HIV/AIDS in Malawi

Geographical location of Malawi

HIV/AIDS is the leading cause of death in Malawi. As of 2011, approximately 910,000 people in Malawi were living with HIV/AIDS, and Malawi had one of the highest adult HIV/AIDS prevalence rates in the world. The epidemic began in 1985, when the first case of HIV/AIDS was identified in Lilongwe, Malawi's capital. Since then, due to a number of policies and initiatives by non-governmental organizations and the Malawian government, HIV prevalence rates in Malawi have gradually decreased. However, Malawi experienced 46,000 new infections in 2011. The epidemic is perpetuated by many factors, including unprotected heterosexual sex, inconsistent condom usage, poverty and poor health, stigma and discrimination, and the low socioeconomic status of women. In addition, Malawi faces many other barriers to the prevention and treatment of HIV/AIDS, including a lack of trained health care professionals, limited access to health services, and inadequate physical infrastructure.

Prevalence

Regions of Malawi: Northern Region (red), Central Region (yellow), and Southern Region (green)

According to the Malawi Demographic and Health Survey (MDHS) conducted in 2010, HIV prevalence among men and women in Malawi is higher in urban areas (17%) than in rural areas (9%). Women living in urban areas are more than twice as likely to be HIV-positive (22.7%) than women living in rural areas (10.5%). The Southern Region of Malawi has more than twice as many people living with HIV than the Central and Northern Regions of Malawi. However, the prevalence of HIV decreased by 3.1% in the Southern Region and by 1.5% in the Northern Region between 2004 and 2010, but increased by 1.1% in the Central Region during this time frame (see map).

The MDHS indicates that HIV prevalence among people between the ages of 15 and 49 is 10.6%, and that HIV prevalence is higher among women (12.9%) than men (8.1%). HIV prevalence among women ages 35-39 (24%) is six times higher than prevalence among women ages 15-19 (4%), and 10.6% of all pregnant women are infected with HIV. On the other hand, men ages 40-44 have the highest rates of HIV prevalence. HIV prevalence among young people ages 15-19 is 2.7%: 4.2% of females are HIV-positive, and 1.3% of males are HIV-positive. The MDHS also states that young people with several sexual partners have higher rates of HIV infection (6.4%) than young people with one sexual partner (2.1%).

A Behavioural Surveillance Survey conducted by the National Statistical Office in 2006 identified truck drivers, fishermen, vendors, schoolteachers, police officers, sex workers, and men who have sex with men as the groups with the highest rates of HIV infection. This survey indicated that sex workers in Malawi have an HIV prevalence rate of 70.7%, and a smaller-scale survey conducted in 2007 indicated that 21.4% of men who have sex with men in Blantyre are infected with HIV; these numbers are significantly higher than the national average (14%). Certain factors such as gender inequality and laws prohibiting homosexual behavior in Malawi make it particularly difficult for certain high-risk groups to access medical and social services.

History

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

The first case of HIV/AIDS in Malawi was reported at Kamuzu Central Hospital in Lilongwe in 1985. In response, President Hastings Banda, who was in power at the time, implemented short-term blood screening and HIV education programs and created the National AIDS Control Programme (NACP), a division of the Ministry of Health, to coordinate the country's prevention and treatment plans; however, these measures failed to control the escalating problem. Banda largely ignored the epidemic because sexual matters, including HIV transmission, were seen as taboo and inappropriate for public discussion. Citizens were legally prohibited from discussing the epidemic, and many people were imprisoned without trials. During this time period, several African leaders denied the widespread nature of the disease, and some claimed that it was a European disease. As a result of Banda's neglect, HIV prevalence among women tested at antenatal clinics increased by 28% between 1985 and 1993. The Malawian government began making serious attempts to control the spread of HIV/AIDS in 1989 when Banda introduced a five-year World Bank Medium Term Plan to combat the epidemic, but HIV prevalence had already increased drastically at this point.

In 1994, when Malawi became a multi-party democracy, Bakili Muluzi, the new president, directly and publicly addressed the nation's need for a coordinated response to the growing epidemic. People began seeing messages about HIV/AIDS on the radio and television, in newspapers and leaflets from the Ministry of Health, and on billboards, school murals, and posters in bars. However, HIV prevalence was already drastically influencing national productivity, and in 2002, Malawi experienced an AIDS-related famine (70% of hospital deaths at the time were AIDS-related), the nation's worst food crisis in over fifty years. In 2000, Muluzi implemented a five-year National Strategic Framework to combat the national epidemic, but the policy was slow to generate positive change due to organizational problems within the National AIDS Control Program. In 2001, the government of Malawi realized that the HIV/AIDS epidemic required a multi-sectoral approach and replaced the NACP with the National AIDS Commission (NAC), which has overseen many prevention and treatment initiatives.

Antiretroviral drugs became available to the public at three sites in 2003, and with a grant 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. During the last days of the Muluzi presidency, Western donors withheld aid out of concern about corruption and political instability, but donations increased again under the government of President Mutharika. However, Muluzi forced Mutharika to resign from the United Democratic Front party after Mutharika implemented a strong anti-corruption program, catalyzing a political catastrophe in Malawi that prevented the government from addressing the food and HIV/AIDS crises. The president launched Malawi's first National AIDS Policy and appointed a Principal Secretary for HIV and AIDS in 2004. HIV prevalence rates gradually slowed between the mid-1990s and 2007, and finally stabilized at about 11% in 2009.

Awareness and risk perception

Partners in Health worker with disease treatment literature in Malawi

Various studies have demonstrated that knowledge regarding the contraction of HIV and the symptoms of AIDS is high among people living in both urban and rural Malawi. Women are most likely to learn about HIV/AIDS through the radio and television, local health workers, and their female friends. Among men, the most common sources of information about HIV/AIDS are radio and television; however, some men also gain awareness through their male friends. When 57 Malawian men were interviewed in 2003, 100% said they had heard a radio program about HIV/AIDS protection, 84.2% said they had heard about HIV/AIDS protection at a clinic or hospital, and 63.2% said that somebody had come to their homes to discuss HIV/AIDS protection with them.

Studies have indicated that personal characteristics such as age, gender, and education level correlate, either positively or negatively, with HIV/AIDS awareness levels. For example, older women are more likely to have knowledge regarding HIV/AIDS than younger women. Because men have greater access to education and other resources, they are typically more knowledgeable about HIV/AIDS than women. For example, while men are, on average, able to list 2.2 ways to avoid contracting HIV, women are only able to list 1.5 ways; condom use, abstinence, and remaining faithful to a single partner are the most commonly known means of HIV/AIDS prevention. Only 40% of women surveyed in 2003 and 2004 suggested that their husbands would be less likely to contract HIV if they used condoms during intercourse with prostitutes and "bar girls." In addition, for men in particular, place of childhood residence corresponds to HIV/AIDS awareness; men raised in towns or cities are more informed about HIV/AIDS than men who grew up in villages. Men and women who have received primary school educations are slightly more informed about HIV/AIDS than men and women who have never attended school. In addition, men and women who have received secondary school educations are significantly more likely to understand nuanced aspects of the disease, such as the fact that people who look healthy can still be HIV-positive. People who have lost friends or relatives to HIV/AIDS, been personally tested for HIV, or received treatment for sexually transmitted infections are also likely to have a better understanding of the disease.

A study conducted in 2004 by Barden-O'Fallon et al., which surveyed 940 women and 661 men, indicated that, despite this awareness, about half of the respondents did not feel personally susceptible to HIV infection. However, 20% of men and 26% of women did believe that their risk of infection was moderate to high. In addition, although knowledge is typically associated with risk perception, knowledge of HIV/AIDS among men does not seem to correspond with perceived risk; on the other hand, although women are typically less informed than men, increased levels of knowledge about HIV/AIDS do cause an increase in perceived risk among women. Another study conducted in rural Malawi between 1998 and 2001 by Kirsten P. Smith et al. indicated that perceptions of risk declined during this four-year time frame, probably because the uptake of preventative strategies gave people a feeling of control. In this study, men were also less likely to express concern about HIV/AIDS than women. This could be due to the assumption that men are inherently promiscuous; therefore, women are more likely than men to worry that their spouses will infect them with HIV. In fact, many men claimed that they were "not at all worried," which could either be interpreted as a form of fatalism or an indication that they believe their behavioral changes have reduced their risk of exposure and contraction.

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. Less than one-third of secondary students in Malawi are satisfied with the HIV/AIDS curricula at their schools. Although non-governmental organizations and the Malawian government have conducted many education-oriented campaigns, there is still a significant shortage of audio and visual educational materials relating to HIV/AIDS available to instructors, particularly in rural areas; also, these materials are often non-stimulating, so they remain largely unused at the school level. In addition, many schoolchildren are able to identify at least one classmate who is caring for a family member infected with HIV/AIDS, but most teachers are unable to do the same, which suggests that school-based support for HIV/AIDS is minimal. However, according to surveys conducted in Malawi, children from HIV/AIDS-affected families rarely experience stigma or discrimination at school from their teachers or peers.

Most schools are required to address HIV/AIDS prevention in their curricula, but teachers often address this information briefly or superficially, occasionally omitting it altogether. Although teachers are concerned about the epidemic and willing to serve as leaders in education and prevention, they face many barriers when incorporating HIV/AIDS into their curricula. Instructors face personal barriers such as risky sexual behavior (which undermines their value as role models), discomfort in discussing sexuality (traditional values condemn conversations about sexuality), and lack of knowledge and awareness (due to limited training). In addition, teachers face several systemic barriers including fatalism, stigmatization, and denial surrounding HIV/AIDS; lack of emphasis on the HIV/AIDS curriculum; perceived constraints on classroom demonstrations (for example, condoms are viewed as inappropriate for the classroom); and uncertainty about support from the community.

However, despite this reluctance among teachers to discuss HIV/AIDS in the classroom, several techniques have successfully improved knowledge and awareness about HIV/AIDS among students. A study conducted in 1997 by Maclachlan et al. demonstrated that active learning approaches to AIDS education in Malawi could establish a thorough and accurate knowledge base among students. As part of this study, the students at one government-run secondary school completed an educational board game about HIV/AIDS once per week for four weeks, while the students at the other secondary school did not. The students in the first school answered more questions about HIV/AIDS correctly every week, and, by the end of the study, they scored significantly higher on a follow-up questionnaire about HIV/AIDS than the students at the second school, who had not played the educational board game.

Affected groups

The HIV/AIDS epidemic in Malawi is diverse, with notable differences in infection rate within different regions and age groups. Most HIV infections in Malawi occur through heterosexual sex, but local studies have indicated that 21.4% of men who have sex with men may be infected with HIV in Malawi. In addition, adult rates of HIV/AIDS prevalence are higher among women than men, indicating that women are particularly vulnerable to HIV contraction. HIV/AIDS has significantly impacted young people; estimates indicate that 170,000 children were HIV-positive in Malawi in 2011, and the epidemic has drastically increased the number of orphans in Malawi.

Men

Man with loaded bicycle in Malawi

Due to the vast scope of the HIV/AIDS epidemic, many Malawian men believe that contraction of HIV and death from AIDS are inevitable. Some of these men believe that HIV contraction is preordained by God or other supernatural forces. Other men refer to their own characters or irresponsible sexual histories when explaining why they believe that death from AIDS is inevitable. These men often believe that abstinence and condom use "go against nature," making HIV contraction unavoidable. Finally, some men falsely claim that they have already been infected with HIV to justify their sexual histories and unsafe sexual practices, hoping to convince themselves that there is no need to use condoms or reduce their number of sexual partners. Because of these fatalistic beliefs, many men continue engaging in extramarital sexual relations despite the prevalence of HIV, which hastens the spread of the disease.

However, despite these widespread feelings of fatalism, some men believe that changes in their behavior will protect them from HIV/AIDS. Men who decide to change their behavior to reduce their risk of infection are less likely to practice strict monogamy, use condoms regularly, or decrease their number of sexual partners; instead, they become increasingly selective when choosing their extramarital partners. For example, they choose women based on appearance, marital status, or age, and use their social networks to learn more about their partners' sexual biographies so they can reduce their risk of infection. Men who practice partner selection commonly believe that bar girls and "town women" who wear non-traditional clothing are more likely to carry HIV, while schoolgirls, who are perceived as sexually inexperienced, are considered "pure." Because of this perception, there is a growing concern that schoolchildren in Malawi, particularly girls, are contracting HIV as a result of sexual harassment or assault by their teachers and peers.

Women

Woman cooking in Karonga District, Malawi

Women are particularly vulnerable to HIV contraction in Malawi because gender inequality combined with widespread poverty has resulted in asymmetrical sexual relations. Due to their status, women often have limited access to education, employment, and productive resources such as land. Traditional gender roles place men, who are responsible for income generation, in the formal work sector, and relegate women to the domestic sphere; these power structures decrease women's autonomy, and, thereby, increase their vulnerability to HIV/AIDS. Women who are employed in the formal sector typically earn lower wages than men, giving them less bargaining power in the home. They are also less likely than men to benefit from government assistance or international aid programs.

Due to their vulnerable position, women are often afraid to discuss HIV/AIDS with their husbands, even if they know that their husbands are engaging in extramarital sex. The majority of women do not view divorce as an option, even when their husbands are HIV-positive and refuse to wear condoms. Because they lack the education needed to seek gainful employment, women often depend on their husbands for financial support. When men are unable to provide for their families, their wives become economically vulnerable; they often resort to commercial sex work to feed their children, but they lack the status to protect themselves by demanding that their clients wear condoms.

However, despite their vulnerability, some women in rural Malawi believe that they do, to a certain extent, have the ability to protect themselves from HIV contraction. Some women discuss the dangers of HIV/AIDS with their husbands directly, and many are confident that, by appealing to the needs of their children (who may be orphaned if their parents contract HIV), they will be able to convince their husbands to remain faithful. Others use their social networks as advocates, seeking help and advice from friends, family members, or respected counselors when they believe that their husbands' unsafe practices are putting their lives at risk. Some will publicly (and occasionally aggressively) confront their husbands' girlfriends as a way to control their husbands' sexuality. Finally, as a last resort, women might threaten to visit the ankhoswe, or traditional marriage counselor, to sanction divorce if their husbands refuse to remain faithful.

Children

AIDS orphans in Lilongwe, Malawi

Estimates suggest that 1.2 million children in Malawi had lost one or both parents to AIDS by 2000. Surveys conducted in schools indicated that 35% of students had lost either one or both parents to AIDS, and around 10-12% of these children had lost both parents. Due to the infection pattern of HIV, when parents co-habit, their children are likely to become double orphans when one of their parents contracts the disease. Double orphans usually live in child-headed households, responsible for the care of their younger siblings. Many double orphans in Malawi do not attend secondary school, presumably because they do not have the financial resources or time (due to their care-taking responsibilities) to do so. AIDS orphans are often forced to migrate to cities to find work due to the limited earning opportunities available in rural areas, which increases their vulnerability.

Because men often leave the care of children to grandparents and other extended family members in the event of maternal death, only 19% of maternal orphans in Malawi live with their fathers. In Malawi, double orphans are usually sent to live in orphanages (21%) or with their grandparents (23%) and other relatives (21%). There is no evidence indicating that extended family members have discriminated against orphans whose parents died from HIV/AIDS. In fact, it is likely that the role of extended family members in supporting HIV/AIDS orphans has slightly softened the community-level impact of the disease. However, female orphans are particularly vulnerable to sexual abuse because they are often forced into early marriages to relieve their guardians of extra care-taking responsibilities. In addition, although primary school absenteeism rates are high in general in Malawi, female double and paternal orphans in Malawi have particularly high rates of school absenteeism.

Evidence suggests that many schoolchildren in Malawi are contracting HIV as a result of sexual harassment or assault by their teachers and peers. Adolescent boys and girls are often targeted by adults because they are perceived as sexually inexperienced, and, therefore, less likely to be HIV-positive. Schoolchildren are particularly vulnerable to "transactional" sexual advances by adults because, due to their poverty, they are unable to afford school fees, books, or even food, making them susceptible to sexual exploitation. Many young girls living in poverty agree to engage in sexual relations with older men, including their teachers, because the men give them money and gifts, which the girls can use to improve their families' quality of life. Interviews indicate that teachers and school administrators in Malawi often do not understand the meaning of sexual harassment: some believe that sexual relations between teachers and students represent consensual sex and "normal" sexual relations, not harassment or assault. Because of this misunderstanding, teachers in Malawi, particularly male teachers, are unlikely to admit that sexual harassment is a problem at their schools. Although regulations for punishing teachers who sexually harass or assault students are in place, they are often ineffective. In Malawi, allegations are sufficient to warrant punitive action, but allegations are uncommon because children are hesitant to accuse adults of wrongdoing. In addition, teachers are often unwilling or unable to investigate the truth behind the accusations.

Marriage and relationships

Although the influence of Christianity has led to a decrease in traditional marriage practices in Malawi, polygynous unions and extramarital relationships, which have the potential to rapidly increase the spread of HIV, are still common. HIV/AIDS is acknowledged as a serious threat among most people in Malawi, and many couples understand that they experience a joint risk for contracting HIV – that is, if one spouse contracts HIV, the other will probably contract the virus as well. However, resistance to condom usage remains high: according to the Malawi Demographic and Health Surveys conducted in 2000, 7.6% of urban men and 6.6% of rural men of reproductive age (15-49) reported regular condom use.

Although condom use outside of marriage is growing in Malawi, the acceptability of condom use within marriage does not seem to be increasing significantly. The association between condoms and commercial sex work is widespread, and, therefore, condom use is seen as inappropriate during marital sex, which is supposed to be based on trust and mutual commitment. Many believe that condom use within marriage violates the purposes of marriage in the eyes of God: sexual pleasure and procreation. In a study published in 2007 by Agnes M. Chimbiri, only 2.3% of married respondents had used condoms with their spouses during their last sexual encounters, while 18.2% had used condoms during other "casual" sexual encounters. Men cited pregnancy prevention as the primary reason why they used condoms with their wives, but they cited protection against sexually transmitted infections as the most important reason why they used condoms during their extramarital sexual encounters.

Both formal and informal sources of information are important in catalyzing discussions about HIV/AIDS among married couples. When men and women have accessed information about HIV/AIDS from clinics, radio broadcasts, or conversations with peers, they are more likely to discuss the risk of HIV/AIDS contraction with their spouses. Concerns about being infected with HIV, which are often motivated by concerns about infidelity, play a significant role in motivating conversations between couples about the risk of HIV/AIDS. Surprisingly, education levels do not significantly impact the likelihood that couples will discuss the risk of HIV/AIDS; however, couples that have discussed family planning issues are more likely to discuss the risk of HIV/AIDS. In addition, couples are more likely to have discussions regarding HIV/AIDS when wives understand that their husbands can contract the disease from "healthy-looking" extramarital partners.

Rates of discussion about HIV/AIDS among married couples are higher in the southern matrilineal/matrilocal regions of Malawi, which suggests that female autonomy and status are positively correlated with spousal conversation regarding HIV/AIDS. On the other hand, in the northern patrilineal/patrilocal regions of Malawi, many women are raised to believe that their husbands control condom use and sexual relations. However, in both the patrilineal/patrilocal North and the matrilineal/matrilocal South, women occasionally claim that there is "no point" in discussing HIV/AIDS with their husbands, either because they trust them to remain faithful, or because they do not believe their conversations will change their husbands' desire for extramarital sex.

Economic impact

Farmers with composting materials in Malawi

A study conducted by CARE International across three districts in the Central Region of Malawi in 2002 examines the impact of the HIV/AIDS epidemic on the productivity and livelihoods of families in rural Malawi. When skilled laborers are unable to work due to HIV/AIDS, their families must shift away from labor-intensive crops such as tobacco towards less labor-intensive crops, which are often less profitable. The disease also affects the productivity of their household members or relatives, who must spend time caring for them, bringing them to the hospital, and obtaining medications for them. Because of this loss of labor, households are often forced to delay their agricultural operations, leave their land fallow, sell their produce before maturity, or change their sources of livelihood. In addition, when family members fall ill, households must use money reserved for agricultural inputs such as fertilizers or seeds to support medical and transportation-related costs, further decreasing economic stability at the household level. Finally, increased financial demands on adults often lead to the withdrawal of children from school, threatening long-term national productivity. In summary, these local changes decrease physical, social, financial, and natural capital in Malawi, and this has negative long-term implications for the national economy.

CARE International proposes several interventions that might reduce the economic burden of HIV/AIDS on rural households. They recommend introducing new technologies and crops that require less labor to allow households affected by HIV/AIDS to continue supporting themselves through agriculture. Women in patrilineal/patrilocal villages are often expected to leave their villages when their husbands die of HIV/AIDS; therefore, helping women acquire traditionally masculine agricultural skills such as tobacco cultivation may decrease their vulnerability while improving agricultural productivity at the household and community levels. CARE International recommends improving community, faith, and kinship-based support networks, which can provide information, advice, and emotional and financial support to affected households. They also suggest promoting the development of community-based labor and food banks, which can serve as safety nets for families affected by the epidemic. Finally, CARE International highlights the importance of increased advocacy and information flow regarding HIV/AIDS in Malawi to help families prepare for and cope with the economic burdens associated with the epidemic.

Impact on health services

A Community Health Worker in Malawi

The HIV/AIDS epidemic in Malawi has been characterized by increasing demands on health services and drastic declines in the number of health workers available to provide treatment and care. Hospital-based studies indicate that 70% of all admissions to hospital wards in Malawi are due to HIV-related conditions. However, Malawi currently faces a considerable deficit in health workers: in 2007, the national Human Resources for Health census reported that there were only 159 doctors (1/100,000 people) and 3,614 nurses and midwives (26/100,000 people) in the country. Only 32% of Malawi's health centers satisfy the Essential Health Package's staffing norms, which recommend placing two nurses or midwives and one clinical officer at every health center.

While migration to more developed countries and limited access to education are partially responsible for the shortage of health care workers in Malawi, many health care workers have died from AIDS; in fact, the National Association of Nurses in Malawi loses an average of four nurses to AIDS every month. HIV/AIDS has also led to chronic absenteeism among many health workers in Malawi, either because of personal infection or the death of family members, and there are no policies in place to hire replacements for people who suffer from long-term illnesses. Because of this, the government often takes up to a year to replace health workers who are chronically ill or deceased, which adds additional strain to the remaining health workers. These health workers frequently leave because they are unable to manage the increased workload or because they are afraid of becoming infected, either with HIV or HIV-related infections such as tuberculosis.

Because of this deficit in health workers, Malawi has adopted task shifting strategies to overcome the shortage of workers available for HIV/AIDS treatment and care. Task shifting involves delegating certain medical tasks that require less knowledge and training, such as the initiation of antiretroviral therapy (ART), to less specialized health workers such as nurses and non-physician clinicians. For example, at Thyolo District Hospital, health workers undergo a one-week classroom training course and a two-week clinical attachment at an experienced ART site before they receive a certificate of competence and are legally (under Ministry of Health guidelines) allowed to initiate ART. Another form of task shifting involves shifting the responsibility of HIV testing and counseling from nurses to counselors who have undergone three weeks of formal training.

Interventions

Malawi has taken many steps towards slowing the spread of HIV, including the implementation of voluntary counseling and testing services, mass media campaigns, life skills education for young people, and mother-to-child transmission prevention services, as well as the promotion of condoms, voluntary medical male circumcision, and blood safety measures. Access to antiretroviral therapy is extremely limited, particularly in rural areas, so many interventions have focused on information and education campaigns promoting preventative measures such as condom use, fidelity, and abstinence. However, intervention attempts have faced many structural issues including laws that criminalize high-risk groups (e.g., men who have sex with men), a lack of resources, the stigma associated with the disease, and gender inequality, which makes condom use negotiations difficult.

About 75% of the funding Malawi receives for HIV/AIDS prevention and care comes from international donors. Malawi's most significant international donors include the World Bank, the Global Fund, the World Health Organization, the President's Emergency Plan for AIDS Relief (PEPFAR), and the Joint United Nations Programme on HIV and AIDS (UNAIDS). The World Bank has lent $407.9 million to Malawi, the Global Fund has given $390 million to Malawi, and PEPFAR has promised to give $25 million towards voluntary counseling and testing, condom distribution, and mother-to-child prevention programs in Malawi. In 2011, 65.9% of Malawi's budget was allocated towards treatment and care, while only 11% was allocated towards prevention and behavior change.

Antiretroviral therapy

Recent studies have suggested that the number of people receiving antiretroviral treatment in Malawi has increased drastically in the past decade: in 2004, only 13,183 people were receiving treatment, but in 2011, 322,209 people were receiving treatment. In addition, antiretroviral therapy use increased by 13% between 2010 and 2011. This success stems partially from the fact that Malawi implemented World Health Organization treatment guidelines in 2008, which changed the quality of the drugs, the treatment timeline, and the rate of mother-to-child transmission. However, Malawi's proposals for a new antiretroviral treatment plan in 2011, which would have cost $105 million per year, were rejected by the UK Department for International Development and the Global Fund, threatening Malawi's ability to increase access to antiretroviral treatment.

In 2000, Malawi's Ministry of Health and Population devised a proposal for providing antiretroviral therapy to the population through the public health system, and, as of 2003, there were several systems of antiretroviral provision operating in Malawi. The Malawian government supports the provision of antiretroviral drugs at the Lighthouse, a Malawi-registered trust in Lilongwe working in partnership with the Ministry of Health and Population, at a cost of 2,500 kwacha per month to the patient. Queen Elizabeth Central Hospital has an antiretroviral therapy clinic within its outpatient department, and Médecins Sans Frontières provides free medication to the Chiradzulu and Thyolo Districts. In urban centers, many private providers offer antiretroviral drugs; however, very few patients can afford to receive drugs from the private sector. In addition, private providers are not currently required to obtain certification before selling antiretroviral drugs, which raises concerns about the quality of care provided in the private sector. Finally, some employees receive access to antiretroviral drugs through their workplaces, but this practice is not widespread.

Due to the advent of antiretroviral drugs, HIV/AIDS has become a manageable chronic illness for people who can afford treatment. However, because antiretroviral therapy is expensive and complex, it remains largely inaccessible to most people in Malawi. Although Malawi's National HIV/AIDS Policy specifically outlines the need for equitable access to antiretroviral therapy, this goal has not yet been achieved: 449 HIV treatment clinics exist in Malawi, but the Central East and Northern areas have significantly more access to treatment than the South East region of Malawi. In many rural areas, limited transportation, drug shortages, inability to treat opportunistic infections, and food crises have made sustained, high-quality antiretroviral therapy difficult or impossible. In addition, the money donated by the Global Fund to Fight AIDS, Tuberculosis, and Malaria was used to fund an antiretroviral therapy program, but the provision of drugs was based on a "first-come, first-served" system, making the drugs more accessible to the male, urban, educated population. Without more explicit criteria regarding equitable distribution, individual healthcare workers become responsible for deciding who will receive treatment, which inevitably leads to "informal" selection criteria and corruption.

Condom distribution

Although latex condoms, when used correctly, prevent the spread of HIV effectively, availability and affordability have hindered widespread condom use in Malawi. Condoms are often unavailable in rural areas, and they are rarely provided at bars or other places of entertainment, where they could have a significant impact on HIV prevention. Many people oppose condom use because they believe condoms make sex less enjoyable, are ineffective, or even cause the spread of HIV. As mentioned previously, due to gender inequality, women are often unable to request that their sexual partners use condoms. However, despite these factors, condom use among the unmarried has increased in Malawi, which is probably due to widespread concern about HIV contraction.

Many non-governmental organizations in Malawi, including Population Services International and Banja La Mtsogolo, have conducted campaigns to increase knowledge regarding condom use and make condoms more accessible to the public. Banja La Mtsogolo, an organization founded in 1987 that provides sexual and reproductive health services to women in Malawi, has distributed millions of condoms and held educational campaigns about female condom use. Together, Population Services International and Banja La Mtsogolo distributed 4.3 million condoms between 2009 and 2010. Because of their efforts, half of all unmarried young men and women between ages 15 and 24 report using a condom when they last engaged in sexual intercourse.

In 2000, Malawi's Council of Churches condemned the distribution and use of condoms to prevent HIV transmission, arguing that condoms encourage promiscuity, which is viewed as immoral by the church. The Church in Malawi also emphasizes that strict monogamy and abstinence are the only reliable ways to prevent infection because condoms are not 100% effective at preventing the transmission of HIV. However, recent evidence has suggested that some faith-based organizations are changing their positions on condom use, and are recommending that people who have multiple partners use condoms.

Voluntary counseling and testing

People living in areas with high rates of HIV/AIDS, including Malawi, face many psychological barriers when deciding whether to undergo testing for HIV. For example, people may be afraid to receive a positive result, not know about the testing services that are available to them, have religious beliefs that prevent them from getting tested, assume that they have already been infected, or believe that they have no chance of being infected. However, despite these barriers, both mobile and static testing services have become more widely available in Malawi: 1,392 testing and counseling sites existed in 2011, and more than 1.7 million people received HIV testing and counseling that year, which represents 28% of the sexually active population in Malawi. Certain non-governmental organization such as the Malawi Aids Counseling and Resource Organisation (MACRO) provide door-to-door counseling and testing services. According to the Malawi Demographic and Health Survey conducted in 2010, 96.9% of women and 96.4% of men between ages 15 and 49 knew where they could receive an HIV test, and 73.1% of women and 52.2% of men had been tested for HIV. In addition, 81.3% of young women and 52.9% of young men between ages 15 and 24 had been tested for HIV in 2010. Respondents with higher incomes and higher levels of education were more likely to have undergone testing for HIV.

Community efforts

According to a study conducted in the Thyolo District of Malawi by Zachariah et al. in 2006, communities can serve as "unexploited resources" to soften the impact of the HIV/AIDS epidemic. Since 2000, voluntary counseling and testing programs have expanded from Thyolo Hospital, the main district hospital, to thirteen rural health facilities. Before Médecins Sans Frontières started providing care in the district, church groups, traditional chiefs, district representatives, and community members had already organized themselves into groups to support patients with HIV/AIDS. In addition, a community executive committee with a president, coordinator/liaison officer, and treasurer was created. These community members increased the availability of voluntary counseling and testing services and HIV tests while providing the long-term care and support needed for successful HIV/AIDS treatment. They also trained 1,694 AIDS orphans in vocational skills, organized pre-school activities for 900 AIDS orphans, and planted twelve vegetable gardens and three maize farms. This study demonstrates that community-level action can serve as an effective intermediate step; however, as of now, the role of the community in addressing the nation-wide epidemic remains largely undefined.

See also

• Sub-Saharan Africa
• HIV/AIDS in Africa
• Diseases of poverty
• Epidemiology of HIV/AIDS
• Misconceptions about HIV and AIDS
• AIDS orphan
• Healthcare in Malawi