HIV/AIDS in Malawi

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Prevalence of HIV/AIDS in adult (ages 15–49) populations (1999–2002)

As of 2012, approximately 1,100,000 people in

Malawian food crisis in 2002 resulted, at least in part, from a loss of agricultural productivity due to the prevalence of HIV/AIDS.[1] Various degrees of government involvement under the leadership of Bakili Muluzi (1994–2004) and Bingu wa Mutharika (2004–2012) resulted in a gradual decline in HIV prevalence, and, in 2003, many people living in Malawi gained access to antiretroviral therapy.[1] Condoms have become more widely available to the public through non-governmental organizations, and more Malawians are taking advantage of HIV testing services.[1]

Due to several successful television and radio campaigns by the Malawian government and non-governmental organizations in Malawi, levels of awareness regarding HIV/AIDS are high among the general population.[2] However, many men have adopted fatalistic attitudes in response to the epidemic, convincing themselves that death from AIDS is inevitable; on the other hand, some have implemented preventive techniques such as partner selection to try to reduce their risk of infection.[3] Although many women have developed strategies to protect themselves from HIV, women are more likely to be HIV-positive than men in Malawi.[1] The epidemic has affected sexual relationships between partners, who must cooperate to protect themselves from the disease.[4] In addition, many teachers exclude HIV/AIDS from their curricula because they are uncomfortable discussing the topic or because they do not feel knowledgeable about the issue, and, therefore, many children are not exposed to information about HIV/AIDS at school.[5] Finally, the epidemic has produced significant numbers of orphans in Malawi, leaving children vulnerable to abuse and exploitation.[6]

History

Bingu wa Mutharika, third President of Malawi (2004–2012)

The first case of HIV/AIDS in Malawi was reported at Lilongwe's Kamuzu Central Hospital in 1985.[7] President Hastings Banda, who was in power at the time, responded with several small-scale prevention initiatives and created the National AIDS Control Programme, a division of the Ministry of Health, to manage the growing epidemic.[1] Banda believed that issues relating to sex, including HIV transmission, should not be addressed in the public sphere; during this time, it was illegal for Malawian citizens to discuss the epidemic openly.[8] In 1989, Banda introduced a five-year World Bank Medium Term Plan to combat the epidemic, but HIV prevalence had already increased drastically at this point.[1]

In 1994, when

famine in 2002.[1]

Malawians gained access to

antiretroviral drugs in 2003, and, with a donation from the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the election of new President Bingu wa Mutharika in 2004, government interventions increased substantially.[1] However, soon after his election, Mutharika experienced tensions with Muluzi after implementing an anti-corruption program, which distracted the government from addressing the nation's food and HIV/AIDS-related crises.[9] Despite these obstacles, Mutharika successfully developed a National AIDS Policy and appointed a Principal Secretary for HIV/AIDS during his presidency.[1]

Awareness and risk perception

Partners in Health
worker with disease treatment literature in Malawi

Despite Malawi's limited health and educational infrastructure, knowledge regarding HIV/AIDS is high among many people living in both urban and rural Malawi.

Sub-Saharan Africa, and that there is a socio-economic knowledge gap.[10]

Personal traits such as age, gender, location, and education correlate, either positively or negatively, with HIV/AIDS awareness levels. For example, older women have demonstrated higher levels of knowledge regarding HIV/AIDS than younger women in Malawi.

prostitutes and other women from high-risk groups.[9] In addition, men who are raised in urban environments are, on average, more informed about HIV/AIDS than men who are raised in rural environments, presumably because urban children typically have greater access to educational resources than rural children.[2] Among both men and women, higher levels of education correspond to increased knowledge about HIV/AIDS: men and women who have received secondary school educations are significantly more likely to understand complex aspects of the disease, such as the fact that people who appear healthy can still be HIV-positive, than those who have not.[2] Finally, people who have lost friends or family members to the disease are likely to have greater knowledge about HIV/AIDS due to their personal, firsthand exposure to the problem.[2]

The aforementioned study by Barden-O'Fallon et al., which surveyed 940 women and 661 men, indicated that, despite their knowledge and awareness, many people in Malawi do not feel

preventive strategies gave people a sense of control.[11] In fact, many participants in this study claimed that they were "not at all worried" about HIV/AIDS; unless they had simply adopted a fatalistic standpoint towards the epidemic, these respondents probably felt that they had successfully reduced their risk of exposure through personal behavioral changes.[11]

Education

Health Education Center in Blantyre, Malawi

Students in Malawi have expressed high levels of dissatisfaction regarding the HIV/AIDS-related education and support they receive at school.[6] According to a survey of students in Malawi, most secondary students do not believe that the HIV/AIDS curricula at their schools provide them with an adequate understanding of the disease.[6] Although the Malawian government and non-governmental organizations have conducted many campaigns to improve awareness about HIV/AIDS in schools, there is still a significant shortage of age-appropriate audio and visual educational materials relating to HIV/AIDS available to instructors, particularly in rural areas.[6] In addition, most teachers cannot identify the students in their classes who have been personally affected by the epidemic, either through friends or relatives, which suggests that school-based support for HIV/AIDS is minimal.[6] However, despite this lack of support, surveys indicate that children who have been affected by the epidemic do not usually experience HIV/AIDS-based discrimination at school.[6]

Most teachers are required to address HIV/AIDS in their curricula; although instructors are, for the most part, committed to helping their students understand and avoid the disease, they face many obstacles that prevent them from informing their students about HIV/AIDS in productive ways.[5] For example, some teachers cannot advise their students to remain faithful to their sexual partners without seeming hypocritical because they engage in extramarital sexual relations themselves.[5] Others feel uncomfortable discussing sexual matters with their students, and some believe that, due to their limited training, they are not knowledgeable enough about HIV/AIDS to direct classroom discussions about the disease.[5] In addition, many teachers feel unsupported by community members, who often either deny the extent of the epidemic or believe that HIV/AIDS should not be addressed in the classroom.[5]

Affected groups

Although the HIV/AIDS epidemic has affected men, women, and children in Malawi, certain factors such as

heterosexual sex, but the epidemic has also significantly impacted the homosexual male population in Malawi.[1] In addition, women in Malawi are more likely to be HIV-positive than men, suggesting that women are particularly vulnerable to HIV/AIDS.[1] Finally, the disease has affected children and young adults both directly and indirectly; 170,000 Malawian children were HIV-positive in 2011, and the number of orphans in Malawi has increased dramatically since the epidemic began in 1985.[1]

Men

Due to the vast scope of the HIV/AIDS epidemic, many Malawian men believe that HIV contraction and death from AIDS are inevitable.

unprotected sex is natural (and therefore necessary and good) when justifying their lack of condom use during sex with extramarital partners.[3] Finally, some men identify as HIV-positive without having undergone testing for HIV, preferring to believe that they have already been infected so they can avoid adopting undesirable preventive measures such as condom use or strict fidelity.[3] Because of these fatalistic beliefs, many men continue engaging in extramarital sexual relations despite the prevalence of HIV/AIDS in Malawi.[8]

However, despite these widespread feelings of fatalism, some men believe that they can avoid HIV contraction by modifying their personal behaviors.

gender norms by, for example, wearing modern clothing are more likely to carry HIV, while young girls, who are perceived as sexually inexperienced, are considered "pure".[3] Because of this perception, many people are concerned that schoolchildren in Malawi, particularly girls, are becoming exposed to the virus through sexual harassment or abuse by their instructors.[6]

Women

According to

formal sector typically earn significantly less money than men, even when they are completing the same tasks, making it difficult for them to elevate their status.[9]

Many women are convinced that their husbands are putting their lives at risk by engaging in extramarital sexual relations without using protection; however, because of their secondary status, they are often unwilling to initiate discussions about HIV/AIDS in the home.

commercial sex work for money.[9]

However, despite their vulnerability, some women in rural Malawi believe that they do, to a certain extent, have control over their own health and well-being.

faithful and actively prevent the transmission of the disease.[12]

Children

AIDS orphans in Lilongwe, Malawi

The number of orphaned children in Malawi has increased dramatically since the HIV/AIDS epidemic began in 1985, with certain surveys indicating that more than 35% of schoolchildren have experienced the death of at least one parent due to HIV/AIDS.

unprotected sexual relations put their children at increased risk of becoming double orphans, or children who have lost both parents to HIV/AIDS.[6] Older children who have lost both parents to HIV/AIDS often become responsible for the care of their younger siblings, and many double orphans drop out of school or migrate to urban areas to try to support themselves and their siblings.[6] Girls who have been orphaned by HIV/AIDS have unusually high rates of school absenteeism in Malawi.[6]

When parents die of HIV/AIDS,

grandparents or other close relatives.[6] Extended family members often provide crucial support to HIV/AIDS orphans;[13] however, some sources indicate that extended family members mistreat orphans whose parents have died from HIV/AIDS.[6] For example, family members who are unable to support adopted children often arrange early marriages for female orphans, who may then become victims of domestic violence and sexual abuse.[6]

Evidence suggests that schoolchildren in Malawi are at risk of being exposed to HIV by their teachers, who sometimes value them as sexual partners because they believe that children have not yet been exposed to the virus.

administrators are unwilling or unable to investigate the truth behind the accusations.[6]

Marriage and relationships

Although couples are starting to use condoms during extramarital intercourse more frequently,

sexually transmitted infections when discussing condom use with extramarital sexual partners.[4]

Many different sources of information can motivate discussion about HIV/AIDS among married couples.[14] After hearing information about HIV/AIDS at local health facilities or during conversations with friends or family members, people are more likely to address the risk of HIV contraction with their spouses.[14] In addition, women are more likely than men to mention the dangers of HIV/AIDS when they suspect that their spouses are engaging in extramarital sexual relations. According to a 2003 study by Eliya Msiyaphazi Zulu and Gloria Chepngeno, although higher levels of education do correspond to greater knowledge about HIV/AIDS, education levels do not significantly impact the likelihood that couples will discuss HIV-related prevention strategies.[14]

Economic impact

Farmers with composting materials in Malawi

A 2002 study conducted by

labor-intensive crops such as tobacco.[16] When family members fall ill with HIV/AIDS, their relatives invest time in their treatment and care, further reducing household productivity.[15] In addition, when family members are infected with HIV, households often use the money they would normally invest in agriculture to cover medical expenses, further decreasing economic stability at the household level.[15] Finally, when adults contract HIV, their children often remain home from school to work in the fields, threatening long-term productivity and economic advancement in Malawi.[16]

CARE International proposes several strategies that might reduce the destructive economic impact of HIV/AIDS on

patrilocal villages are often unable to support themselves and their children when their husbands die of HIV/AIDS; therefore, helping women acquire traditionally masculine agricultural skills might decrease their vulnerability while improving agricultural productivity at the household and community levels.[15] CARE International recommends increasing cooperation at the community level by establishing labor and food banks in areas that have been devastated by the HIV/AIDS epidemic.[15] Finally, CARE International highlights the importance of increasing access to information about HIV/AIDS in Malawi to help families prepare for and cope with the economic burdens associated with the epidemic.[15]

Impact on health services

The HIV/AIDS epidemic in Malawi has been characterized by drastic declines in the number of health workers available to provide treatment and care and increasing strain on health services: more than half of all hospital admissions in Malawi are related to HIV/AIDS.

significant deficit in human resources: only 159 doctors were practicing in Malawi in 2007.[18] The World Health Organization's Essential Health Package recommends placing at least three health workers at every health facility in the country, but the vast majority of Malawi's health facilities fail to meet this standard.[18]

While migration to more developed countries in search of better opportunities, also known as "

brain drain", is partially responsible for the shortage of health care workers in Malawi, many health care workers have been personally affected by the HIV/AIDS epidemic; in fact, an average of 48 nurses die of HIV/AIDS in Malawi every year.[1] The HIV/AIDS epidemic has resulted in high levels of absenteeism among health workers in Malawi, who often leave work to spend time with HIV-positive friends or relatives, and the Malawian government has failed to respond to the declining number of full-time employees working in the health sector.[17] Health workers who are not chronically absent frequently abandon their jobs because they are unable to cope with the heavy patient loads or because they are afraid that working in a medical environment will increase their risk of becoming infected with HIV.[17]

Malawi has adopted task shifting strategies to overcome the shortage of workers available for HIV/AIDS treatment and care.

antiretroviral therapy.[18] For example, at Thyolo District Hospital, health workers spend one week learning how to initiate antiretroviral therapy in a classroom setting and an additional two weeks practicing their knowledge in a supervised clinical setting; after completing this course, they are legally (under Ministry of Health guidelines) allowed to initiate antiretroviral therapy.[18] Another form of task shifting involves training health-oriented counselors in HIV testing and counseling, which relieves nurses of this additional task.[18]

Interventions

Malawi has taken many steps towards slowing the spread of HIV/AIDS, such as increasing access to condoms and improving

Joint United Nations Programme on HIV and AIDS (UNAIDS).[1] The World Bank has lent $407.9 million to Malawi, the Global Fund has agreed to give $390 million, and PEPFAR has donated $25 million for prevention and treatment campaigns.[1]

Antiretroviral therapy

The number of people using antiretroviral therapy in Malawi has increased dramatically in the past decade: between 2004 and 2011, an estimated 300,000 people gained access to antiretroviral treatment.[1] In addition to improving access to antiretroviral therapy, in 2008, Malawi introduced the WHO's treatment guidelines for antiretroviral therapy, which improved the quality of treatment available to Malawians.[1] However, Malawi's proposal for a new antiretroviral treatment plan in 2011, which would have cost $105 million per year, was rejected by the Global Fund, threatening Malawi's ability to continue expanding access to antiretroviral treatment.[1]

In 2000, Malawi's Ministry of Health and Population began developing a plan to distribute antiretroviral drugs to the population, and, as of 2003, there were several sites providing antiretroviral drugs in Malawi.[17] The Lighthouse, a trust in Lilongwe that fights HIV/AIDS, provides antiretroviral drugs at a cost of 2,500 kwacha per month.[17] Queen Elizabeth Central Hospital in Blantyre provides antiretroviral therapy through its outpatient department, and Médecins Sans Frontières distributes antiretroviral drugs to patients for free in the Chiradzulu and Thyolo Districts.[17] Many different private providers sell antiretroviral drugs, particularly in cities; however, very few patients can afford to receive drugs from the private sector in Malawi.[17] In addition, private providers are not currently required to obtain certification before selling antiretroviral drugs, and, therefore, this practice is not closely monitored.[17] Finally, some employees receive access to antiretroviral drugs through the health insurance policies provided by their employers, but this practice is not widespread.[17]

Due to the advent of antiretroviral drugs, HIV/AIDS has become a manageable disease for people who can access and afford treatment; however, antiretroviral therapy remains largely unaffordable and inaccessible to most people in Malawi.

fair distribution of antiretroviral drugs in Malawi, individual health care workers often become responsible for deciding who will receive treatment, which inevitably leads to inequitable distribution.[17]

Condom distribution

Although

condoms effectively prevent the sexual transmission of HIV, several factors have limited widespread condom distribution and uptake in Malawi.[1] People living in non-urban areas often have difficulty accessing condoms, and condoms are not typically available at bars and other social locations where they could have a significant impact on HIV prevention.[1] Many people oppose condoms because they believe that condoms make sex less enjoyable or because they question their ability to prevent the transmission of HIV.[1] However, despite these factors, many unmarried couples have started using condoms more consistently as concern and fear about the HIV/AIDS epidemic have increased.[4]

Non-governmental organizations such as

condom use as an effective form of protection against HIV/AIDS.[1] Banja La Mtsogolo provides condoms to both men and women, and has significantly improved the availability of condoms for women in particular.[1] Because of efforts by Population Services International, Banja La Mtsogolo, and many other organizations, condoms have become more widely available to many people in Malawi.[1]

Voluntary counseling and testing

People living in areas with high rates of HIV/AIDS face several psychological barriers when deciding whether to undergo testing for HIV.[1] For example, people may prefer not to know if they are HIV-positive because, due to the obstacles they often face in gaining access to antiretroviral drugs, many view HIV/AIDS diagnoses as death sentences.[1] Others may simply believe that they are HIV-negative, either because they practice strict monogamy and consistently use condoms during sexual intercourse or because they are in denial about the prevalence of the disease.[1] However, despite these barriers, both mobile and static testing services have become more widely available in Malawi recently: 1,392 testing and counseling sites existed in 2011.[1] Certain non-governmental organization such as the Malawi AIDS Counseling and Resource Organisation (MACRO) provide door-to-door counseling and testing services, which have drastically improved the accessibility of HIV testing.[7]

See also

References

  1. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj "HIV & AIDS in Malawi". AVERT. Retrieved 14 March 2014.
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  5. ^ a b c d e Kachingwe, Sitingawawo (2005). "Preparing Teachers as HIV/AIDS Prevention Leaders in Malawi: Evidence from Focus Groups". International Electronic Journal of Health Education. 8: 193–204.
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  7. ^ a b Government of Malawi (2012). GLOBAL AIDS RESPONSE PROGRESS REPORT: Malawi Country Report for 2010 and 2011 (PDF) (Report). Retrieved 14 April 2014.
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  15. ^ a b c d e f g h Impact of HIV/AIDS on agricultural productivity and rural livelihoods in the central region of Malawi. Malawi: CARE International. January 2002. pp. 5–10.
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  17. ^ a b c d e f g h i j k l Kemp, Julia; Jean Marion Aitken; Sarah LeGrand; Biziwick Mwale (2003). "Equity in health sector responses to HIV/AIDS in Malawi". Regional Network for Equity in Health in Southern Africa (EQUINET).
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