HIV/AIDS in Malawi

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

As of 2012, approximately 1,100,000 people in Malawi are HIV-positive, which represents 10.8% of the country's population. [1] Because the Malawian government was initially slow to respond to the epidemic under the leadership of Hastings Banda (1966–1994), the prevalence of HIV/AIDS increased drastically between 1985, when the disease was first identified in Malawi, and 1993, when HIV prevalence rates were estimated to be as high as 30% among pregnant women. [1] The 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]

Malawi Country in Africa

Malawi, officially the Republic of Malawi, is a landlocked country in southeast Africa that was formerly known as Nyasaland. It is bordered by Zambia to the northwest, Tanzania to the northeast, and Mozambique on the east, south and west. Malawi spans over 118,484 km2 (45,747 sq mi) and has an estimated population of 18,091,575. Lake Malawi takes up about a third of Malawi's area. Its capital is Lilongwe, which is also Malawi's largest city; the second largest is Blantyre, the third largest is Mzuzu and the fourth largest is its old capital Zomba. The name Malawi comes from the Maravi, an old name of the Nyanja people that inhabit the area. The country is nicknamed "The Warm Heart of Africa" because of the friendliness of the people.

HIV/AIDS Spectrum of conditions caused by HIV infection

Human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency virus (HIV). Following initial infection, a person may not notice any symptoms or may experience a brief period of influenza-like illness. Typically, this is followed by a prolonged period with no symptoms. As the infection progresses, it interferes more with the immune system, increasing the risk of developing common infections such as tuberculosis, as well as other opportunistic infections, and tumors that rarely affect people who have uncompromised immune systems. These late symptoms of infection are referred to as acquired immunodeficiency syndrome (AIDS). This stage is often also associated with unintended weight loss.

Politics of Malawi

Politics of Malawi takes place in a framework of a presidential representative democratic republic, whereby the President of Malawi is both head of state and head of government, and of a multi-party system. Executive power is exercised by the government. Legislative power is vested in both the government and the National Assembly. There is a cabinet of Malawi that is appointed by the President of Malawi. The judiciary is independent of the executive and the legislature. The government of Malawi has been a multi-party democracy since 1994. The Economist Intelligence Unit has rated Malawi as "hybrid regime" in 2016.

Contents

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 preventative 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]

Television Telecommunication medium for transmitting and receiving moving images

Television (TV), sometimes shortened to tele or telly, is a telecommunication medium used for transmitting moving images in monochrome, or in colour, and in two or three dimensions and sound. The term can refer to a television set, a television program, or the medium of television transmission. Television is a mass medium for advertising, entertainment and news.

Radio Technology of using radio waves to carry information

Radio is the technology of signaling and communicating using radio waves. Radio waves are electromagnetic waves of frequency between 30 hertz (Hz) and 300 gigahertz (GHz). They are generated by an electronic device called a transmitter connected to an antenna which radiates the waves, and received by a radio receiver connected to another antenna. Radio is very widely used in modern technology, in radio communication, radar, radio navigation, remote control, remote sensing and other applications. In radio communication, used in radio and television broadcasting, cell phones, two-way radios, wireless networking and satellite communication among numerous other uses, radio waves are used to carry information across space from a transmitter to a receiver, by modulating the radio signal in the transmitter. In radar, used to locate and track objects like aircraft, ships, spacecraft and missiles, a beam of radio waves emitted by a radar transmitter reflects off the target object, and the reflected waves reveal the object's location. In radio navigation systems such as GPS and VOR, a mobile receiver receives radio signals from navigational radio beacons whose position is known, and by precisely measuring the arrival time of the radio waves the receiver can calculate its position on Earth. In wireless radio remote control devices like drones, garage door openers, and keyless entry systems, radio signals transmitted from a controller device control the actions of a remote device.

Non-governmental organization organization that is neither a part of a government nor a conventional for-profit business

Non-governmental organizations - commonly referred to as NGOs, are usually non-profit independent of governments, many are active in humanitarian etc. areas; however, NGOs can also be as lobby groups for corporations, such as the World Economic Forum. NGOs is also sometimes expanded to nongovernmental or nongovernment organizations. They are thus a subgroup of all organizations founded by citizens, which include clubs and other associations that provide services, benefits, and premises only to members. Sometimes the term is used as a synonym of "civil society organization" to refer to any association founded by citizens, but this is not how the term is normally used in the media or everyday language, as recorded by major dictionaries. The explanation of the term by NGO.org is ambivalent. It first says an NGO is any non-profit, voluntary citizens' group which is organized on a local, national or international level, but then goes on to restrict the meaning in the sense used by most English speakers and the media: Task-oriented and driven by people with a common interest, NGOs perform a variety of service and humanitarian functions, bring citizen concerns to Governments, advocate and monitor policies and encourage political participation through provision of information.

History

Bingu wa Mutharika, third President of Malawi (2004-2012) Lula Mutharika (Cropped).JPG
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]

Kamuzu Central Hospital is a tertiary referral hospital in the Lilongwe, Malawi. It is estimated to have 600-1,000 beds, though the true number of patients always exceeds the number of beds. It serves approximately 5 million people. It has a partnership with the University of North Carolina and Haukeland University of Norway. Additionally, it receives support from Baylor Pediatric AIDS Initiative and a partnership project, called Magnet, with the Institute of Public Health of the University Hospital Heidelberg in Germany, the University Hospital Cologne and the University Hospital Bonn.

Hastings Banda First president of Malawi

Hastings Kamuzu Banda was the prime minister and later president of Malawi from 1964 to 1994. In 1966, the country became a republic and he became president.

Healthcare in Malawi and its limited resources are inadequate to fully address factors plaguing the population, including infant mortality and the very high burden of diseases, especially HIV/AIDS, malaria and tuberculosis.

In 1994, when Bakili Muluzi became president, he addressed the nation's need for a coordinated response to the HIV/AIDS epidemic. [1] In 2000, Muluzi introduced another five-year policy known as the National Strategic Framework, but, like Banda's five-year World Bank Medium Term Plan, this plan was largely ineffective. [1] In 2001, in response to problems within the National AIDS Control Programme established by Banda, Muluzi created the National AIDS Commission. [1] Unlike Banda, who prevented the public from accessing information about the epidemic, Muluzi ensured that information about HIV/AIDS was available on the radio and television, in newspapers, and on billboards. [8] However, despite Muluzi's efforts, HIV prevalence was already significantly influencing national agricultural productivity during this period, and Malawi experienced an AIDS-related nationwide famine in 2002. [1]

Bakili Muluzi Malawian politician

Elson Bakili Muluzi is a Malawian politician who was the first freely elected President of Malawi from 1994 to 2004. He was also chairman of the United Democratic Front (UDF) until 2009. He succeeded Hastings Kamuzu Banda as Malawi's president. He also served in Banda's cabinet as Minister without Portfolio, before retiring in 1980.

Malawian food crisis

Malawi is one of the world's least developed countries and is ranked 170 out of 187 countries according to the 2010 Human Development Index. It has about 16 million people, 53% of whom live under the national poverty line, and 90% of whom live on less than $2 per day. The United Nations Children's Fund (UNICEF) estimated that there are 46,000 severely malnourished children.

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]

The Global Fund to Fight AIDS, Tuberculosis and Malaria is an international financing and partnership organization that aims to “attract, leverage and invest additional resources to end the epidemics of HIV/AIDS, tuberculosis and malaria to support attainment of the Sustainable Development Goals established by the United Nations.” The international organization maintains its secretariat in Geneva, Switzerland. The organization began operations in January 2002. Microsoft founder Bill Gates was one of the first private foundations among many bilateral donors to provide seed money for the partnership.

Bingu wa Mutharika politician and economist

Bingu wa Mutharika ) was a Malawian politician and economist who was President of Malawi from May 2004 until his death in April 2012. He was also President of the Democratic Progressive Party, which he founded in February 2005; it obtained a majority in Malawi's parliament in the 2009 general election. During his two terms in office, he was noted for being the Chairperson of the African Union in 2010–2011, as well as for several domestic controversies. In 2009, he purchased a private presidential jet for $13.26 million. This was followed almost immediately by a nationwide fuel shortage which was officially blamed on logistical problems, but was more likely due to the hard currency shortage caused by the freezing of aid by the international community He died of cardiac arrest in Lilongwe while in office on 5 April 2012, at age 78.

Awareness and risk perception

Partners in Health worker with disease treatment literature in Malawi PIH worker with disease treatment literature for the community.jpg
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. [2] According to a 2004 study by Barden-O'Fallon et al. involving 100 households, women in Malawi are most likely to learn about HIV/AIDS through radio and television, health workers at local clinics, and female members of their social networks. [2] Men are also likely to access information about HIV/AIDS through radio and television; however, unlike women, they are not likely to gain information about HIV/AIDS from their male friends. [2] When 57 Malawian men were interviewed in 2003, 100% of them said they had heard about the HIV/AIDS epidemic on the radio, and 84.2% of them said they had learned about HIV/AIDS during their visits to local health facilities; this supports the fact that many people in Malawi have access to information about the epidemic, both through the radio and other sources. [8]

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. [2] Because men typically have greater access to education and other social resources, they are often more knowledgeable about HIV prevention and transmission than women. [2] While men are, on average, able to list 2.2 ways to prevent HIV transmission, women are only able to list 1.5 ways. [2] Only 38% of women surveyed in 2003-2004 understood that their husbands would be less likely to contract HIV if they used condoms during intercourse with 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 personally susceptible to HIV infection. [2] On average, only 23% of the adults who were surveyed during this study, both male and female, believed that they were likely to contract HIV and die of AIDS. [2] Greater HIV/AIDS awareness among men does not seem to correspond with increased perceived risk; on the other hand, increased levels of knowledge about HIV/AIDS do correlate positively to perceived risk among women. [2] Another study conducted in rural Malawi between 1998 and 2001 by Kirsten P. Smith et al. indicated that concerns about personal vulnerability to HIV/AIDS declined during this four-year time frame, probably because the increased use of preventative strategies gave people a sense of control. [10] 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. [10]

Education

Health Education Center in Blantyre, Malawi HEC Blantyre.JPG
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 sexual orientation, gender, and age influence infection patterns. In Malawi, HIV/AIDS is usually transmitted through 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. [3] Older men in particular often claim that the HIV/AIDS epidemic is a punishment issued by God or other supernatural forces. [3] Other men refer to their own irresponsible sexual behaviors when explaining why they believe that death from AIDS is inevitable. [3] These men sometimes claim that 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 preventative 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. [3] Men who decide to change their behaviors to reduce their risk of infection are unlikely to use condoms consistently, particularly during marital intercourse; instead, they usually continue engaging in extramarital sexual relations, but alter the ways in which they choose their sexual partners. [3] For example, before selecting extramarital sexual partners, men sometimes survey their peers to determine whether their potential partners are likely to have exposed themselves to the virus. [10] Men who choose their sexual partners based on external appearances and peer recommendations often believe that women who violate traditional 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 traditional gender roles in Malawi, men operate primarily in the formal work sector and are responsible for supporting their families through paid labor, whereas women, who are valued for their domestic skills, are responsible for agricultural labor and care work; this gender-based division of labor decreases women's autonomy, thereby increasing their vulnerability to HIV/AIDS. [9] Even within the home, women often lack bargaining power because they have limited access to education, formal employment, and other resources that could give them a sense of financial and personal independence. [9] Women who are able to work in the 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. [9] Most women in Malawi do not view divorce as a viable option, even when their husbands are HIV-positive and refuse to protect them from the virus by wearing condoms during marital intercourse. [9] Because they lack the education and training needed to seek gainful employment, women are not usually able to support themselves and their children outside of marriage without resorting to 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. [11] They tell their husbands that the HIV/AIDS epidemic has made sexual infidelity extremely dangerous and encourage them to refrain from engaging in extramarital sexual contact. [11] In addition, many women are convinced that, by appealing to the vulnerability of their children (who will probably be orphaned if their parents contract HIV), they can convince their husbands to use condoms consistently during extramarital sexual encounters. [11] Other women seek support from their friends and family members when they believe that their husbands' unsafe behaviors are putting their lives at risk. [11] Finally, as a last resort, women might warn their husbands that they will visit the ankhoswe, or traditional marriage counselor, and demand divorce if their husbands refuse to remain faithful and actively prevent the transmission of the disease. [11]

Children

AIDS orphans in Lilongwe, Malawi Aids Orphans in Malawi.jpeg
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. [6] Because HIV is transmitted sexually, married couples who engage in 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, extended family members usually become the children's primary caregivers: in Malawi, 44% of double orphans are adopted by grandparents or other close relatives. [6] Extended family members often provide crucial support to HIV/AIDS orphans; [12] 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. [6] Children are particularly vulnerable to exploitation by adults who offer them money in exchange for sex; because they are often unable to afford basic necessities, they might feel compelled to accept gifts in exchange for sex out of desperation. [6] Interviews indicate that teachers and school administrators in Malawi often misinterpret the definition of sexual assault, as some believe that sexual relations between teachers and students are appropriate as long as the children have consented. [6] Although most schools have strict policies against sexual abuse, children are often hesitant to accuse adults of wrongdoing, and many 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, condom use during marital sex is still viewed as inappropriate by many Malawians; in 2000, only 2.3% of people reported using condoms regularly during sexual intercourse with their spouses. [4] Some people believe that condoms are only necessary during sex with high-risk partners such as sex workers, and that condom use during marital sex implies infidelity. [4] Others believe that marital condom use violates the religious purposes of marriage: sexual pleasure and reproduction. [4] In a study published in 2007 by Agnes M. Chimbiri, men claimed that they use condoms with their wives for the sake of avoiding unwanted pregnancies; on the other hand, they were more concerned about 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. [13] 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. [13] 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. [13]

Economic impact

Farmers with composting materials in Malawi Composting in Malawi.jpg
Farmers with composting materials in Malawi

A 2002 study conducted by CARE International across three districts in the Central Region of Malawi considers how HIV/AIDS has affected economic well-being in rural Malawi. [14] When skilled laborers are infected with HIV, they are usually unable to work; therefore, they often shift agricultural production on their land to less labor-intensive crops, sacrificing the opportunity to grow more profitable, labor-intensive crops such as tobacco. [15] When family members fall ill with HIV/AIDS, their relatives invest time in their treatment and care, further reducing household productivity. [14] 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. [14] 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. [15]

CARE International proposes several strategies that might reduce the destructive economic impact of HIV/AIDS on rural households. [14] They recommend introducing new technologies that improve productivity to allow households affected by HIV/AIDS to continue supporting themselves through agriculture. [14] Women in patrilineal/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. [14] 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. [14] 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. [14]

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. [16] However, Malawi currently faces a significant deficit in human resources: only 159 doctors were practicing in Malawi in 2007. [17] 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. [17]

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. [16] 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. [16]

Malawi has adopted task shifting strategies to overcome the shortage of workers available for HIV/AIDS treatment and care. [17] Task shifting, which has been successful in many other regions, involves training less specialized health workers to perform health-related tasks that do not require professional training, such as the initiation of antiretroviral therapy. [17] 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. [17] Another form of task shifting involves training health-oriented counselors in HIV testing and counseling, which relieves nurses of this additional task. [17]

Interventions

Malawi has taken many steps towards slowing the spread of HIV/AIDS, such as increasing access to condoms and improving testing services and treatment options. [1] Many of these efforts have been funded by international donors including 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). [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 World Health Organization'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. [16] The Lighthouse, a trust in Lilongwe that fights HIV/AIDS, provides antiretroviral drugs at a cost of 2,500 kwacha per month. [16] 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. [16] 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. [16] In addition, private providers are not currently required to obtain certification before selling antiretroviral drugs, and, therefore, this practice is not closely monitored. [16] Finally, some employees receive access to antiretroviral drugs through the health insurance policies provided by their employers, but this practice is not widespread. [16]

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. [16] For example, the South East region of Malawi has disproportionately low access to antiretroviral drugs. [1] In many rural areas, poor health infrastructure combined with widespread famine have made sustained, high-quality antiretroviral therapy difficult or impossible. [1] In addition, donations from the Global Fund to Fight AIDS, Tuberculosis, and Malaria were used to fund antiretroviral therapy programs that distributed medication on a "first-come, first-served" basis, making the drugs more accessible to the male, urban, educated population. [16] Because there are no explicit policies regarding the 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. [16]

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 Population Services International (Malawi), an organization that strives to improve the health of Malawians, and Banja La Mtsogolo, an organization that distributes information and resources related to family planning, have conducted campaigns advertising 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

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HIV/AIDS in Africa HIV/AIDS in Africa

HIV/AIDS is a major public health concern and cause of death in many parts of Africa. Although the continent is home to about 15.2 percent of the world's population, more than two-thirds of the total infected worldwide – some 35 million people – were Africans, of whom 15 million have already died. Sub-Saharan Africa alone accounted for an estimated 69 percent of all people living with HIV and 70 percent of all AIDS deaths in 2011. In the countries of sub-Saharan Africa most affected, AIDS has raised death rates and lowered life expectancy among adults between the ages of 20 and 49 by about twenty years. Furthermore, the life expectancy in many parts of Africa is declining, largely as a result of the HIV/AIDS epidemic with life-expectancy in some countries reaching as low as thirty-four years.

The Caribbean is the second-most affected region in the world in terms of HIV prevalence rates. Based on 2009 data, about 1.0 percent of the adult population is living with the disease, which is higher than any other region except Sub-Saharan Africa. Several factors influence this epidemic, including poverty, gender, sex tourism, and stigma. HIV incidence in the Caribbean declined 49% between 2001 and 2012. Different countries have employed a variety of responses to the disease, with a range of challenges and successes.

Abstinence, be faithful, use a condom, also known as the ABC strategy or abstinence-plus sex education, also known as abstinence-based sex education, is a sex education policy based on a combination of "risk avoidance" and harm reduction which modifies the approach of abstinence-only sex education by including education about the value of partner reduction safe sex and birth control methods. Abstinence-only sex education is strictly to promote the sexual abstinence until marriage, and does not teach about safe sex or contraceptives. The abstinence-based sex education program is meant to stress abstinence and include information on safe sex practices. In general terms, this strategy of sex education is a compromise between abstinence-only education and comprehensive sex education. The ABC approach was developed in response to the growing epidemic of HIV/AIDS in Africa, and to prevent the spread of other sexually transmitted diseases. This approach has been credited by some with the falling numbers of those infected with AIDS in Uganda, Kenya and Zimbabwe, among others. From 1990 to 2001 the percentage of Ugandans living with AIDS fell from 15% to between 5 and 6%. This fall is believed to result from the employment of the ABC approach, especially reduction in the number of sex partners, called "Zero-Grazing" in Uganda.

Since the first HIV/AIDS case in the Lao People's Democratic Republic (PDR) was identified in 1990, the number of infections has continued to grow. In 2005, UNAIDS estimated that 3,700 people in Lao PDR were living with HIV.

HIV/AIDS in Lesotho

HIV/AIDS in Lesotho constitutes a very serious threat to the Basotho people and Lesotho's economic development. Since its initial detection in 1986, HIV/AIDS has spread at alarming rates in Lesotho. In 2000, King Letsie III declared HIV/AIDS a natural disaster. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS) in 2016, Lesotho's adult prevalence rate of 25% is the second highest in the world, following Swaziland.

HIV/AIDS in Eswatini was first reported in 1986 but has since reached epidemic proportions. As of 2016, Eswatini has the highest prevalence of HIV among adults aged 15 to 49 in the world (27.2%). The HIV/AIDS epidemic in Eswatini, having contributed largely to high mortality rates among productive Swazi age groups. Over the long-term, the epidemic and its respondents induced major cultural changes surrounding local practices and ideas of death, dying, and illness, as well as an expansion of life insurance and mortuary service markets and health-related nongovernmental organizations.

HIV/AIDS in Mozambique

Mozambique is a country particularly hard-hit by the HIV/AIDS epidemic. In fact, according to 2008 UNAIDS estimates, this southeast African nation has the 8th highest HIV rate in the world. With 1,600,000 Mozambicans living with HIV, 990,000 of which are women and children, Mozambique's government realizes that much work must be done to eradicate this infectious disease. To reduce HIV/AIDS within the country, Mozambique has partnered with numerous global organizations to provide its citizens with augmented access to antiretroviral therapy and prevention techniques, such as condom use. A surge toward the treatment and prevention of HIV/AIDS in women and children has additionally aided in Mozambique's aim to fulfill its Millennium Development Goals (MDGs). Nevertheless, HIV/AIDS has made a drastic impact on Mozambique; individual risk behaviors are still greatly influenced by social norms, and much still needs to be done to address the epidemic and provide care and treatment to those in need.

HIV/AIDS in Namibia is a critical public health issue. HIV has been the leading cause of death in Namibia since 1996, but its prevalence has dropped by over 70 percent in the last 10 years(2006-2015). While the disease has declined in prevalence, Namibia still has some of the highest rates of HIV of any country in the world. In 2016, 13.8 percent of the adult population between the ages of 15 and 49 are infected with HIV. Namibia had been able to recover slightly from the peak of the AIDS epidemic in 2002. At the heart of the epidemic, AIDS caused the country's live expectancy to decline from 61 years in 1991 to 49 years in 2001. Since then, the life expectancy has rebounded with men living an average of 60 years and women living an average of 69 years

HIV/AIDS is considered the deadliest epidemic in the 21st century. It is transmitted through sex, intravenous drug use and mother-to-child transmission. Zambia is experiencing a generalized HIV/AIDS epidemic, with a national HIV prevalence rate of 17% among adults ages 15 to 49. Per the 2000 Zambian census, the people affected by HIV/AIDS constituted 15% of the total population, amounting to one million, of which 60% were women. The pandemic results in increased number of orphans, with an estimated 600,000 orphans in the country. It was prevalent more in urban areas compared to rural and among all provinces, Copperbelt Province and Lusaka Province had higher occurrence.

UNAIDS has said that HIV/AIDS in Indonesia is one of Asia's fastest growing epidemics. In 2010, it is expected that 5 million Indonesians will have HIV/AIDS. In 2007, Indonesia was ranked 99th in the world by prevalence rate, but because of low understanding of the symptoms of the disease and high social stigma attached to it, only 5-10% of HIV/AIDS sufferers actually get diagnosed and treated.

HIV/AIDS in Nepal

Nepal's first cases of HIV/AIDS were reported in 1988 and the disease has primarily been transmitted by intravenous drug use and unprotected sex. Among the two, HIV epidemic is largely attributed to sexual transmissions which account for more than 85% of the total new HIV infections.Available data indicate that there was a sharp increase in the number of new infections starting in 1996, coinciding with the outbreak of civil unrest. The infection rate of HIV/AIDS in Nepal among the adult population is estimated to be below the 1 percent threshold which is considered "generalized and severe". However, the prevalence rate masks a concentrated epidemic among at-risk populations such as female sex workers (FSWs), male sex workers (MSWs), injecting drug users (IDUs), men who have sex with men (MSM), Transgender Groups (TG), migrants and Male Labor Migrants(MLMs) as well as their spouses. Cultural factors have also been shown to play a significant role in the spread of HIV and AIDS in Nepal. Some of these cultural factors are related with social taboos which creates challenges for open discussions regarding sex and sexual habits, as do denial, stigma, and discrimination that surround HIV and AIDS. Other factors such as poverty, low levels of education and literacy, political instability combined with gender inequality make the tasks challenging.

Cases of HIV/AIDS in Peru are considered to have reached the level of a concentrated epidemic. According to a population-based survey conducted in Peru’s 24 largest cities in 2002, adult HIV prevalence was estimated to be less than 1 percent. The survey demonstrated that cases are unevenly distributed in the country, affecting mostly young people between the ages of 25 and 34. As of July 2010, the cumulative reported number of persons infected with HIV was 41,638, and there were 26,566 cases of AIDS, according to the Ministry of Health (MOH), and the male/female ratio for AIDS diagnoses in 2009 was 3.02 to 1. The Joint United Nations Program on HIV/AIDS (UNAIDS) estimates 76,000 Peruvians are HIV-positive, meaning that many people at risk do not know their status. There were 3,300 deaths due to AIDS in Peru in 2007, down from 5,600 deaths in 2005.

With less than 1 percent of the population estimated to be HIV-positive, Egypt is a low-HIV-prevalence country. However, between the years 2006 and 2011, HIV prevalence rates in Egypt increased tenfold. Until 2011, the average number of new cases of HIV in Egypt was 400 per year. But, in 2012 and 2013 it increased to about 600 new cases and in 2014 it reached 880 new cases per year. According to UNAIDS 2016 statistics, there are about 11,000 people currently living with HIV in Egypt. However, unsafe behaviors among most-at-risk populations and limited condom usage among the general population place Egypt at risk of a broader epidemic.

HIV/AIDS in Haiti

With an estimated 150,000 people living with HIV/AIDS in 2016, Haiti has the most overall cases of HIV/AIDS in the Caribbean and its HIV prevalence rates among the highest percentage-wise in the region. There are many risk factors groups for HIV infection in Haiti, with the most common ones including lower socioeconomic status, lower educational levels, risky behavior, and lower levels of awareness regarding HIV and its transmission. However, HIV prevalence in Haiti is largely dropping as a result of a strong AIDS/HIV educational program, support from non-governmental organizations and private donors, as well as a strong healthcare system supported by UNAIDS. Part of the success of Haiti's HIV healthcare system lies in the governmental commitment to the issue, which alongside the support of donations from the Global Fund and President's Emergency Plan For AIDS Relief (PEPFAR), allows the nation to prioritize the issue. Despite the extreme poverty afflicting a large Haitian population, the severe economic impact HIV has on the nation, and the controversy surrounding how the virus spread to Haiti and the United States, Haiti is on the path to provide universal treatment, with other developing nations emulating its AIDS treatment system.

Prevention of HIV/AIDS prevent and minimize the occurrence of HIV and AIDS

HIV prevention refers to practices that aim to prevent the spread of the Human Immunodeficiency Virus (HIV). HIV prevention practices may be undertaken by individuals to protect their own health and the health of those in their community, or may be instituted by governments or other organizations as public health policies.

Malawi ranks 170th out of 174 in the World Health Organization lifespan tables; 88% of the population live on less than £2.40 per day; and 50% are below the poverty line.

HIV/AIDS in South African townships

South Africa’s HIV/AIDS epidemic, which is among the most severe in the world, is concentrated in its townships, where many black South Africans live due to the lingering effects of the Group Areas Act. A 2010 study revealed that HIV/AIDS infection in South Africa is distinctly divided along racial lines: 13.6% of black Africans in South Africa are HIV-positive, whereas only 0.3% of whites living in South Africa have the disease.

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