By EGPAF TEAM
Malawi was at the peak of its HIV and AIDS epidemic between 1993 and 1994, when approximately 110,000 Malawians contracted HIV. By 2005, the number of new infections had dropped to 66,000, but nearly 65,000 people died that year due to AIDS-related illnesses.
Since then, Malawi has made great progress in the fight to end HIV and AIDS. New HIV infections declined by more than 40 percent from a high of 66,000 new HIV infections in 2005 to 38,000 people in 2018. AIDS-related deaths declined by 20 percent from 65,000 deaths in 2005 to 13,000 in 2018. New infections in children have also dropped by more than 20 percent –going from 15,000 new HIV infections in children in 2010 to 3,500 new infections in 2018.
Today, Malawi is on the cusp of achieving the 2020 UNAIDS 90-90-90 targets, which means 90% of all people living with HIV know their status; 90% of these people are on treatment; and 90% of those on treatment are virally suppressed. Malawi’s progress can be attributed to the government’s enabling policy environment as well as the Ministry of Health’s leadership in policy and guidance for the biomedical response.
Strategic interventions in support of various policies were implemented across the country, including the Option B+ Program in 2011 (mandating that all pregnant women living with HIV have lifelong access to treatment) and the Test and Treat Strategy in 2016 (which provided immediate access to treatment for people living with HIV without requiring a CD4 count).
Thanks to the Viral Load Strategic and Implementation Scale-Up Plan and adoption of optimized treatment regimens in 2018, more than 95% of patients on first line were taking highly effective Dolutegravir-based regimens by June 2020—an intervention that has improved viral load suppression rates in the majority of patients.
Progress has also been driven by the government’s prioritization of health systems strengthening in key areas such as Human Resources for Health (HRH), infrastructure improvement, laboratory equipment and supplies, antiretroviral treatment (ART) along with other medicines and strong data systems.
With a national prevalence of 9.2% among adults, Malawi’s ability to reach epidemic control and end HIV and AIDS rests firmly upon the continued commitment and shared responsibility from the government, civil society, faith institutions, business coalitions, media, donors, and non-governmental organizations.
Anthony Chipala, a Ministry of Health (MOH) Clinician at Chiradzulu District Hospital, reaffirms that the government has made remarkable progress to ensure there are no antiretroviral (ARV) stock-outs at the country’s health facilities. Chipala noted that the government is supported by partners focused on ending HIV.
“Organizations like Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) have helped with human resource expertise in the diagnosis and treatment of HIV and AIDS through HIV diagnostic assistants and care and treatment officers,” says Chipala. “We have also attended various trainings [facilitated by EGPAF] that have kept us updated on new trends in HIV treatment.”
In partnership with the Ministry of Health (MOH), EGPAF began supporting prevention of mother to child transmission (PMTCT) services in 2001. Today, EGPAF-Malawi implements evidence‐based HIV prevention, care, and treatment interventions at 179 health facilities in nine districts across Malawi. This work, funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), allows EGPAF to provide dedicated support to the government of Malawi by a team of health providers, technical experts, researchers, and policy advocates within EGPAF.
“The U.S. CDC is proud to support EGPAF and other excellent implementing partners in building strong, resilient health systems that deliver improved health outcomes for the people of Malawi, including clients living with HIV, in strong partnership with the Government of Malawi.” Dr Andrew Auld, Director, US Centers for Disease Control and Prevention (CDC) -Malawi.
EGPAF supports the MOH with technical assistance around updated guidelines and services and seconds staff to ensure people with HIV are diagnosed, initiated on treatment, provided with the right drugs and support to manage their lifelong treatment.
Christina Yoyola, a nurse with EGPAF at St Luke’s Anglican Hospital in Zomba, developed her passion for helping people in 1992 when she was convinced through a career talk to pursue nursing.
“As a linkage nurse at EGPAF, I particularly work with pregnant mothers who upon being tested positive are put on antiretroviral therapy [called ART] in order to suppress their viral load, and in the process, avoid infecting the baby. [Upon delivery of the baby], I also administer treatment to babies, at the same time orienting mothers on how best to administer the drugs to the babies at home,” says Yoyola.
Most pregnant women with HIV do not know they have the infection, and a test is the only way to know their status. When pregnant women and their spouses attend antenatal care clinics together, they can both be tested for HIV. If they test positive, they can begin treatment together, helping to prevent transmission of the virus to their baby.
One challenge that remains, however, is that many men are not willing to attend ART clinics and thus miss the opportunity to receive lifesaving care for themselves, their partners and children.
“Some women are not able to disclose their status to their spouses, and in the process, they resist adherence to ART due to fear of their loved ones, rendering it a challenge to reduce their viral load which – and puting the child at risk of contracting the virus,” explains Yoyola.
For the women who are able to seek care, Yoyola and nurses in MOH health facilities conduct mother-infant pair clinics. These clinics provide routine counselling and monitoring of mothers living with HIV and their babies who are tested for HIV at 6 weeks, 12 months, and 24 months to reduce pediatric infections and ensure the mothers’ well-being. Most children living with HIV are infected via mother-to-child transmission during pregnancy, childbirth, or breastfeeding. In such situations, parents or guardians, in collaboration with healthcare workers, are very important figuresin ensuring that the child lives a positive, healthy life.
Sankhani Sinkonda, EGPAF’s clinical coordinator for a health facility in Mwanza, says many children stay with their relatives, including grandparents, who do not have HIV knowledge and are unaware of the importance of drug adherence. As a result, many children stop responding to their first line of treatment and must prematurely resort to a second line.
“Initially, it took us some time to accept the condition of our child, but we just had to accept the situation,” says the father of a 9-year-old child living in Malawi’s central region. “We always make sure that we don’t miss appointments, and we always make sure that she adheres to medication.”
Victor Gandali, a nurse and midwife technician for the MOH at Ntcheu District Hospital, says that he works hard to ensure young people stay free from HIV. Adolescents living with HIV often struggle to manage their illness and cope with mental development, physical change and HIV stigmas in communities. With support from EGPAF, Victor leads teen clubs to provide a forum for adolescents to access their medications and work through challenges associated with HIV.
“As a trained health worker, I help in providing a safe and nurturing environment for adolescents in which they can build supportive relationships, increase their self-esteem and develop and reinforce good habits such as taking the first step in testing for HIV.”
Fostering positive, healthy and promising futures in children and adolescents living with HIV is a shared responsibility of parents, guardians and healthcare workers.
Effective service delivery is not possible without the voice and support of recipients of HIV care. As part of the multidisciplinary approach to providing HIV care, EGPAF supports expert clients, individuals living with HIV who provide peer support to people newly diagnosed with HIV. Expert clients offer professional services, acting as role models to engage and educate communities on HIV/AIDS, sharing important information with HIV recipients of care and in their catchment areas.
Razia Patel is an Expert Client for Mothers to Mothers (m2m), from Thyolo District Hospital. She was diagnosed with HIV in 2003 and says that one of her roles is to follow up with those who have tested positive to ensure they are linked to the right care and remain adherent to their medication. With Patel’s support, people diagnosed with HIV are able to find comfort and guidance from peers to whom they can directly relate. EGPAF in partnership with m2m supports 325 expert clients across Malawi.
A key milestone in ending the epidemic is reducing new infections and ensuring those unaware they are infected with HIV, know their status. In partnership with Malawi AIDS Counselling and Resource Organization (MACRO), EGPAF supports HIV diagnostic assistants (HDAs) to complement the government’s effort to improve access to HIV testing and psychosocial counselling at 495 health centers in eight districts.
With 10 years of experience as an HDA, Desmond Tenthani of Police College Hospital in Zomba says that during counselling, he can assess a client’s risks and address their fears. He noted that some clients fear disclosing their status to their partners and facing discrimination within their family members or the community. When this happens, Tenthani explains that HDAs “give counselling on positive living, which is more about acceptance and ability to disclose their status to at least one or two members of the family. The advantage of disclosing status to family members is that they are likely to accept the condition and provide necessary assistance. Moreover, family members will be able to follow-up on drug adherence of their relation.”
Most recently EGPAF with support from CDC, is also working closely with Government of Malawi to modernize,using digital technologies and Electronic Medical Record Systems to improve the provision of patient care to end HIV.
In addition to supporting patient care, EGPAF works closely with media and influential leadership to continue the political commitment to end HIV. EGPAF works with Media Institute for Southern Africa (MISA-Malawi Chapter) in rallying their support to ending pediatric and adolescent HIV by promoting greater understanding of the needs and impact of HIV. EGPAF also works closely with the Organization of African First Ladies for Development (OAFLAD), which spearheaded the Free to Shine initiative. Free to Shine aims to stop new HIV infections among children and keep mothers healthy by uniting people and organizations at the local and global levels to ensure access to HIV services.
“Ending HIV is certainly possible with our commitment and shared responsibility,” says EGPAF Country Director Veena Sampathkumar. “In Malawi—with progressive and path-breaking policies, a dedicated health services team nurtured by leadership and political commitment, and an active civil society inclusive of people living with HIV and responsible media—we are moving faster and closer to an AIDS-free generation.”