malawi first introduced Antiretroviral Drugs (ARV) to the
population, which were used to delay the onset of AIDS for those infected with the HIV virus.
Following a grant by the Global Fund in 2004, the government in Malawi established a five-year
plan to distribute ARVs into hospitals and clinics around the country and make ARVs more
Dong 31

available in the public sector.
11
By 2003, an Antiretroviral Therapy program was implemented in
Malawi, prolonging HIV patients lives and reducing the risk that the patients will infect others.
8
At the beginning of 2004, there were only 9 facilities in the public sector that delivered ART and
only 3,000 patients were on treatment. In 2006, a 5 year plan to scale up ART in Malawi was
approved by the Ministry of Health to provide universal access of ART therapy by 2010.
19
By
2011, there were 449 ART clinics and 322,209 people were able to receive treatment.
11
The
scaling up of ART treatment in Malawi was largely a success as ART coverage increased from
54% to 67% in 2011.
11
As a result of these programs, there was a significant decline in AIDS
death between 2010 and 2011 from 49,000 to 44,000.
11
However, there are still many limitations to ART accessibility/availability as coverage is
only around 67%. Some of these limitations include the 6 months lag between ordering ARV and
receiving supply, which has led to drug shortages in many health facilities.
11
Another limitation
is that access to treatment in low in rural southern areas due to the lack of transportation and
resources.
11
This prevents people in the rural southern areas from receiving proper health
services that they need. In order to reach the goal of zero HIV transmissions in the future, many
improvements can be made. One possible solution is to improve the drug supply chain by
creating a buffer stock of ARVs in health care facilities to prevent stock-outs. Furthermore,
Malawi should invest more resources in ART facilities in the southern rural regions of Malawi.
This is because studies show that HIV incidence is more prevalent in the South than in the north
and central regions.
11

As a whole, efforts over the years to reduce the effects of HIV/AIDS on the population in
Malawi have been largely successful and effective. The combination of ARV treatment and a
push to increase testing and prevention has successfully decreased HIV prevalence and incidence
Dong 32

in Malawi. The scale up of HTC and ART have been the biggest success in the country, with
over 147,000 people alive and on ART out of 276,161 of those in need of ART as of December
2008.
8

Conclusion
Overall, the HIV/AIDS epidemic in Malawi is dynamic and is driven by a multitude of
high risk behaviors and factors. Although programs in Malawi have been largely successful in
reducing the HIV/AIDS prevalence and incidence in the country, as a whole, Malawi will not
reach the WHO UNAIDS goal of zero HIV transmissions by 2015 due to the severity of the
epidemic. In order to reach this goal in the near future, Malawi must increase the effectiveness of
its HIV prevention programs and improve the outreach/accessibility of its treatment programs.
Most importantly, it is imperative that Malawi targets high risk groups such as MSMS, FSWS,
people with tuberculosis, people vulnerable to transmission by blood, children, and young people
that are the main drivers of the HIV/AIDS epidemic in Malawi. If Malawi is able to allocate
more resources and time towards these goals, it is reasonable to believe that the country will
eventually be able to reach the WHO UNAIDS goal of zero HIV transmissions in the future.







Dong 33

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Dong 35

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