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Malawi HIV and AIDS Monitoring and Evaluation Report 2005-2006 Estimated Population
based HIV prevalence
per Region
Acknowledgements
The National AIDS Commission (NAC) is grateful to the following organizations for providing data
used to compile this report; all CBOs that reported to district assemblies in the 2005-6 Financial
Year; NGOs, FBOs, public sector and private sector institutions that submitted reports to NAC,
and District Assemblies during the 2005-2006 Financial Year; District AIDS Coordinators and
numerous individuals that assisted in data abstraction from data source institutions, namely: Mr. J.
Ghobede (Population Services International) Mrs. Veronica Chirwa, Mr James Gondwe and Mr. J.
Zingeni (Ministry of Health, John Snow Incorporated Project); Mr. Chris Moyo and Mr. Naphini
(Ministry of Health, HMIS); Dr Felix Salaniponi (Ministry of Health, TB Control Programme); Mr
George Bello (Ministry of Health-CHSU); Dr. Eric Schouten (Ministry of Health, HIV Co-
ordinator); Professor Tony Harries (Ministry of Health, HIV and AIDS Unit), Tupochele Mtila and
Felistas Sibweza (Banja la Mtsogolo), Mrs Kanyuka and Mr. Derick Zanera (National Statistics
Office); Mr. Wellington Limbe and Mr Tapson Ndundu (Malawi AIDS Counselling and
Rehabilitation Organisation); Mr. D. Runganaikaloo (National AIDS Commission- Financial
Management Agency); HIV Sentinel Surveillance Technical Working Group; Dr Kalanda (MASAF);
National Health Accounts and HIV Resource Tracking Technical Working Group; and, the Malawi
Demographic and Health Survey Steering Committee,
The Commission extends its appreciation to Dr Biziwick Mwale (NAC Executive Director), Mr Roy Hauya (Director Policy and Programmes) and Mr Kaimvi (Director of Finance and Administration) for their leadership and moral support towards production of this report. The Commission is sincerely grateful to Mr Davie Kalomba (Acting Head of Planning, Monitoring, Evaluation and Research) and Mrs Chimwemwe Mablekisi (Planning Officer) for reviewing initial versions of this report and providing technical guidance accordingly. The commission further sincerely thanks Mrs Bridget Chibwana (Head of Behaviour Changes Interventions); Mr Christopher Teleka (Communications Officer) and Mr Blackson Matatiyo (Research Officer) for their technical input. Special thanks go to Mr John Chipeta (Monitoring and Evaluation Officer) and Mr Melachias Mwale (Data Management Officer) for data gathering, processing and compilation of this report. Executive Summary
1. HIV and AIDS profile
HIV prevalence
Estimates from the 2005 Sentinel Surveillance Survey indicated that 14% of Malawians aged 15 to 49
years were living with HIV and AIDS in 2005. The 2004 Malawi Demographic and Health Survey
(MDHS) revealed that HIV prevalence was 12% among persons aged 15 to 49 years in 2004. The
confidence interval of the MDHS prevalence point estimate overlaps with the range of the sentinel
surveillance point estimate. This illustrates that results from the two surveys are in agreement.
MDHS results are very useful in understanding HIV prevalence and associated factors. On the other
hand, sentinel surveillance results are handy in monitoring HIV prevalence trends.
Based on the Demographic and Health Survey (MDHS), HIV prevalence was higher among women (13%) compared to men (10%). At regional level, the Southern Region recorded the highest prevalence (18%) compared to Northern Region (8%) and Central Region (7%). HIV prevalence was higher in urban areas (17%) compared to rural areas (11%). HIV estimates and implications
About a million people were living with HIV and AIDS in Malawi in 2005. A total of 187,336
people were estimated to be in need of ART in 2005. By the end of 2010, about 233,675 persons
would be in need of ART. In 2005, about 87,000 people died of HIV and AIDS related illnesses.
These deaths resulted into another problem- orphan-hood. In 2005, Malawi was estimated to have
501,963 maternal/paternal and dual orphans as a direct result of AIDS deaths. Overall, the country
is estimated to have slightly over a million orphans.
As a result of AIDS key public sector institutions including health, education and home affairs are facing a huge human resource crisis. For example, there has been a high teacher attrition rate in the education sector between 1999 and 2005. Over 6,000 teachers are estimated to have died of HIV and AIDS related conditions in the specified period. 2. Impact of the HIV and AIDS National Response
The national response is having a positive impact on sexual behaviour. Implementation of the
National Strategic Framework 2000-2004 and partly the NAF 2005-2009 has yielded encouraging
results, notwithstanding various problems continuously counteracting gains in the fight against HIV
and AIDS. High levels of poverty, low literacy rate, gender imbalances and a wide range of social-
cultural issues undermine the national response.


Trends in behaviour change

Impact of the national response has been demonstrated by positive changes in sexual behaviour
between the year 2000 and 2004. Some of the indicators showing positive behaviour change in the
four-year period are; a decrease in proportion of men having sex with multiple partners from 33% to
12%, a tremendous decrease in the proportion of men paying for sex from 21% to 5%, and an
increase in the proportion of male youth using condoms at last high risk sex from 47% to 59%. It
was also interesting to note that age at sex debut has increased among youth aged 15-24 years. In the
same vein the proportion of youth aged 15-19 abstaining from sex increased over the four-year
period from 39% to 48% among boys and from 43% to 48% among girls. After stratifying
behaviour data by location it was observed that rural areas are still lagging behind in terms of
harmful sexual practices. Information on programme coverage clearly shows disparities in coverage
of intervention programmes with higher coverage rates in urban areas compared to rural areas.

Trends in STI prevalence

Positive changes in sexual behaviour have resulted into a decline of syphilis prevalence from 7% in
1996 to 2% in 2005, similarly prevalence of self-reported STI related conditions has gone down
from 2000 to 2005 among male youth.
Trends in HIV prevalence
HIV prevalence is declining in urban areas of the country. Prevalence among antenatal clinic attendees aged 20 to 24 years decreased from about 30% in 1999 to 16% in semi urban sites1, and from 25% to 19% in urban sites2. Prevalence is however stable in rural Central Region and rural Southern Region, and increasing in rural Northern Region. Stigma and discrimination
There is no concrete evidence of reduction in stigma and discrimination. Stigma and discrimination are still widespread in various settings of the Malawi society. Only about 30% persons aged 15-49 years expressed accepting attitudes towards people living with AIDS (PLWA) in 2004. Such high levels of stigma negatively affect access to HIV and AIDS services, especially counseling and testing, PMTCT and ART among others. 3. Prevention and Social Mobilization

Communications and social mobilization

Knowledge on HIV and AIDS is lower in rural areas compared to urban areas, higher in Southern
Region compared to the other two Regions and lower among women compared to men.
Communications materials were distributed equitably in all the regions, however mass media was
more accessible in urban areas compared to rural areas. The 2005-20066 HIV and AIDS Integrated
Annual Work Plan (IAWP) milestones for mass media and communications were achieved.
1 District hospitals 2 Health facilities in the 3 cities of Malawi However the milestone for life skills based HIV and AIDS education exposure to youth (1.5 million) was not accomplished. About 914,622 youth were reached with HIV and AIDS education programmes. HIV counseling and testing (HCT) and PMTCT (prevention of mother to child transmission) The 2005-2006 IAWP milestone of reaching 350,000 persons with counseling and testing programmes was reached. It is encouraging to note that there is no sex difference in proportions of persons were counseled and tested in the 2005-2006 financial year. It is worrisome however, to note that persons living in urban areas were 2 times more likely to access HCT than rural counter parts. HCT and PMTCT were equitably provided across all the three regions of the country. The 2005-2006 IAWP milestone of reaching 35% HIV positive pregnant women with PMTCT prophylaxis was far from being met, only 5% of HIV positive pregnant women accessed Nevirapine. Worse still, PMTCT is offered largely in district and central hospitals. This implies that rural masses are at a bigger disadvantage in accessing PMTCT services compared to women residing in urban areas. Looking at regional distribution access to PMTCT was much better in central region and worst in Southern Region. Condom distribution The 2005-2006 IAWP milestone was almost reached; roughly 27 million condoms were distributed in 2005. Condoms were equitably distributed in all the three regions of the country. Information from Populations Services International (PSI), Banja La Mtsogolo (BLM) and Ministry of Health (MOH) indicate that condoms were distributed in all the districts in the country. Reaching vulnerable populations Dialogue sessions were initiated with sex workers and owners of entertainment places in Blantyre, Lilongwe, Mzuzu, Mwanza, Karonga, Mulanje in the reporting period. Video shows are being used as an entry point for dialogue. This programme is expected to expand to busy points in all districts. BLM is supporting work place programmes in the transport sector to assist institutions and firms with condom distribution to Truck Drivers. Communications materials including vehicle stickers are provided. NAC is also working with Ministry of information (RPU) and World Vision International to promote community dialogue with fishing communities. Human Rights Campaigns The Centre for Human Rights and Rehabilitation was engaged to conduct community sensitization campaigns in all cities and some districts in the reporting period. The organization has also conducted sensitization meetings on stigma and discrimination with PLWAS organisations and support groups, including PLWA umbrella bodies, that is, NAPHAM and MANET. Gender issues
Information from the Education Management Information System indicates that significant
numbers of girls are dropping out of primary school due to early marriages and pregnancies. Girls
are more vulnerable to early marriages and pregnancies in the Northern Region and Southern
Region of the country.
Women were economically empowered through FINCA and other small scale lending institutions.
Various women groups have been economically empowered to do some small business in order to
avoid them from joining sex work, through district and city assemblies.

4. HIV and AIDS Treatment, Care and Support

ART scale up
The ART programme is progressing very well. The only shortfall is the lower proportion (6%) of
children aged 0-14 years receiving ART. About 25% of those in need of ART are children age
between 0 to 14 years. Efforts are underway, however, to roll out paediatric ART. Another challenge
in ART scaling up is reaching out to rural areas. Due to human resource crisis most clinicians trained
in ART are based in hospitals, as a result peripheral health facilities, which already have shortage of
clinical staff have no capacity to run ART programmes.
TB Control Programme This programme is running very well as evidenced by sustained high cure rate in all the districts. Evaluation of a cohort of smear positive TB cases in 2005 revealed a 76% cure rate. The target of achieving a 75% cure rate was met. It is also encouraging to note that TB case fatality rate decreased from 19% in 2003 to 15% in 2005. Community Home Based Care and Support
Over 181 thousand households that are caring for chronically ill patients received external assistance.
This figure surpasses the milestone set in the 2005-2006 IAWP. Despite high levels of stigma and
discrimination, 18,000 chronically ill patients enrolled with PLWA organizations and support groups
in the reporting period. Again, this figure exceeds the milestone set in the 2005-2006 IAWP.
STI and OI drug stocks
Milestones for STI and OI drug stock outs were not achieved. Large proportions of health centers
and hospital had stock outs of various essential STI and OI drugs. The medical supply chain
management system needs to be strengthened especially in the areas of coordination, networking
and procurement.


5. HIV and AIDS Impact Mitigation

Orphans
About 359 thousand orphans were provided with some kind of support in the 2005-2006 Financial
Year, exceeding a target of 120 thousand orphans. The number of organizations caring for orphans
has also increased. By June 2006, six hundred community based organizations received support from
the NAC Grants Facility alone.
6. Mainstreaming and Capacity Building

The number of public and private institutions that have developed work place policies has increased.
The 2005-6 milestone of ensuring that at least 55% large private companies and 80% public
institutions was more or less reached. By June 2006 about 65% of large private companies and about
72% of public institutions had work place policies. To ensure that work place programmes are
effectively implemented HIV and AIDS coordinators in all sectors were trained. In addition HIV
and AIDS mainstreaming committees were set up in all sectors. After all these efforts it is expected
that more employees and spouses will be reached with work place programmes at both national and
district level. In 2005-6 Financial Year only about 50 thousand employees were reached with work
place programmes.
7. Programme Management
Malawi has put in place adequate structures for coordination and implementation of the national response. The country has a sound HIV policy and a comprehensive action framework (NAF) for guiding programme implementation. Financial resources have been mobilized from multilateral and bilateral donors for managing the national response. By June 2006, NAC had disbursed roughly MK4.5 billion. The Malawi Government also contributes towards HIV and AIDS pool funds. Although the contribution has been increasing in the past 2 years, the proportion coming from the Government is still too low. Government contribution towards funding for HIV and AIDS programmes need to increase for sustainability and predictability of programme financing. In the 2004-2005 financial year the Government contributed only 20% towards HIV and AIDS funding. Donors contributed 73%. 8. Research, Monitoring, and Evaluation
The country has a functional HIV and AIDS monitoring and evaluation system, which includes routine Monitoring and Evaluation, national level participatory bi-annual reviews, participatory annual reviews and independent evaluations. The M&E system is complemented by research studies earmarked in the HIV and AIDS Research Strategy. Studies have been conducted to determine HIV prevalence levels and to understand trends in behaviour and practices at national level. Efforts are currently underway to devolve research and M&E responsibilities to the local level. Successes
1. Noticeable decline in HIV prevalence in some urban areas as evidenced by a decline in prevalence among young pregnant women aged 15-24 years. This finding is complemented with evidence of positive behaviour change in urban areas. 2. Remarkable decline in STI prevalence especially in men. Based on self-reported signs and symptoms of STI, the DHS has also revealed a decline in STI prevalence among male youth from 2000 to 2004. Syphilis prevalence among pregnant women has declined since 2001. 3. Positive changes in sexual behaviour. Primary abstinence among adolescents and youth aged 15-
19 years has increased. Proportions of married men engaging in high-risk sex and those having sex with multiple partners have decreased. The proportion of sexually active persons using a condom at last high-risk sex has increased significantly. The proportion of men paying for sex has drastically gone down. 4. Sustained high awareness levels on HIV and AIDS. 5. Effective structures for coordination of the national response have been put in place. Major steps include establishment of the Malawi Interfaith AIDS Association, MBCA and engagement of the Department of the Human Resource Department in the fight against HIV and AIDS. 6. Successful mobilisation and effective management of resources from a wide-range of bilateral and multilateral donors. 7. Significant increase in coverage of HIV counseling and testing and ART services. 8. Sustained high TB cure rate since 2002. Challenges
There is no evidence of HIV prevalence decline in rural areas. The prevalence and occurrence of new infections remain highest in rural Southern Region, and increasing in rural Northern Region. Gaps in behaviour change still exist for instance condom use at last high-risk sex remains relatively low in rural areas compared to urban areas, and in Southern Region compared to the other two regions. Stigma and discrimination are still widespread in Malawi. Nationally, PMTCT coverage is still very low. Programme coverage remains lower in rural areas compared to urban areas. Such programmes include HIV counseling and testing, ART, mass media and condom distribution. Decentralised district-based responses that are truly multi-sector are not yet fully-fledged. Mechanisms are not yet in place to mobilize resources locally to support and sustain a rapidly expanding response. The number of months taken to process HIV and AIDS grants proposals are still very high to entice would be a grant applicant. Lack of legal mandate at national and district assembly levels to enforce reporting by partners. Major Recommendations
Following the experience that has been gained and lessons learnt in the areas of programme planning, implementation, coordination, monitoring and evaluation of HIV and AIDS activities through implementation of the NSF and NAF, it is recommended that the following should be implemented: - 1. Conduct studies to under stand social-cultural and social-economic issues influencing the spread of HIV in rural and urban areas at all level. 2. Scale up implementation of targeted and evidence based preventive and behaviour change 3. Evaluate the impact of existing youth programmes including life skills education, and consequently roll out implementation of evidence based youth friendly programmes. 4. Support the health sector to beef up its human resource base to effectively scale-up biomedical HIV interventions in rural areas. 5. Decentralise the HIV and AIDS Grants facility system 6. Explore mechanisms for mobilizing financial resources locally. 7. Enhance capacity building efforts at district level to effectively manage HIV and AIDS interventions based on local data. 8. Establish legal requirements for all implementing agencies of HIV and AIDS activities to report to district assemblies, in a timely manner, using harmonised formats, to ease consolidation of data at national level. Glossary of Terms
African Development Fund Acquired Immune Deficiency Syndrome Ante-natal Clinic Anti-retroviral Therapy Anti-retroviral (drugs) Behavioural Change Intervention Banja La Mtsogolo Behavioural Surveillance Survey Community Based Organisation Christian Hospital Association of Malawi Community Health Sciences Unit Central Medical Stores Counseling and Testing Core Welfare Indicator Questionnaire District AIDS Coordinator District AIDS Coordinating Committee Demographic and Health Survey Education Methods Advisory Services Estimation and Projection Package Faith Based Organisation Financial Management Agency Global Monitoring and Evaluation Team Gross Domestic Product Global Fund to fight AIDS, Tuberculosis, and Malaria Gross National Income Government of Malawi Human Development Index Human Immunodeficiency Virus Health Management Information System Highly Indebted Poor Countries Head of Planning, Monitoring & Evaluation at NAC Health Technical Services Integrated Annual Work Plan International Development Agency International Monetary Fund Information Technology John Snow Incorporated Logistics Management Information System Life Skills Education Malawi AIDS Counseling and Rehabilitation Organisation Malawi Social Action Fund Monitoring and Evaluation Malawi Business Coalition Against AIDS Monitoring and Evaluation Information Systems Maternal Mortality Rate Ministry of Education, Science, and Technology Ministry of Gender and Community Services Ministry of Health and Population Ministry of Labour and Vocational Training Multi-sector Policy Advisory Committee Medium Term Plan Médecins sans Frontières Malawi National AIDS Commission National AIDS Commission Activity Report System National AIDS Control Programme National Composite Policy Index Non-governmental Organisation National Strategic Framework National Statistics Office National Blood Transfusion Service Opportunistic Infection Office of the President and Cabinet Other Recurrent Transactions Orphans and Vulnerable Children Persons Living With HIV and AIDS Prevention of Mother-to-Child Transmission Population Services International Quarterly Service Coverage Report Southern African Development Community Strategic Management Plan Sexually Transmitted Disease Sexually Transmitted Infection Malawi Technical Working Group on HIV and AIDS Joint United Nations Programme on HIV and AIDS United Nations Children's Fund United Nations General Assembly Special Session on HIV and AIDS United States Agency for International Development Venereal Diseases Reference Laboratory World Food Programme World Health Organisation Malawi Logistics System Assessment and Stock Status report Table of contents
Introduction
Geography and Population Education Profile Impact of HIV and AIDS Impact of HIV and AIDS National Response
Trends in behaviour change School attendance among orphans Conclusion on the National Response Prevention and Social mobilisation
HIV and AIDS Communications Promotion of safer sex HIV counseling and Testing Prevention of Mother to Child Transmission STI case management Vulnerability of young girls HIV and AIDS Treatment Care and Support
Antiretroviral Therapy STI,OI and ARV stock-outs Care and Support programs Summary and conclusion on treatment care and support HIV and AIDS impact mitigation
Care orphans and vulnerable children Mainstreaming and capacity building
Summary on Mainstreaming and capacity building Program management Research and Monitoring and Evaluation
National Policy Coordination and Programme Planning Resource Mobilization and Utilization Research Monitoring and Evaluation Summary of Key Successes and Challenges
Major Recommendations List of Tables
Table 1: National HIV Prevalence (%)
Table 2: HIV Prevalence (%) among young persons aged 15 to 24 years Table 3: Proportion of Young People (15-24 years) who Correctly Identify Ways of Preventing HIV and Reject Misconceptions Table 4: Media HIV and AIDS radio / television programmes produced and number of minutes aired Table 5.1-5.3: HIV and AIDS brochures/booklets distributed Table 6: Proportion of Teachers Trained in Life Skills Education Table 7.1-7.3: Numbers of Young People Aged 15-24 Years Exposed to Life Skills Based Education Table 8: Government Free condoms dispensed from January to December 2005 Table 9: Number of PSI condoms distributed to various out lets (retail shops, clinics etc) Table 10: Number and percentage of persons accessing VCT services by Sex and Region and Sex from July 2005 to June 2006 Table 11: Primary school girls dropping out of school due to marriage and pregnancy Table 12: Number of households receiving external assistance to care for adults who have been chronically ill for 3 or more months by type of assistance, Jun05-Jul 06 Table 13.1-13.2: community home based care visits Table 14: Number of Orphans and other vulnerable children receiving external assistance Table 15: Reach of HIV and AIDS Workplace Interventions to Employees and their Spouses Table 16: Project Staff and Volunteers Trained in HIV and AIDS Related Issues List of Figures
Figure 1: HIV Prevalence Trend Among Young Pregnant Women Aged 15-24 years
Figure 2. Trend of new HIV infections (prevalence) among young women aged 20-24 years
Figure 3: HIV prevalence among pregnant women in urban sentinel sites by Region
Figure 4. HIV prevalence among pregnant women in rural sentinel sites by Region
Figure 5: Percentage of clients testing HIV positive in integrated and stand alone HIV testing sites
Figure 6: Prevalence of Syphilis among Sentinel Pregnant Women from 1995 to 2005
Figure 7: Percentage of men reporting abnormal genital discharge
Figure 8: Percentage of young men and women self reporting having an STI/or discharge or genital ulcer
Figure 9: Percentage who never had intercourse among adolescents and youth aged 15-19
Figure 10: Trends of condom use at last high-risk sex, among women aged 15-49 years by location
Figure 11:Trends of condom use at high-risk sex among sexually active men by location
Figure 12: Distribution of IEC materials by Region, January 2005-June 2006
Figure 13: Exposure to life skills education
Figure 14: Number of Facilities Offering VCT Services*
Figure 15: Proportion of persons undergone an HIV test in the general population in the past 12 months by sex and
year
Figure 16.1 Distribution of Female VCT clients by Age July 2005 to June 2006
Figure 16.2 Distribution of Male VCT clients by Age July 2005 to June 2006
Figure 17: Proportion of Women on Nevirapine and Number of PMTCT sites by year
Figure 18: Percentage of Hospitals that experienced a stock-out of STI/OI drugs in the last 6 months
Figure 19: Percentage of health centers that experienced a stock-out of STI/OI drugs in the last 6 months
Figure 20: Trends in types of assistance between Jan 05 and June 06
Figure 21 PLWA by Sex and Age, Jul 05 to June 06
Figure 22: Types of Assistance Given to Orphans, Jul 05 to Jun 06
Figure 23.1: Number of orphans in primary schools in Malawi, 2005
Figure 23.2 Number of non-orphan pupils in primary schools in Malawi 2005
Figure 24: Proportion of Funds Disbursed by Type of Intervention 2005-6

Introduction
HIV and AIDS have become a serious socio-economic and public health problem threatening the human race especially in sub-Saharan Africa. The joint UN Committee on HIV and AIDS (UNAIDS, 2006) indicates that 64% (24.5 million) of all people living with HIV in the world are from sub-Saharan Africa. Almost nine in ten children (younger than 15 years) living with HIV are in sub-Saharan Africa. Malawi is located in Southern Africa a region worst hit by the HIV epidemic in sub-Saharan Africa. Heterosexual contact is the major mode of HIV transmission in Malawi. However, parent-to-child transmission accounts for about 25% of new HIV infections. The spread of HIV and the impact of AIDS are influenced by local socio-economic, demographic and cultural factors. These factors determine people's behaviour regarding HIV prevention, seeking health care and support services and their attitude towards those infected and affected with HIV and AIDS. Furthermore, these factors determine the extent and quality of response by various authorities and communities to the HIV epidemic. This chapter discusses in brief the socio-economic, cultural and demographic environment in which HIV is occurring. The chapter also outlines broad challenges the country is facing in its efforts to address the HIV and AIDS epidemic and its implications. 1.1. Geography and Population
Malawi is a landlocked country south of the equator in the south-eastern tip of Africa. The
population of Malawi was estimated at 12,757,883 in 2006 (NSO Projections Report 1999-2023).
The population is largely young, with 43.6% aged between 0 to 14 years and 46.7% aged 15 to 49
years. Between 2000 and 2004, the estimated annual population growth has been 2.25% (United
Nations Population Database). Geographically, the country is divided into three regions: the Northern,
Central, and Southern regions, whose population is 12.4%, 40.9%, and 46.6%, respectively.
According to the 1998 census, the male to female ratio is estimated to be 51:49. The vast majority of
Malawi's population ( 85%) resides in rural areas.
1.2. The Economy
Malawi is one of the poorest countries in the world. The country ranked 161 out of 174 on the Human Development Index (HDI) in 2000. In 2003, Malawi's Gross National Income (GNI) per capita was US$160, which was 6th from the bottom among 207 countries worldwide, and well below the average for sub-Saharan Africa (GNI per capita of US$500). Over 65% of the population live below the poverty line (<US$1 per day expenditure on basic needs), the proportion being higher among rural residents (66.5%) than urban residents (54.9%). The proportion of poor households is higher in the Southern Region (68.1%) than in the Central and Northern Regions (62.8% and 62.5%, respectively). In addition to this poor economic index, income is unevenly distributed, with a heavy bias towards rich individuals. The richest 20% of the population consume 46.3% of total goods and services, while the poorest 20% consume 6.3% (Gini coefficient of 0.52 in urban areas and 0.37 in rural areas. This poor economic standing has serious implications on the HIV epidemic. Malawi's economy is highly reliant on agriculture, which accounts for about 90% of its export earnings and 45% of its Gross Domestic Product (GDP). Since 2000, the economy has been adversely affected by shortages in rainfall causing severe droughts, especially in the 2001-02 and 2004-05 agricultural seasons. Due to Malawi's low GNI, its national budget is highly reliant on donor aid. Donors finance as much as 40% of the total budget and 80% of the development budget. Ultimately, the unfavourable macro-economic environment hampers government's expenditures on social services such as health and education. 1.3. Education Profile
In 2002, the literacy rates among people aged 15 and above were 79% for males and 46% for females (DHS EdData Survey, 2002). The literacy rates were worse in rural than in urban areas: 77% vs. 99% for males and 42% vs. 72% for females. Despite the government's introduction of free primary school education in 1994, the primary school completion rate in 2003 was estimated at only 41%, and the rate of absenteeism was estimated at an average of 17 days per student per year (Education Statistics, 2003). Furthermore, of the 2 million youths eligible for secondary education, only 172,108 (8.6%) were enrolled in government schools in 2005. In general, females were more likely to drop out of school than males. Apart from gender, reasons for high absenteeism and dropout rates in primary schools include poverty and hunger. The low enrolment in secondary schools is partly due to low government investment in the education sector and sub-optimal management of resources. 1.4. Gender Issues
Girls-to-boys ratio in schools: The ratio of females to males in the lower primary school grades (1 to 3) is nearly 50:50. However, from grades 4 to 8 the ratio begins to drop. In secondary school the male:female ratio is estimated at 72:28, while in university it is estimated to be 74:26. Reasons for the high dropout of girls include pregnancies, early marriages, and the need for household labour, especially in the face of widespread poverty and disease. Ultimately, women's lower educational levels are related to lower work force participation and decreased earnings, and thus poor economic independence. This situation increases women's dependence on men. Proportion of female legislators A study by Kakhongwe (2005) regarding representation of women in Malawi's parliament shows some improvement in the proportion of women in the chamber from 5.7% (n=10) in 1994 to 8.9% (n=17) in 1999 to 14.4% (n=27) in 2004. In spite of the increase, women's representation still falls far short of the recommended 30% in the SADC region. 1.5. Health Profile
Morbidity and Mortality The majority of the causes of morbidity and mortality in Malawi are preventable or curable. In children, infectious diseases such as malaria, pneumonia, and diarrhoea are the major contributors to morbidity and mortality. In pregnant women, the major causes of death are bleeding before or soon after delivery (pre- and postpartum haemorrhage) and reproductive system infections, which develop after delivery (puerperal sepsis). In the most productive age group (20-49 years), HIV and AIDS is prevalent and is currently the leading cause of mortality. As a result of the HIV epidemic, tuberculosis (TB) has become an important direct cause of morbidity and mortality in this age group. The number of reported TB cases increased at least five-fold in the last 20 years, from 4,863 in 1984 to 26,375 in 2004 (Malawi National TB Control Programme). The major underlying causes of the poor health indicators include widespread poverty, chronic malnutrition, low education status, poor sanitation, poor access to safe water, and inadequate capacity of the health care system to deliver quality and accessible health services. Life expectancy at birth in Malawi has fallen sharply over the past decade; it was estimated at 36.3 years in 2004 compared to around 42 in 1994. This decline has largely been attributed to the HIV and AIDS epidemic. The Malawi Demographic Health Survey (MDHS), however, show that, in the period 2000-04, the under-five mortality rate was 133 per 1000 live births while the infant mortality rate was 76 per 1000 live births, figures which are substantially lower than those reported in preceding years. The under-five mortality rates were 190 and 187 per 1000 live births in the periods 1990-1994 and 1995-1999, respectively. The corresponding figures for infant mortality rates in these years were 104 and 112 respectively. Despite this recent improvement, Malawi's under-five and infant mortality rates remain among the poorest in sub-Saharan Africa and worldwide. The maternal mortality ratio (MMR) in Malawi rose sharply from 620 to 1120 per 100,000 live births from 1992 to 2000. In 2004, MDHS estimated MMR at 984 deaths per 100,000 live births. Malawi remains one of the countries with the highest MMR in the world. Malnutrition Malnutrition is a serious problem among children in Malawi. The rates of malnutrition or stunting (restriction in growth due to chronic under-nutrition) among under-five children have remained constant since 2001. Preliminary data (MDHS, 2004) indicate that 48% of under-five children were malnourished/stunted as compared to 49% in 2001. Recurrent food shortages due to poor rains and the low education status of rural communities are among the major reasons for the persistent malnutrition problem. Malnutrition increases children's susceptibility to a host of infectious diseases, as well as stunting intellectual growth. 1.6. The Impact of HIV and AIDS
HIV and AIDS profile About a million people are living with HIV and AIDS (estimated range 780,000-1,120,000). A total of 187,336 people are in need of ART and by the end of 2010 233,675 would be in need of ART. In 2005 about 87,000 people died of HIV and AIDS related illnesses. These deaths result into another problem of orphan-hood. In 2005 Malawi was estimated to have 501,963 maternal/paternal and dual orphans as a direct result of their parents death due to AIDS. Household level medical expenditures Medical expenditure and transport costs make up a large share of the household budget for those affected by HIV/AIDS-related illness. Malawian households pay a large share of the health bill, i.e. 26 per cent in 98/99. The National Health Accounts from 2001 showed that the average individual (not household) health care expenditure (in prices of March 2000) was US$ 3.7. This cost is expected to be substantially higher for HIV/AIDS-affected households. The 2005 NHA revealed that households' direct out of pocket spending by PLWA was the major financing agent of HIV and AIDS resources in the country accounting for 29% in 2003/2004 and 35% in 2004/2005. In a survey conducted by the Afro barometer in 2004 (across fifteen countries in East and Southern Africa), it was found that four in ten Malawians (43 per cent) spend more than five hours a day caring for sick household members. Differences between areas of residence are also found and rural people are more likely to bear the burden of illness and care for sick household members more especially because many urban-based individuals return to their rural birthplace during the chronic phase of AIDS Human resource crisis in the public sector Despite the substantial increase in the commitment and availability of financial resources from donors and government since the mid-1990s, delivery of health services is currently hampered by the lack of skilled health workers, particularly in peripheral health facilities, which provide basic health services to rural populations. A health facility survey (JICA & MOH) conducted in 2002 showed that of the 26 districts in Malawi, 15 ( 60%) had less than 1.5 nurses per health center, while 5 ( 20%) had less 1 nurse per health center. Furthermore, the survey showed that of the 26 districts, 10 had no doctor in the government district hospitals and four had no doctor at all. On average, Malawi had a population-to-nurse ratio of 3500:1 and population-to-doctor ratio of 64,000:1. These statistics were far worse than those from Malawi's neighbouring countries. The Ministry of Health currently estimates that the vacancy rates for doctors, nurses, and laboratory technicians in the public health sector range from 44% to 68%. In addition to the above-mentioned shortages, the vacancy rates for specialist doctors (surgeons, obstetricians / gynecologists, physicians, pediatricians, pathologists, etc.) in the public health sector range from 71% to 100%. In an effort to resolve the human resource crisis, in 2004, the Ministry of Health (MOH), with the support of its development partners, put together a plan called ‘The 6-Year Emergency Human Resources Relief Programme [EHRP].' This programme included the expansion of the capacity of health worker training institutions and the retention of health workers in the public sector, through improvements in their remuneration package and provision of incentives to health workers operating in underserved areas. By October 2005, this US$273 million programme had been fully funded. The education sector, like most other public sectors in Malawi, is facing a huge human resource crisis. With a total primary school enrolment of approximately 3.2 million in 2004, the qualified teacher-student ratio was estimated to be 1:83 (Education Statistics, 2005). A high teacher attrition rate due to HIV and AIDS-related deaths is one of the major reasons for this poor ratio. Between 1999 and 2005, it is estimated that over 6,000 teachers died of HIV and AIDS-related conditions. To improve the teacher-student ratio to the recommended ratio of 1:60, it is estimated that the education sector needs about 25,500 extra teachers in primary and secondary schools. Impact of the HIV and AIDS
2 National Response
This Chapter presents results on effectiveness and efficiency of the national response by looking at trends in HIV prevalence, STI prevalence and behaviour change. Major sources of data for information presented in this chapter are population-based surveys. The chapter highlights areas in which the national response has worked well and where it has not yielded expected results.
2.1 HIV Prevalence
Trends in HIV prevalence Malawi monitors HIV prevalence through ANC sentinel surveillance surveys. The history of HIV sero-prevalence surveys in Malawi dates back to 1985 when the first case of AIDS was confirmed and reported. It was not until 1994 that data was routinely collected from women attending antenatal clinics (ANC) in 19 urban and rural sites across the country. Since then, sentinel surveillance surveys have been conducted almost annually in all the 19 sentinel sites. Data on HIV prevalence among pregnant women attending ANC for the first time at the sentinel sites are used to estimate national prevalence using statistical modeling techniques. See results in Table 1. Estimates from the sentinel surveillance survey indicated that 14% (range 12%-17%) of Malawians aged 15 to 49 years were living with HIV and AIDS in 2005. A national population based HIV sero-survey; the DHS, estimated the prevalence at 12% (Confidence Interval 11%-13%). It is encouraging to note that the range of the sentinel surveillance point estimate, and the confidence intervals of the DHS point estimates overlap. This illustrates that results from the two methodologies are in accord. The demographic and Health Survey was conducted from October 2004 to end January 2005. HIV prevalence at national level was higher among women (13.3%) compared to men (10.2%). At regional level, the Southern Region recorded the highest prevalence of 17.6% compared to the Northern (8.1%) and Central (6.5%). HIV prevalence was found to be higher in urban areas (17.1%) compared to rural areas (10.8%). The same patterns have been demonstrated by sentinel surveillance surveys. Sero prevalence results from the DHS are only a baseline. The next MDHS will be conducted in 2008-9. Consequently DHS results can only be used to describe patterns of HIV prevalence and associated factors as of 2004. However sentinel surveillance results will always be handy in monitoring HIV prevalence trends. Table 1: National HIV Prevalence (%) 1995 1996 1998 1999 2001 2003 2005 HIV prevalence estimated from sentinel 13.8% 13.2% 16.2% 15.0% surveillance Prevalence among pregnant women aged 18.1 19.1 23.1 17.1 18.3% 15-24 yrs Proportion of rural women in the sample 20.8% 23.2% 13.1% 16.6% 18.7% 21.0% 26.3% Figure 1: HIV Prevalence Trend (Median) Among Young Pregnant Women Aged 15-24 years Source: Sentinel Surveillance Reports Prevalence among pregnant women attending ANC services has gradually declined between 1999 and 2005. Infections in this age group are relatively new compared to those in older age groups. Prevalence would not decline due to deaths in this age group. Table 1 and Figure 1 show that prevalence has decreased among young women. The increase in the proportion of women from rural areas, where prevalence is relatively low, could possibly have an effect of lowering overall HIV prevalence. However, looking at prevalence trends among urban young women aged 20 to 24 years, in Figure 2, it is evident that occurrence of new infections is going down gradually in some urban and semi-urban areas of Malawi. Figure 3 shows prevalence trends among urban ANC attendees, aged 15-49 years by Region. The Figure shows a decline in prevalence among women in urban areas in all the 3 regions of Malawi. However, Figure 4 suggests an increase in prevalence among women in rural areas by region. There is an overall increase in prevalence in rural Northern Region of Malawi than rural Southern and rural Central Regions, which show stabilizing prevalence. This explains the general increase in prevalence among young women in rural areas as depicted in figure 2. Figure 2. Trend of new HIV infections (prevalence) among young women aged 20-24 years Figure 3: HIV prevalence among pregnant women in urban sentinel sites by Region Source: Sentinel Surveillance Reports Figure 4 further shows that HIV prevalence among pregnant women in rural south and central leveled off since 1999. On the other hand there is an overall increase in prevalence in rural northern region. Figure 4. HIV prevalence among pregnant women in rural sentinel sites by Region Figure 5 shows that the proportion of patients and clients testing HIV positive in MOH integrated testing sites has been decreasing since 2002. Likewise, there is a gradual decrease in HIV prevalence among clients going for VCT at MACRO. Prevalence results from testing and counseling need to be interpreted with care since they come from a self-selected population, which may be distinct from the general population. However with results from population based sample surveys available, these results could still be useful. A further limitation of results in Figure 5 is lack of disaggregation by sex, age and location; this may mask real trends on the ground. Figure 5: Percentage of clients testing HIV positive in integrated and stand alone HIV testing sites Source: Report of a Country Wide Survey of HIV/AIDS Services, MOH 2006 2.1.2 New HIV Infections
It is noteworthy that Malawi still has unacceptably high occurrence of new HIV cases, especially among young women as shown in Table 2. The high incidence rate is responsible for very high HIV prevalence in Southern Region and an increase in HIV prevalence in the Northern Region. It is vital to understand the characteristics of new HIV infections in the country. Currently, Malawi does not have molecular biology technologies for determining HIV incidence. However, knowledge of HIV prevalence among young people aged 15-24 years gives an indication of the magnitude of new infections because all people born with the virus, or those contracting it vertically from their mothers die by the age of 15 years. As a result HIV infections among people aged 15-24 are fairly new and the majority of them die with AIDS when they are older than 24 years. The Demographic and Health Survey provided an opportunity to understand the dynamics of the epidemic among young people in Malawi as shown in table 2. Table 2: HIV Prevalence (%) among young persons aged 15 to 24 years Background characteristics
Source: MDHS 2004 New infections are 4 times more likely to occur among women than among men nationally. New infection rates are above national average in Southern Region and urban areas, that is 8.8% and 7.2% respectively. Table 2 further shows that urban male youth are at a lower risk of infection (prevalence 0.3%) compared to their counterparts in rural areas (2.5%). Rural male youth are 8 times more likely to be infected compared to their urban counterparts. In contrast, prevalence among urban female youth (13.3%) is higher compared to that among rural female youth (8.2%). Differences in exposure between rural and urban areas are more pronounced among young men. It seems female youth in both rural and urban areas are highly vulnerable to HIV infection in comparison to male youth. The wider gap in prevalence between urban female and male youth is disturbing. This could suggest that in addition to social-cultural issues rendering women more vulnerable, other socio-economical issues inherent in urban areas are responsible for the wide gap in HIV prevalence levels. Summary on HIV prevalence and incidence
HIV prevalence is declining in some urban areas of the country and stable in rural Central and rural Southern Region. Prevalence is however increasing in rural Northern Region due to high occurrence of new infections among young girls. However it is alarming to note that there is no evidence of decline in rural areas, which constitute 85% of the Malawi population. Surveys have demonstrated that HIV prevalence is highest in Southern Region. High HIV prevalence among youth suggests that Malawi still has large numbers of new infections. This is enough evidence that overall, though behaviour is changing as presented in subsequent sections, behaviour has not changed enough to reverse the epidemic in rural areas. DHS sero-survey results show that male youth are at a lower risk of infection compared to female youth. 2.2 STI prevalence in Malawi

2.2.1 Estimates from ANC sentinel surveys
Malawi implements a syndromic management approach in treating STIs. As a result biomarker data on STI is unavailable in health facilities. Nevertheless, the Ministry of Health collects data on syphilis at sentinel sites. All women who are reactive on VDRL (Venereal Disease Reference Laboratory) tests are subjected to the Treponema Haemagglutination Assay (TPHA) test to confirm syphilis infection. Figure 6 shows the prevalence of syphilis from 1995 to 2005. Syphilis prevalence has declined from 4.2% in 1998 to 1.9% in 2005. According to the 2003 Sentinel Surveillance Survey, syphilis prevalence was highest in the Southern Region of the country at 4.3% compared to 2.3% and 1% in the Central and Northern Regions. In 2005 the same trend was observed, but over syphilis prevalence was very low (1.9%). Figure 6: Prevalence of Syphilis among Sentinel Pregnant Women from 1995 to 2005 Source: sentinel surveillance system 2.2.2 Self-reported Sexually transmitted infections and STI symptoms The 2000 and 2005 Malawi Demographic and Health Surveys collected information on self-reported prevalence of STIs among respondents. The respondents were asked whether they had had an STI (other than HIV) in the last 12 months. They were also asked whether they had experienced a genital sore or ulcer and whether they had had any genital discharge in the last 12 months. Figure 7: Percentage of men reporting abnormal genital discharge Source: MKAPH and DHS Figure 8: Percentage of young men and women self reporting having an STI/or discharge or genital ulcer Figure 7 shows a decline in prevalence of abnormal genital discharge among men in the period between 1996 and 2004. Similarly there was a decline of abnormal genital discharge prevalence among women from 4.8% in 2000 to 3.4%. Prevalence of self reported STI among young men were considerably lower in 2004 compared to 2000 as shown in Figure 8. The decline is however smaller among young women. DHS prevalence data for 2004 indicated that respondents reporting having STI related symptoms were 2 times more likely to be HIV positive than those reporting having no STI symptoms. This finding gives confidence in self reported STI symptoms. Summary on STI prevalence
Syphilis prevalence has declined since 2001. Based on self-reported signs and symptoms of STI the DHS has shown a decline in STI prevalence among male youth from 2000 to 2004. STI prevalence has not declined significantly among female youth. This result is in agreement with findings in the preceding section indicating that HIV prevalence is higher among young women. In addition the result is in agreement with results in subsequent sections of this report that indicate that condom use at high risk sex is lower among women compared to that among men. 2.3. Trends in Behaviour Change
Success in behaviour change is dependent on a number of factors, including the type and quality of information that is provided to the population, the means by which that information is disseminated, and social-economical, and socio-cultural factors. This section focuses on achievements that have been made with respect to levels of change in sexual behaviour and attitudes towards PLWAs. To reverse the spread of the HIV epidemic, the national responses has to excel in behaviour change interventions. In Malawi, nation-wide public education has been successful. HIV and AIDS awareness was almost universal (99%) in 2004. However, levels of misconceptions are still high among young persons aged 15-24 years. According to the 2004 MDHS, only 37% young men and 25% young women correctly identified major ways of preventing HIV and rejected major misconceptions. Major objectives for behaviour change interventions include promoting abstinence and delayed sex debut for young people, monogamy within relationships, reduction in the number of non-regular sex partners, correct and consistent condom use. Countries that have lowered HIV new infections have experienced reduced commercial sex transaction, as is the case for Cambodia and Thailand, delayed sex debut in Zimbabwe, increasing emphasis on monogamy in Uganda (UNAIDS 2006). In addition, countries that have lowered HIV incidence have witnessed an increase in condom use. Some of these characteristics have started emerging in Malawi. 2.3.1 Sexual Behaviour Median Age at sex debut There has been a modest increase in median age at sexual debut among people aged 20-24 years between 2000 and 2004: from 17.1 to 17.4 years among females and 17.7 to 18.1 years among males aged 20-24 years. Amongst urban young women aged 20-24 years median age at first sexual intercourse increased from 17.8 years in 2000 to 18.1 years in 2005, in the same vein the change was smaller in rural areas (17.0 to 17.2 years). Across the Regions, the Southern Region recorded minimal improvements in median age at first sexual intercourse, as compared to significant improvements in the Northern and Central Regions. Primary abstinence Figure 9 shows that there has been an increase in percentage of youth aged 15-19 years abstaining from sex. Levels of primary abstinence are not different between young men and women. Between 2000 and 2004 abstinence among young women aged 15 to 19 years increased from 42.7% to 47.8%. Similarly, there was an increase among males aged 15 to 19 years from 38.9 to 47.7%. Abstinence among young women significantly increased in urban areas and among those with secondary education and above. However, proportion of those abstaining remained stable in rural areas and among those with low education. Figure 9: Percentage who never had intercourse among youth aged 15-19 Sex with multiple partners (2 or more sexual partners) In 2004, the proportion of men having sex with two or more partners was highest in Northern (19.4%) and Central (12.4%) Regions compared to southern Region (9.5%). This practice was highest among men in rural areas (12.4%) compared to urban (9.7%) areas. Overall, proportion of men having sex with multiple partners has decreased from 33% in 2000 to about 12% in 2004. The decrease is so dramatic among male youth from 56% in 2000 to 13% in 2004. Similarly there is also a decrease among female youth aged 15-24, from 16.4% to 1.7% over the same period. Proportion of married men having sex with non-regular partners Malawian married men are steadily realizing the importance of fidelity in regular relationships. The proportion of married men and those in stable relationships (15-49 years) having sex with non-regular partners has also gone down from 17.5% in 2000 to 8.3% in 2004. The practice is so minimal (0.8%) among married women and has remained the same over the same period. Payment for sexual intercourse The 2000 and 2004 MDHS determined the proportion of men who paid for sexual intercourse. There has been a dramatic decline in proportions of men paying for sex from 20.5% in 2000 to 4.8% in 2004. However, the problem is that of those reporting paying for sex in 2004-2005. Only 42.5% reported using condoms in the past 12 months. In 2000 payment for sex was higher in urban areas (24.9%) compared to rural areas (19.6%) while in 2004 there was a reverse with higher percentage of men paying for sex in rural areas (5.5%) compared to urban (3.1%). This shows that behaviour has changed with a wider margin in urban areas. This partly explains why prevalence in declining in urban areas. Proportion of young people (15-24) reporting condom use at last high risk sex (sex with non regular partners) The proportion of male youth using condoms has increased from 46.9% in 2000 to 58.5% in 2004. Similarly, the proportion has increased from 32.6% to 35.6% among female youth. For young males, Malawi has reached condom use levels of Uganda (55%), one of the few countries that have reversed the HIV epidemic. Unlike for Uganda, Malawi has not experienced a significant increase in condom use among female youth, which is 53% in Uganda (UNAIDS Report). Proportion of people aged 15-49 years reporting condom use at last high risk sex (sex with non regular partners) Condom use during last sexual intercourse with a non-cohabiting partner was considerably low, 35.2% and 46.8% among sexually active females and males in 2004. Condom use at last high-risk sex also varied by location. Higher rates of condom use were reported among urban men 57.2% compared to rural men 43.5%. Similarly, higher rates of condom use were reported among urban women 43.7% compared to rural women 24.8%. Again this explains the HIV prevalence decline observed in urban areas. By and large, condom use at high-risk sex has been increasing between 1996 and 2004. It is critical to note, however, that condom use at last high-risk sex among women has slightly decreased in Southern and Northern Regions whereas it has increased in Central Regions as shown in Figure 10. On the other hand condom use has increased among men between 2000 and 2004 in all locations as shown in Figure 11. Of the three regions, the Southern Region had the lowest proportion of people using a condom during high-risk sex as shown in Figure 10 and 11. The difference is enormous among women whereby only 23.6% used a condom at high-risk sex compared to 39.0% in Central Region and 43.0% in Northern Region. Figure 10: Trends of condom use at last high risk sex, among women aged 15-49 years by location Figure 11:Trends of condom use at high-risk sex among sexually active men by location 2.3.2. Proportion of the population expressing accepting attitudes towards PLWHAs Stigma is a highly complex phenomenon noticeable in various spheres of life; be it in households, communities, workplaces, within individuals, in markets and many other settings. Stigma and discrimination have been associated with AIDS since the first AIDS case was identified in 1985. The 2004 MDHS collected information on attitudes towards people living with HIV and AIDS (PLWHAs)3. Only about 30% persons, 30.8% females and 29.7% males expressed accepting attitudes towards PLWHAs on all the four questions. These findings confirm that stigma is still rampant in the country despite massive campaigns aimed at curbing discrimination of AIDS patients, persons declaring their HIV positive status and orphans. The high level of stigma apparently affects access to services such as counseling and testing, PMTCT, ART and other health care and social services. People living with HIV and AIDS would find it difficult to reveal their status in such an environment. Consequently, only about 14% of sexually active Malawians have ever tested for HIV and extremely few are ready to declare their HIV status. Summary on behaviour change in Malawi

Primary abstinence among adolescents and youth aged 15-19 years has increased. Primary abstinence
was higher in urban areas and among youth with higher education. Proportions of married men
engaging in high-risk sex and those having sex with multiple partners have decreased. The
Proportion of sexually active persons using a condom at last high-risk sex has increased significantly.
It is also interesting to note that the proportion of men paying for sex has drastically gone down
overall but with a greater magnitude in urban areas.
Despite achievements highlighted above, condom use at last high risk sex remains relatively low in
rural areas compared to urban areas, and in Southern Region compared to the other two regions. In
general, there is little progress in behaviour change among women, in Southern Region and rural
areas. These findings match with HIV sero-survey results, which shows that new HIV infections are
higher among women than among men and higher in Southern Region compared to the other two
regions of Malawi. On the other hand the MDHS demonstrated that stigma and discrimination are
still rampant in Malawi.
Factors responsible for poor behaviour indicators in the Southern Region need to be investigated.
Similarly disparities in risk of infection between young men and women in urban areas and northern
region need to be probed. Factors behind positive behaviour change in central region need to be
explored and documented.
2.4. Ratio of current school attendance among orphans to that
among non-orphans

The 2004 MDHS collected information on school attendance among children aged 10-14 years in
Malawi. Out of 5,413 children with both parents alive (who were living with at least one of them),
90.2% were in school. School attendance rate among orphans (both parents dead) was 87.4%
3 Specifically, the respondents (both men and women) were asked whether they would care for a family member with HIV and AIDS at home; whether they would buy fresh vegetables for the patient; whether an HIV+ teacher should be allowed to teach; and whether they would want the sero-status of a HIV+ family member to remain a secret or not. Table 15, on the next page, provides an extract of the findings on this. (N=528). Ratio of school attendance among orphans (both parents dead) to that among non-
orphans increased from 0.94 in 2000 to 0.97 in 2004. Across the regions, the Southern Region had
the highest ratio (0.99), with the lowest ratio observed among children in the Northern Region
(0.93). High school attendance among orphans indicates willingness of the society to take
responsibility and reduced levels of discrimination against them. Information in chapter 5 shows no
differential drop out from primary schools between orphans and non-orphans.
2.5 Conclusion on the National Response Impact

The national response through the 2000-2004 NSF and 2005-2009 NAF is having a positive impact
on peoples' behaviour. Implementation of the NSF and NAF has yielded encouraging results
notwithstanding developments such as poverty, low literacy levels, gender imbalance, unemployment
and others as described in chapter 1; which have continuously counteracted gains in the fight against
HIV and AIDS. Positive impact of the national response has been demonstrated by a decrease in
proportion of men having sex with multiple partners and those paying for sex, an increase in
condom use among male youth, increment in age at sex debut and an increase in proportion of
youth aged 15-19 abstaining from sex. Changes in behaviour have resulted into a decline of syphilis
prevalence, self reported STI cases/signs/symptoms and HIV prevalence in urban areas. Positive
changes in behaviour among men in general could in a couple of years result in HIV prevalence
decline in rural Central Region.
Gray areas still remain and need urgent attention through evidence based targeted interventions. Programmes targeting young women have not yielded expected results. Investigations need to be done to understand barriers to adoption of safer sex practices among young females with a focus on social-cultural issues making women vulnerable in rural Southern and Northern Regions and socio-economical issues making women vulnerable in urban areas. Chapter 3 shows that HIV knowledge is highest in Southern Region and programme out put data shows that Southern Region was equally well covered with intervention programmes but still has relatively higher occurrence of HIV new infections and has poor behaviour indicators. This development suggests existence of underlying factors that need to be uncovered and addressed. Rural areas are still lagging behind in terms of harmful sexual practices. Programme data clearly show that coverage of preventive programmes is low in rural areas compared to urban areas. Local social-cultural issues could further compound this situation. The Universal Access Strategy needs to be capitalized as an entry point for scaling up intervention programmes in rural areas. Programmes have also failed to impact on stigma and discrimination, these are still widespread and are apparently negatively affecting access to preventive interventions such as counseling and testing and PMTCT among others. Prevention and Social
3 Mobilization
IAWP milestone: 1. 300 TV/Radio programmes produced by June 2006
2. 300,000 communications materials distributed by June 2006 3. 1,500,000 young people exposed to life skills based HIV and AIDS education by 4. 30,000,0000 condoms distributed by June 2006 Achievements: 1. 2,119 TV and Radio programmes were produced 2. 719,518 communications were distributed nation wide 3. 914,622 young people were exposed to life skills based HIV and AIDS education 4. About 26,000,000 condoms were distributed to out lets and end users 3.1. HIV and AIDS Communications
3.1.1 Knowledge of ways of preventing HIV and AIDS Almost all sexually active Malawians (99%) are aware that HIV is transmitted mainly through unprotected sexual intercourse. However, studies conducted in various parts of the country also point out that misconceptions about HIV transmission and prevention still exist. In the 2004 MDHS, respondents were asked whether they thought they could protect themselves from contracting HIV by having sex with only one faithful uninfected partner; whether they thought they can protect themselves from contracting HIV by having sex using condoms; whether a healthy-looking person can have HIV; and whether HIV can be transmitted through mosquito bites, or by working together or close to an HIV infected person. Table 4 presents an extract of the findings from 2004 MDHS. As may be seen, comprehensive knowledge of methods of HIV protection is still low among youth aged 15 to 24 years, despite being higher among males and in urban areas. About 37% of male youth had comprehensive knowledge, compared to 25% female youth. Huge differences were observed between young people in the urban and rural areas, with more rural dwellers lacking the knowledge. Across the regions, the Southern Region has a higher proportion of individuals with comprehensive knowledge of HIV prevention than the other two regions. Table 3: Proportion of Young People (15-24 years) who Correctly Identify Ways of Preventing HIV and Reject Misconceptions Background
Percentage of people aged 15-24 who correctly identify ways of
preventing HIV and reject misconceptions
Females Males
Northern Region
Central Region
Southern Region
Source: 2004 MDHS BSS also showed that comprehensive knowledge on HIV prevention is relatively low, even among well-educated adult Malawians that is male secondary teachers (45.3%) and primary school teachers (46.8%). Both BSS and DHS indicate that misconceptions of HIV prevention and transmission still exist in the general population. Malawi still needs to intensify general HIV and AIDS education by using innovative approaches befitting community level needs. Proportion of population exposed to media campaigns in last 30 days Various media are being used to disseminate information on HIV and AIDS in Malawi. The 2004 MDHS collected data regarding access to information on HIV and AIDS, and the radio was mentioned as by far the most common source of HIV and AIDS information, both in rural and urban areas. The results revealed that 80.3% males and 66.1% females had heard HIV and AIDS radio messages within 30 days prior to the interview day. The second most common source of information was the print media (magazines / newsletters / newspapers), as reported by male (33.2%) and female (14.8%) respondents. Television came third, being mentioned by 20.1% of male and 11.2% of female respondents. As expected, exposure to the media is consistently higher in urban areas than in rural areas. The gap in the source of media between urban and rural areas is wider for television and print media. For instance, 32.7% of the women in the urban areas and only 6.6% of the women in rural areas mentioned TV as a source of information. Regardless of the type of media source, exposure to HIV and AIDS messages is higher in males than in females. Communications materials There is only one television service provider (Television Malawi—TVM) and more than seven radio
stations in Malawi, all of which carry HIV and AIDS programmes/ advertisements/ slots/ jingles/
plays. Table 5 shows that radio and TV programmes are under continuous implementation. The
number of TV programmes produced and hours of TV programmes aired increased from January 2005 to June 2006. Table 4: Media HIV and AIDS radio / television programmes produced and number of minutes aired Jan – Jun 2005
Jul- Dec 2005
Jan-Jun 2006
Number of Programs Produced 365 36 1543 17 434 125 Number of Minutes Aired 1741 Source: ARS, NAC Enormous work has been done in producing and disseminating IEC materials (brochures/ booklets,
leaflets and magazines). Between January 2005 and June 2006 at least 340,000 communications
materials were distributed countrywide every six months. See Table 6. All districts were covered and
figure 12 shows that all the three Regions were roughly reached equitably according to their
population sizes. Overall the distribution of IEC materials and the status of reporting improved with
378,677 distributed between January and June 2006. In comparison, 276,539 IEC materials were
distributed nationwide in 2004, from January to December.
Table 5.1-5.3 HIV and AIDS brochures/booklets distributed Jul- Dec 05
Jan- Jun 06
Jan-Jun 05
Jul- Dec 05
Nkhotakota 3,744 Northern
District
Jan-Jun 05
Jul Dec 05
Jan Jun 06
Source: ARS, NAC Figure 12: Distribution of IEC materials by Region, January 2005-June 2006 Media and drama/theatre Recognizing the important role of the media and drama/theatre in the national response, 610 drama shows were conducted across the country by various drama groups including NAPHAM. The media was also very active to cover HIV and AIDS issues. Up to 648 articles were written and published. HIV and AIDS thematic areas covered included stigma and discrimination, gender, youth, leadership, prevention, treatment, care and support. Community dialogue, video shows, market campaigns, Advocacy and social mobilization Advocacy and mobilization activities were implemented through engagement of political and Government leadership. A World AIDS Campaign was held on 1st December 2005 in Blantyre with Minister of Health in attendance as guest of honour. District and community campaigns were held after the national event. The National Candlelight Memorial was commemorated in Ntchisi on 21st May 2006 where the Minister of Home Affairs and Internal Security was guest of honour. A national conference for PLHAs was also held in September 2005. Reaching vulnerable populations NAC has initiated dialogue session with sex workers and owners of entertainment places in Blantyre, Lilongwe, Mzuzu, Mwanza, Karonga, Mulanje. This programme is expected to expand to busy points in all districts nation wide. Video shows are being used as an entry point for dialogue. BLM is working with work place in the transport sector to assist them with condom distribution to Truck Drivers. Communications materials including stickers for vehicles are also provided. NAC is also working with Ministry of information (RPU) AND World Vision to promote community dialogue with fishing communities. The latter are also conducting mobile rural video screening programs. Human Rights Campaigns The Centre for Human Rights and Rehabilitation has been engaged to conduct community sensitization campaigns in all cities and some districts. The organization has also conducted sensitization meetings on stigma and discrimination with PLWHAS organisations and support groups including the umbrella bodies, NAPHAM and MANET. 3.1.2. Promotion of Safer Sex Practices Life Skills-Based HIV and AIDS Education In 2002, the proportion of schools with at least one teacher trained in life skills education was estimated at 6.0%. By 2005, it was estimated that all schools in Malawi had at least one teacher who had been exposed to Life Skills Education (LSE). About 41% and 11% primary and secondary school teachers respectively were trained in LSE in 2005. See table 7. The findings therefore suggest greater LSE training among teachers in primary schools than teachers in secondary schools. However there is no good methodology yet of establishing whether the subject is being taught and taught adequately. Table 6: Proportion of Teachers Trained in Life Skills Education
Category of teachers
Primary school teachers Secondary school teachers Source: Life Skills Study Report 2005, MOEST Presented in Table 8 are absolute figures of male and female youths (both in and out of school) who
have been exposed to life skills by community based organization and faith based organizations. It is
noteworthy that reporting rate declined between October and March 2005. This may mean that
some community based organizations did not train youth or did not report to DACs/NAC. In
general, there appears to be a decrease in the number of youths being exposed to life skills education
on HIV and AIDS except for Northern Region as shown in Table 8.
Some districts have been slow in training youths and in some cases, training has taken place but documentation and reporting have been inadequate. Efforts are currently under way to address the issue of underreporting and to ensure that more youths are exposed to LSE. Figure 13 shows that there is more or less equal coverage of male and female in-school and out-of-school youth. However, considering that female youth are four times more at risk of HIV infection than boys, one would conclude that female youth were not adequately targeted in the reporting period. Table 7.1-7.3: Numbers of Young People Aged 15-24 Years Exposed to Life Skills Based Education District Jan-Jun05
Jul-Dec 05
Jan-Jun06
District Jan-Jun05
05 Jan-Jun06
Nkhotakota 13,500 North 36,307
District Jan-Jun05 Jul-Dec
F igure 13: Exposure to life skils education
Chiradzulu 4,039 South 256,630
50000 100000 150000 200000 MALAWI 429,775
3.1.3. Distribution of Condoms In Malawi, condoms are distributed using various channels, including social marketing agencies such as Population Services International (PSI) and Banja la Mtsogolo (BLM), health facilities (government, mission, and private) and NGOs, either at their offices, through peer educators, or in clinics and other distribution points in their impact areas. This section presents aggregated figures of condoms that were distributed in 2005 in the various districts across the country by the various distribution channels. Statistics are presented in Tables 10 and 11. Distribution of free condoms to end-users and to various out lets was equitable in all the three regions of the country. Over 26,678,144 million condoms were distributed in 2005. Some districts did not report or underreported numbers of condoms distributed. For example, Zomba did not report number of free government condoms dispensed. Highly urbanized districts had more socially marketed condoms distributed than free government condoms. BSS 2004 and ARS data on condoms distributed to end-users also indicate that condoms are more accessible in urban areas compared to rural areas. Numbers of Condoms Distributed Table 8: Government Free condoms dispensed Table 9: Number of PSI condoms distributed to from January to December 2005 various out lets (retail shops, clinics etc) District Name
No of condoms
Region District distributed
Nkhota-kota 369900 Nkhotakota 126,396 3,081,100
2,642,778
Nkhata-Bay 320300 Nkhatabay 69,984 Northern Region
1,753,440
1,668,495
Chiradzulu 696085 Chiradzulu 102,816 South 4,661,855
Malawi 9,496,395
Sources: JSI Project, MOH South Total
4,541,676
PSI and BLM mainly distribute condoms in bulk to out lets such as clinics, retail shops, private and
public institutions as well as NGOs. MOH supply chain system supplies condoms directly to end
users in various points in health facilities. Each one of these systems has its challenges. Firstly
condoms distributed in bulk form BLM and PSI must be made available to end-users. Systems need
to be put in place to track the proportion of these distributed condoms reaching the end user.
Secondly, the free government condoms dispensed to end users in health facilities may not be
available to all clients. In some health centers, condoms are made available for family planning
purposes. In others they are made available to STI clients while other facilities use non-human
condom dispensers (i.e placing them in strategic places for people to serve themselves). Traditions
vary from one facility to another. Again mechanisms should be developed to make free government
condoms available to communities within health center catchment areas through HSAs.
In 2005 PSI and BLM distributed 8,852,949 and 8,328,800 condoms respectively. See table 11. At
least 17,181,749 socially marketed condoms were therefore distributed to outlets in 2005. In the
same period 9,496,395 free government condoms were dispensed to end-users. See table 10.
Efforts to distribute condoms to outlets and end users are ongoing; from January to June 2006 PSI
and BLM distributed 3,659,238 PSI and 1,312,292 condoms respectively. MOH through the supply
chain management systems dispensed 6,230,792 condoms. Therefore at least 11,202,322 condoms
were distributed in the first half of 2006. The figure may be lower due to under reporting.
3.2. HIV Counseling and Testing
Improving coverage of ethically sound HIV testing is one of the strategies of preventing the spread of HIV infection among Malawians. Counseling and testing is also an entry point for treatment care and support. Malawi has two models of counseling and testing service delivery, stand alone services provided by civil society and integrated services run by mostly government and CHAM health facilities. Both models are constrained by several challenges including inadequate infrastructure, human and financial resources and stock outs of test kits. Number and proportion of facilities offering CT services Malawi planned to have 190 operational VCT sites in the FY 2005-6. By the end of the financial year, 250 sites were functioning with over 1,000 counselors; about half of these work on part time basis. The sites vary considerably in size, organizational an institutional capacities and in quality. Each district in the country has at least a site offering HIV testing. From 2001 to 2006, there has been a steady increase in the number of sites offering HIV counseling and testing services, as illustrated in Figure 14. Almost 40% of the approximately 620 health facilities in Malawi were providing CT services as of June 2005. Of the 146 sites that were offering counseling and testing services in 2005, only 70 (48%) were located in rural areas. Considering that over 85% of Malawians reside in the rural areas, the provision of CT services has so far been biased towards the urban areas. The challenge for Malawi is to rapidly increase CT sites in the rural areas. Figure 14 : Number of Facilities Offering VCT Services* HIV Testing Coverage
The proportion of people who have ever tested for HIV and received results is very low. The 2004
MDHS estimated that 14% Malawians had ever tested for HIV (13% women, 15% men). However,
the number of persons going for testing is increasing every year. See figures 14. The CT scaling up
will likely reach its 2007 target earmarked in the NAF. The 2005-6 Financial year milestone of
reaching 350,000 was also accomplished.
NAF Target: 1,400,000 HIV tests done and results given by end 2007 IAWP Milestone: 350, 000 tests done and results given in 2005-6 Financial Year Achievement: 1,096, 403 tests were done and results given by August 2006 The 2005 Welfare Monitoring Survey showed that there is no difference in accessing CT for both sexes. It also reveals that the number of people testing for HIV had doubled between 2002 and 2005. See Figure 15. More respondents from urban (22%) areas reported to have had an HIV test compared to those from rural areas (11%). Furthermore women and men in the lowest wealth quintile were less likely to go for an HIV test, that is 8.6% and 10.1% respectively; compared to those from the highest wealth quintile; women (22.3%) and men (25.2%). Differences by Region of residence were minimal North (15%), Central (10%) and South (13%). Figure 15: Proportion of persons undergone an HIV test in the general population in the past 12 months by sex and year Source: 2002 CWIQ Survey and 2005Welfare Monitoring Survey, NSO Number of clients tested for HIV at CT sites and receiving results There has been an increase in the numbers of people going for CT services in various sites across the country. From 2001 to 2005, the number of CT increased from 40,806 to 359,065 (MOH, 2006), as shown in Figure 14. Although this increase is impressive, the reported data indicate that only 12% of males and females aged >15 years have undergone HIV counseling and testing. The Government is trying its best to overcome this enormous challenge4. VCT data collecting through the HIV and AIDS Activity Reporting system (ARS), which is mainly from stand alone sites show that 52% males and 48% females accessed VCT services between July 2005 to June 2006. This is an improvement from patterns observed in the past whereby only 30% of females accessed VCT services. Much still needs to be done to close up the gender gap considering that more women (58%) are infected by HIV and AIDS than men (42%). Routine data collected through ARS also indicates that the majority who go for VCT are adults aged above 24 years. Strategies have to be in place to establish and strengthen youth friendly CT services. Youth programmes should also include CT as a priority intervention programme. The NSO population projections report projected that youth aged 0-24 years would constitute 66% of the population in 2005. Figure 16 shows that 42% female youth and 43% male youth aged 0-24 years accessed VCT. 4 In August 2006 Malawi launched an HIV testing week. Through this initiative 95,000 people were tested just in 1 week. Figure 16.1 Distribution of Female VCT clients by Figure 16.2 Distribution of Male VCT clients by Age Age July 2005 to June 2006 July 2005 to June 2006 The majority of CT clients were reached in the Southern Region of Malawi (49%) as expected since almost half of the Malawi population is in the Southern Region. About 20% and 31% were reached in Northern and Central Regions respectively. Table 12 shows that there was equitable distribution of VCT across the three Regions of Malawi between July 2005 and June 2006 just as shown with 2005 CT from the Country Wide Survey on HIV and AIDS Services. Table 10: Number and percentage of persons accessing VCT services by Sex and Region and Sex from July 2005 to June 2006 Region Male
116,657 (52%)
105,624 (52%)
222,281 (100%)
Source: ARS, NAC 3.4 Prevention of Mother to Child Transmission (PMTCT)
NAF Target: Povide a minimum PMTC package to 80% mothers by 2007 IAWP milestone: 35% of HIV+ pregnant women were provided Nevirapine in 2005-6 FY Achievement: 5% of HIV+ pregnant women in the general population provided with Nevirapine in 2005 Implementation of prevention of mother-to-child transmission (PMTCT) programmes started only recently in Malawi. In addition the programme faces a broad range of challenges including lack of knowledge about PMTCT in communities, stigma and human resource constraints. As a result coverage of PMTCT is still minimal. However, efforts are underway to scale up the programme and some achievements have been documented. Proportion of health facilities providing at least the minimum package of PMTCT services In 2002, only nine facilities were providing PMTCT services. By December 2005, of about 514 health facilities with ANC services at least 40 (8%) were providing PMTCT services. The number of sites providing PMTCT increased to 89 by June 2006. By the end of 2004, Ntchisi, Dedza, Ntcheu, Balaka, and Phalombe had not yet established PMTCT sites. However the situation improved by end 2005 with Ntchisi, Dedza and Ntcheu reaching substantial numbers of PMTCT clients. PMTCT services need to be provided in Balaka and Phalombe. Out of all pregnant women tested for HIV more than expected were tested in Central Region (63%) compared to South (25%). In the Northern Region the proportion of those tested was not very bad (12%). Proportion of HIV+ pregnant women receiving Nevirapine According to a report of a country-wide survey of HIV and AIDS services in government facilities (2005), 52,904 pregnant women had been tested for HIV in various ANCs across the country. Out of these 7,052 (13%) were HIV+ and 5054 (72% of HIV+ women) were given Nevirapine. Considering that about 617,059 women were expected to have been pregnant in 2005 and that the 2005sentinel surveillance reported an HIV prevalence of 16.9% among pregnant women, it can be estimated that there were almost 104,283 pregnant women who were HIV+ in 2005. About 4.8% (5054) of HIV+ women received Nevirapine in 2005. In 2004, (2.0%) received Nevirapine. See figure 17. Figure 17: Proportion of Women on Nevirapine and Number of PMTCT sites by year % nevirapine
No of sites
3.5. Blood Safety
Proportion of transfused blood units screened for HIV. A policy on Blood Safety was developed in June 2000, and the Malawi Blood Transfusion Service
Project (MBTSP) was officially launched in November 2002. In 2004, MBSTP collected only 5,523
units of blood of which 4,721 usable. The number increased to 19,112 with 18,196 usable units in
2005. The majority (76%) of blood donors were male.
3.6 STI case management

A comprehensive STI case management programme is a good strategy for HIV prevention. Studies
have proved that STI treatment reduces HIV transmission rate. STI clinics are also linked with
various HIV preventions programmes such as health education, CT, condom distribution among
others. Latest statistics from HMIS (MOH) indicate that 207,136 cases were treated in government
and CHAM health facilities nation wide in the financial year 2004-2005. Campaigns need to be
sustained to encourage STI patients to go for treatment at health facilities. Based on self-reported
STI cases in 2004 and the sexually active population, the guesstimate is that there could be about
480,000 STI cases occurring annually in the country. All these need to be managed accordingly and
reached with appropriate HIV messages.
3.7 Vulnerability of young girls

The girl child is very vulnerable to many kinds of abuse due to the social-ecomic status and
consequently to HIV infection. Table 16 shows that young primary school girls are vulnerable to
early marriages and pregnancies hence at high risk of HIV infection. Primary school girls are
exceptionally more vulnerable to early marriages and pregnancies in the Northern Zone5 (13.5 per
5 Zone consists of all Northern Region Districts 1000 girls), Southern East6 Zone (13.1 per 1000 girls) and Shire highlands Zone (10.3 per 1000 girls). Looking at marriage and pregnancy separately, most primary school girls drop out of school due to early marriages in Northern Zone (11.4%) and South East (9.7%) whereas early pregnancies are commonest in South East (3.4 per 1000 girls) and Shire Highlands7 (2.9 per 1000 girls). See Table 16. Table 11: Primary school girls dropping out of school due to marriage and pregnancy Zone Girls
dropping
Married per Pregnant per Married/pregnant
out due to
dropping
1000 school
per 1000 school girls
Marriage
out due to
Pregnancy
Shire high lands Malawi 11184

Information presented in table 16 justifies the need for tailored interventions by all sectors to
protect school going young girls. Such programmes need to be urgently implemented in all districts
in the Northern Region of Malawi, Balaka, Machinga, Zomba, Chiradzulu, Thyolo, Mulanje and
Phalombe. This indicator from the education sector is in line with results from surveys, which are
indicating high rates of new infections in the Southern Regions and an increase of prevalence in
rural Northern Region.

3.8 Summary and conclusion on prevention and social mobilization
programmes
Communications and social mobilization Knowledge on HIV and AIDS is lower in rural areas compared to urban areas, higher in Southern Region compared to the other two Regions and lower among women compared to men. Communications materials were distributed equitably in all the regions however mass media was more accessible in urban areas compared to rural areas. The 2005-6 IAWP milestones were achieved for mass media and communications but slightly fell short for HIV and AIDS education to youth HCT and PMTCT The 2005-6 IAWP milestones for counseling and testing were reached. It is encouraging to note that there is no sex difference in proportions of persons who have under gone counseling and testing. It is worrisome however to note that urban dwellers are 2 times more likely to access HCT than rural counter parts. This anomaly needs to be reversed. Both the WMS survey and DHS indicated 6 South East Zone consists of Balaka, Machinga and Zomba 7 Shire Highlands Zone consists of Chiradzulu, Thyolo, Mulanje and Phalombe negligible variation of proportions of those ever tested and received results in the three regions of the country. The 2005-6 IAWP milestones for PMTCT were too far from being met. Worse still PMTCT is only offered mainly in government and CHAM hospitals and a couple of rural hospitals and health centers. This implies that rural masses are not yet able to access PMTCT services. Looking at regional distribution, access to PMTCT was much better in central region and worse in Southern Region. Condom distribution The 2005-6 IAWP milestones slightly fell short for condom distribution. Condoms were equitably distributed in all the three regions of the country. HIV and AIDS Treatment, Care
4 and Support
4.1. Antiretroviral Therapy (ART)

The MOH 2006-2010 ARV and OI scale up plan was completed in December 2005. The goal of the
plan is to scale up to about 250,000 patients ever started on ART by the end of the year 2010. ARV
treatment guidelines were revised to factor in new WHO Clinical Staging, Paediatric management of
ART and management of TB/HIV/AIDS co-infection.
NAF Target: 92,000 PLWA with advanced HIV infection receiving ART by end 2007
IAWP milestone: 35,000 PLWA with advanced HIV infection receiving ART by June 2006
Achievement: 57,000 PLWA with advanced HIV infection were receiving ART by June 2006
Number of facilities providing ARVs By June 2006, there were 129 facilities in Malawi (101 public and 28 private delivering anti-retroviral therapy (ART) free of charge to eligible HIV positive patients (MOH, 2005). There has been a rapid scale-up in the establishment of sites for ART delivery in the public sector, especially in 2005 from 60 in September 2005 to 101 in June 2006. The ARV programme funded by Global Fund to fight HIV and AIDS, TB, and Malaria (GFATM) has enhanced the government's ability to scale up HIV and AIDS treatment to the whole country. The Malawi Business Coalition Against AIDS (MBCA) provides another opportunity for coordinating the expansion of ART delivery in the private sector. As of December 2005, 23 private sector sites had started providing ARVs at a subsidised rate. Thus, it is expected that in subsequent years, there is room for rapid expansion of delivery of ARVs across the country. Proportion of men and women with advanced HIV infection receiving ARV therapy There has been a rapid increase in treatment of AIDS patients with ARVs, despite enormous logistical requirements for delivering the drugs. In 2003, only 2.3% of eligible HIV+ patients were on ART. At the end of September 2005, a cumulative total of 30,055 patients had been started on ART, by June 2006, 57,533 patients had ever been prescribed ARVs, surpassing the milestone of 35,000 reached in the 2005-6 IAWP. More women (61%) were receiving ART than men (39%). Only The NAF target for 2007 is likely to be reached. Considering that there are an estimated 187,000 Malawians with advanced HIV infection, ART coverage by June was estimated at 30.8%. This coverage is one of the highest in Southern Africa. For instance coverage in countries in the region are as follows: Zambia (27%), South Africa (21%), Mozambique (9%) and Tanzania (7%). Proportion of patients still alive 12 months after initiation of ARVs The CWHS 2006 indicated that 80% of 7098 HIV positive patients who had started receiving free ART between January and December 2005 were still alive (69% were alive and on ART at the sites, 11% had transferred out to other sites and 10% were dead). 4.2. STI/OI/ARV Drugs Stock Levels
NAF Target: 65% health facilities without stock outs by end 2007 IAWP milestone: 50% health facilities without stock outs in the 2005-6 FY 0% ART site with ARV stock out Achievement: All ART sites had no ARV stock outs in the 2005-6 FY Health facilities without STI and opportunistic infections (OI) drug stock-outs Approximately 80% of the hospitals experienced a stock out of Nystatin pessaries in the last six months in 2006 compared to 31% in 2004. Likewise, 68% of the hospitals were stocked out of Erythromycin compared to 50% in 2004. This means that the 2005-6 IAWP milestone was not met. Delays in procurement have caused major stock-outs of all drugs including STI drugs. The Malawi Logistics System Assessment and Stock Status Report for 2006. MLSASR survey noted that for example Erythromycin was stocked out at two of the three Regional Medical Stores. There were also significant stock-outs of Diflucan and Erythromycin at the hospital level as shown in figure 18. Figure 18: Percentage of Hospitals that experienced a stock-out of STI/OI drugs in the last 6 months Percen 30
Benzathine pen.
Adapted from the MLSASS Report In 2006 health centers fared better in stock levels compared to hospitals. However, all health centers had stock outs of Diflucan and at least 60% had stock outs of Nystatin and Erythromycin. Generally, in 2006 there were significant stock-outs of Nystatin and Erythromycin both at hospital and health center level. See figure 19. Figure 19: Percentage of health centers that experienced a stock-out of STI/OI drugs in the last 6 months Benzathine pen.
Adapted from the MLSASS Report To improve stock status of OI and STI drugs there is need for an improvement in communication, networking and coordination among working groups and development agencies focusing on supply chain management. The procurement plan has to be implemented fully considering that it takes long periods of time for the procurement cycle to be completed. Indicators on drug stock outs in the HIV and AIDS M&E plan are not harmonized with those from the data source (the MLSASS Report). The HIV and AIDS M&E plan regards a stock out as unavailability of all essential STI/OI drugs for more than 7 days. Another problem is that there is no agreed upon list of essential STI/OI drugs to be tracked for stock outs. However, it is clear from the MLSASS report that there were serious stock outs of Nystatin and Diflucan and Erythromycin in 2006 with average durations of more than the minimum 7 days acceptable stock out period. For example, the average duration of stock-outs for Nystatin was 120 days for hospitals and 100 days for health centers. Health facilities without ARV stock-outs The HIV and AIDS Unit (MOH) assesses ART drug stocks in all sites on quarterly basis. There were no stock-outs in any ART site between July 2005 and June 2006. The observed status is an achievement that needs to be maintained. Percent of detected TB cases successfully completing treatment IAWP milestone: 75% smear positive TB cases successfully complete treatment in the 2005-6 Financial Year Achievement: 76% cure rate for the cohort evaluated early in 2005 Tuberculosis (TB) is the most common OI in HIV-infected individuals. With the increasing prevalence of HIV in Malawi, the number of reported TB cases has increased at least five-fold, from 4,863 in 1984 to 27,610 in 2005 (Malawi National TB Control Programme). This number includes smear negative cases (40%), extra pulmonary TB cases (23%) and relapses (4%). TB is the single most important cause of death in HIV-infected individuals. Thus, effective management of TB has a big impact in reducing mortality in HIV positive individuals. TB treatment outcome in 2005 was better than that observed in 2004. A cohort of 8,047 new smear positive TB cases was treated, monitored for a period of 8 months between January and December 2004. Upon evaluation in 2005, 76% patients successfully completed treatment, up from 73% in 2004, while the death rate was 15%, default rate 3%, and transfer-out rate 2%. The 2005-6 IAWP milestone on cure rate (75%) was achieved. 4.3. Care and Support programmes
Number of Households Receiving External Support for HIV and AIDS Care NAF Target: 450 thousand households receiving external assistance to care for chronically ill persons by end 2007 IAWP milestone: 65 thousand households receiving external assistance to care for chronically ill persons in 2005-6 Achievement: 181, 139 households received external assistance in 2005-6 FY NGOs, CBOs, and FBOs receive different types of external support from NAC and other donor agencies. Some implementing agencies submit reports to NAC on what they have implemented. Presented in Table 13 are absolute figures of types of support that households received in 2005 and 2006. Table 13 shows that at least 181,139 households received some kind of external support to care for chronically ill patients (patients ill for 3 or more months). The most common types of support provided to households were psychosocial (32% of households), nutritional (25%) and medical (20%). The HIV and AIDS activity reporting system shows that out of all types of support provided to households, the proportion of nutritional support has increased from 18.9% in 2003 to 25 % in 2005-2006. Figure 20 shows a six monthly increase in number of households receiving nutritional support and a stagnant trend for medical support. The increase in nutrition support is good because it is complementary to the ART programme. The proportion of financial support out of all kinds of support is the lowest but has also increased from 2.5% in 2003 to 6% in 2005-6. The Malawi government's public works Program-Conditional Cash Transfers initiative is a notable achievement that would indirectly assist some households caring for the sick. A MASAF report indicates that 593,832 households benefited Under the Public Works Conditional Cash Transfer (PWP-CCT) these were reached with cash to mitigate the effects of the drought. The transfer was on condition that beneficiaries participate in labor-intensive public works. The cash transferred benefited an estimated 2.8 million people who used it to purchase food, farm inputs and other basic requirements. Some districts seemed to have had well-established community based programmes aimed at assisting households to care for chronically ill patients between July 2005 to June 2006. These included Phalombe, Thyolo, Lilongwe, Mangochi and Mulanje. However, improvements in providing support for chronically ill patients were observed in most districts and this trend is expected to continue in the coming years. Table 12: Number of households receiving external assistance to care for adults who have been chronically ill for 3 or more months by type of assistance, June 05-July 06 District
Psychosocial Nutritional Financial Medical Domestic Total
Nkhotakota 5,483 Chiradzulu 7,641 Figure 20: Trends in types of assistance between Jan 05 and June 06 Source: HIV/AIDS activity reporting system Enrollment of PLWA with PLWA Support Organisations IAWP milestone: 10,000 persons enrolled with PLWA organizations in the 2005-6 FY Achievement: 17,706 new PLWA enrolled with PLWA organizations A small number of PLWHAs are comfortable to enroll with PLWHA organizations. However the number of people registering has been rising on six-monthly basis. Numbers have increased from 5,900 from January to June 2005; 8,495 from July to December 2005 and 9,211 from January to June 2006. Figure 21 shows that people older than 24 years are more likely to be registered with PLWA organizations, as expected, since the majority of person aged between 15 and 24 years have not yet developed AIDS. Figure 21 also shows that more females (64%) than males (36%) are prepared to enroll with PLWA organizations among persons aged above 24 years. Men need to be deliberately targeted to encourage them to register with PLWA support groups and organizations. Figure 21 PLWA by Sex and Age, July 05 to June 06 Source: 2004 NACARS Report & 2005 NACARS Report Community Home-Based Care Visits IAWP milestone: 150,000 visits to PLWA in the 2005-6 FY Achievement: 243, 362 visits were made in 2005-6 FY The 2005-6 IAWP milestone of paying 150,000 visits to PLWA was surpassed. Overall 243, 362 visits were made to households caring for chronically ill patients. As observed in previous HIV and AIDS monitoring reports, volunteers do pay more CHBC visits to PLWA than health workers. Only 26% and 19% of the visits were done by health workers in urban and rural areas respectively from July 2005 to June 2006. Although more PLWA are estimated to be in rural areas (70%) compared to urban areas (30%) (Sentinel surveillance estimates), available information shows that comparatively, urban areas got fewer visits (20% than the expected 30%); 80% of the visits were done in rural areas, well above the expected 70%. Table 13 shows that community home based care visits have stagnated in urban areas and slightly decreased in rural areas. Table 13.1 –13.2 Community home based care visits District
Jan-Jun 05
Jun-Dec 05
Jan-Jun 06
Rural Urban
Rural Urban
Rural Urban
Nkhotakota 2,427 Central 24,546
Nkhatabay 1,452 3 North 12160
District
Jan-Jun 05
Jun-Dec 05
Jan-Jun 06
Rural Urban
Rural Urban
Rural Urban
Chiradzulu 5,549 South 85,883
122,589 25,396 116,117
4.4. Summary and conclusion on treatment care and support

The 2005-6 IAWP milestones for the following intervention programme areas were met:
1. ART scale up
This programme is progressing very well. The only shortfall is the lower proportion (6%) of children
aged 0-14 years receiving ART compared to 94% adults. About 25% of those in need of ART are
children age between 0 to 14 years. Efforts are underway however to roll out paediatric ART.
Another issues on ART is scaling up to rural areas. Due to human resource crisis mentioned in
chapter 1 most of clinicians trained in ART are based in hospitals and a few rural hospitals, as a
result peripheral health facilities which already have shortage of clinical staff have no capacity to run ART programmes. 2. TB cure rate This programme run very well in all the districts. It is encouraging that the case fatality rate has been kept low at around 15%. 3. Household receiving assistance to care for PLWA There is need to come up with a composite indicators for monitoring assistance to households. This needs consensus on what can be regarded as assistance to a household caring for chronically ill patients. 4. Enrollment with PLWA organizations Despite high levels of stigma and discrimination, this programme is slowly gaining ground. It is interesting however to note that men shy away from registering with PLWA organizations. Men should be sensitized on the benefits of joining PLWA support groups and organizations. Milestones for STI and OI drug stock outs were not achieved. Large proportions of health centers and hospital had stock outs of various essential STI/OI drugs. The supply chain management system in the MOH needs to be supported through enhanced coordination, networking and effective implementation of the drugs and supplies procurement plan. HIV and AIDS Impact Mitigation

Care of Orphans and Vulnerable Children

IAWP milestone: 120, 000 orphans and other vulnerable children receiving care and support in 2005-6 350 organisations receiving support I 2005-6 Achievements: 358, 084 orphans were provided some kind of support in the 2005-6 Financial Year 600 community organizations received support from NAC Grants Facility alone Orphans and other vulnerable children receiving external assistance Considerable achievements have been made to create an enabling atmosphere for rapidly scaling up the response to the crisis of orphans and vulnerable children in Malawi, currently estimated at over 1 million. The country has a National Policy on OVC, which was launched in 2004. The policy focuses on provision of care and support to orphans and other vulnerable children. At least 358, 084 orphans received some kind of support in the financial year 2005-2006 exceeding the 120,000 milestone set in the 2005-6 IAWP. See Table 15. Figure 22 shows that common types of support were psychosocial (48%) and nutrition (35%). Only 6% received financial support. This could mean that fewer activities were conducted due to various reasons including unavailability of funds or it may be due to under reporting. The greatest challenge in this area is timely and nation-wide reporting to build a more complete picture of support reaching orphans. The quality of support rendered to OVCs also needs to be revisited in light of the recently developed impact mitigation framework. The framework identifies educational and material support as of high relevance to mitigating the impact of HIV and AIDS on OVCs. Over 600 community-based organizations (CBOs) have been funded through the NAC Grants Facility and a high proportion of these target the needs of orphans. Table 14: Number of Orphans and other vulnerable children receiving external assistance District Jan-Jun05
Jul-Dec05
Jan-Jun06
District
Dec05 Jun06
Chiradzulu 7,778 Machinga 13,982 Gyufhjgjgfjjklgjkl types of support. Neno 3,227 Nsanje 9,274 Phalombe 13,196 Thyolo 17,213 Zomba 9,773 South 101,530
Malawi 179,886
Figure 22: Types of Assistance Given to Orphans, Jul 05 to Jun 06 School Attendance among Orphans Malawi introduced free primary education in 1994 as a way of encouraging all children to enroll in schools. Unfortunately primary school drop out rate is very high. Various issues contribute to withdrawing or continuing with school for most of the children in Malawi, including socio-cultural, socio-economical and ill health. Monitoring the enrolment, attendance and performance of orphans and other vulnerable children in schools is, therefore, one of the key issues in the national response. In 2005 there were 39,909 orphans in secondary schools (54% male, 46% female). Primary schools had 439, 405 orphans with almost equal proportions of females and males, giving a total of 479,314 orphans in school. Figure 23 shows that most pupils are dropping out from school regardless of whether they are orphans or non-orphans. According to available information orphan-hood cannot be singled out to be a significant reason for dropping out of primary school. Figure 23.2 Number of non orphan pupils in 5.3. Women Empowerment
Figure 23.1: Number of orphans in primary schools primary schools in Malawi 2005 in Malawi, 2005 Women in the country have been economically empowered through FINCA and other small scale
lending institutions. Through district assemblies some women groups have been economically empowered to do some small business in order to avoid them from joining sex work. both parents dead single parents dead Mainstreaming and Capacity Building
This Chapter focuses on the progress that was made in 2005-2006 with regard to mainstreaming HIV and AIDS in the public as well as partnership strengthening. IAWP milestones: 1. 55% large private companies and 80% public institutions have work place policies by June 2006 2. 65% of largest private companies and 80% of public institutions have employees reached with work place interventions Achievements: 1. 65% and 72% large private companies and public institutions respectively had work place policies by 6.1.1. Partnerships towards effective mainstreaming HIV and AIDS
A Malawi Partnership Forum on HIV and AIDS was established to enhance multi-sectoral coordination of the national response. Furthermore, efforts were made to scale up and strengthen the national response through disbursement of grants to public, private and civil society sectors. From June 2005 to July 2006, forty organizations developed work place programmes, which include 10 from the public sector, 20 civil society and 10 from the private sector. All private organizations used their own resources on HIV and AIDS except NASFAM, which has a grant with NAC. NAC through the Malawi Business Coalition Against AIDS (MBCA) and Department of Human
Resource Management and Development facilitated exchange visits within sectors for
information sharing and networking. There were two public sector exchange visits, two private
sector, one civil society and 32 district assembly exchange visits.

6.1.2 Reach of HIV and AIDS workplace interventions to employees and their spouses /
families
The number of employees and spouses reached with work place interventions has remained low.
Only 9,782 were reached in the first half of 2005 while 24,769 were reached in the last half of 2005.
Between January and June 2006, at least 23,589 staff and their spouses were reached with work place
programmes. Reporting could be the problem but even though, there could have been an increasing
trend from organizations funded by NAC since all grantees are obliged to report. More needs to be
done to ensure that organizations are mainstreaming at national and district level.
Table 15: Reach of HIV and AIDS Workplace Interventions to Employees and their Spouses District Male
Central 16,113
North 4617
South 9301
Total 30,031
6.2 Capacity Building
Multi-sectoral/level capacity building
In the 2005-6 financial year twenty eight district assemblies were provided with a vehicle, a computer and a printer each, to assist in coordination and monitoring of HIV and AIDS activities. A public sector coordinators training manual was finalized and 10 HIV and AIDS coordinators were trained based on the manual. Work place committees were set up and trained in 25 government ministries and departments, 9 NGOs and the private sector. The private sector had 10 committees for the large companies and 45 committees for SMEs. MBCA and AWiSA trained a total of 85 private sector HIV and AIDS Coordinators. In addition MBCA trained 67 private sector chief executives in HIV/AIDS leadership and 15 TOT in HIV and AIDS mainstreaming. The civil society was also supported to build capacity in leadership through training of 30 civil society leaders and training of 10 coordinators. Training of project staff and volunteers
The number of project staff and volunteers trained on HIV and AIDS issues has increased
tremendously between January 2005 and June 2006. Only 34,501 persons were trained or oriented
on HIV and AIDS related issues in the first half of 2005 while 108,458 were reached in the last half.
Between January and June 2006, at least 116,803 staff and their spouses were reached with work
place programmes.
As has always been the case more volunteers were trained than project staff. More staff were trained
in Southern Region (51%) and central Region (42%); least (7%) were trained in Northern Region as
shown in table 18. Considering the human resource crisis highlighted in Chapter 1 of this report,
Malawi will still need services of volunteers for a long time. As a result it is critical that volunteers
are trained retained.
Table 16: Project Staff and Volunteers Trained in HIV and AIDS Related Issues District:
Volunteers Trained

Summary on mainstreaming and capacity building

The number of public and private institutions that have developed work place policies has increased.
The 2005-6 milestone of ensuring that at least 55% large private companies and 80% public
institutions more or less reached. By June 2006 about 65% of large private companies and 72% of
public institutions had work place policies. To ensure that work place programmes are effectively
implemented HIV and AIDS coordinators in all sectors were trained. In addition HIV and AIDS
mainstreaming committees were set up in all sectors. After all these efforts it is expected that more
employees and spouses will be reached with work place programmes at both national and district
level. In 2005-6 FY fewer than expected employees were reached with work place programmes.
Programme Management, Research,
7 Monitoring, and Evaluation
This chapter discusses how the national response has been managed, coordinated, and monitored from July 2005 to June 2006. Particular focus is on national policy coordination and programme planning, monitoring and evaluation, resource mobilization and utilization. 7.1. National Policy Coordination and Programme Planning
IAWP milestones: 1. NAC Decision–making structures meet 12 times in a year to make decisions on programme 2. National AIDS Act prepared and approved 3. The National HIV and AIDS Policy disseminated to all districts 4. NAF 2005-2009 approved and launched Achievements: 1. The 2005-9 NAF was finalized and has been disseminated 2. NAC management met every month from July 2005 to 2006 to review progress 3. The National HIV and AIDS Policy was disseminated by a pool of trained facilitators in all regions of the country. Public, private and civil society were targeted for dissemination The Malawi NAC functions as the central coordination unit working in collaboration with other coordination entities in the public, private, faith and civil society sectors. NAC is managed by a Board of Commissioners consisting of representatives from government bodies, nongovernmental organizations, civil society, PLWA and youth organizations. NAC reports to the office of President and Cabinet through the Minister Responsible for HIV and AIDS. The Board of Commissioners meets on quarterly basis to review progress. NAC Management reports to the Board of Commissioners and they are expected to meet on monthly basis to discus programme management issues. NAC faces challenges in its quest to effectively coordinate the national response, because the National AIDS Act has not yet been finalized, hence not endorsed by parliament. However drafting of the National AIDS Act is in progress at the OPC with technical support from Ministry of Justice NAC closely works with The Malawi HIV & AIDS Partnership Forum is in place from 2005 which advises the National AIDS commission Board, The Inter-Faith HIV/AIDS Association coordinating faith organizations, The Business Coalition Against HIV/AIDS for the private sector, The Department of Human Resource Management and Development which is the coordinator of public sector responses and umbrella bodies of People Living with HIV and AIDS. Since 1985, when the first AIDS case was detected, the country did not have an HIV policy to guide the national response. The national HIV & AIDS Policy was developed in 2004 through a consultative and participatory process. The policy was launched in November 2004 by the former head of state. It is an innovative policy in many areas; for instance, in HIV testing it moves away from voluntary counselling and testing to routine testing for all women attending antenatal clinic services, diagnostic testing for patients and mandatory testing for blood and organ donors. In order to effectively fulfil goals of the national HIV and AIDS policy, Malawi developed an action oriented strategic plan, the NAF 2005-9, with in put from the end of term review of the NSF 2000-2004, to guide programme implementation. 7.2. Resource mobilization and utilization
IAWP milestones: 1. Increase disbursement of funds received by the NAC that is granted to its grantees to 50% 2. Reduce average number of months for grant proposal processing (from the time proposals are received to when funding is provided) to 3.5 months Achievements: 1. Disbursement of committed funds in the 2005-6 Financial Year was at 66% 2. The average number of months for grant proposal processing was 5.1 months Malawi has mobilized resources from multilateral and bilateral donors for managing the national response to HIV and AIDS, about two thirds of which are channeled through NAC. From April 2004, NAC engaged a Financial Management Agency (FMA) to administer the HIV and AIDS Grants Facility. In order to facilitate the uptake of grants by implementers at all levels and to build the capacity of district assemblies to coordinate district level responses, NAC engaged five international NGOs as Umbrella Organisations (UOs) to mobilize district level responses to HIV and AIDS and to coordinate district level proposals and projects from the local CBOs, FBOs, and NGOs. The umbrella organization initiative has since been evaluated and a report to this effect was disseminated. Terms of reference for umbrella organizations were revised and there are now three umbrella organizations 7.1. 1 Amount of National Funds Spent on HIV and AIDS The Malawi Government has committed itself to contribute annually approximately US$2 million to NAC towards the fight against HIV and AIDS. In addition, approximately 2% of the annual ORT budget for each ministry/department line is expected to be allocated to HIV and AIDS interventions and 60-70% of the Ministry of Health budget is used to support HIV and AIDS related interventions. In the 2005-06 financial year, the government contributed MWK210,968,487 (US$1,634,671) directly to NAC towards the HIV and AIDS response; an increase from MWK108,231,900 in the 2004-05 financial year. However, these amounts are very minimal for government to sustain the management of the HIV and AIDS national response. The National Health Accounts and AIDS Accounts Survey indicated a total expenditure of 7,527,323,449 billion on HIV and AIDS, in the 2004/2005 Financial Year. Out of this total, HIV and AIDS health expenditure was 6,254,069,140. The survey revealed that in this financial year, government contributed only 20% of the total HIV and AIDS funds which is about MK1,505,464,690. Donors were the major financiers of HIV and AIDS programmes (73%). Private sector funds were at 7%. 7.1.2 Amount and Percent of committed funds Disbursed in 2005 and 2006 By June 2006, NAC had MK 6,751,022,840 committed funds, out of this amount, MK4,484,206,23 had been disbursed since the inception of the grants facility. This represents a disbursement rate of 66%. This is a great improvement and the target of a 50% disbursement rate in the 2005-6 IAWP was exceeded with a big margin. The 2005-6 IAWP was costed at US$91,473,710 of which US$75,148,500 was to be financed through NAC. By end June 2006, a total of MK3.6 billion had been disbursed to various interventions, of which MK2.2 billion was through the grants facility. Out of this amount MK837.9 million was disbursed to the five Umbrella Organizations. The NGOs constituted the largest share of the disbursed grants to a magnitude of MK415.5 million in the financial year. Other beneficiaries of the grants disbursements in the year were the public sector, education and training institutions, faith-based organisations and the private sector on a very small proportion. Figure 24 shows cumulative disbursements by intervention area. Twenty-eight (28%) of funds were disbursed for treatment, care, and support purposes mainly for the purchase of antiretroviral and OI drugs and other health related products. Twenty percent was disbursed for prevention and BCI activities. Twenty-four percent was disbursed for mainstreaming activities, the majority of which focus on advocacy and prevention. One would conclude therefore that 44% of disbursed funds targeted prevention programmes. Figure 24: Proportion of Funds cumulatively disbursed by Type of Intervention 2005-6 7.1.3 Average Period (Months) for Grant Proposals to be Processed On average it took 5.1 months for a proposal submitted to NAC to be processed, that is from the time a proposal is received to the time it is approved. After that, it takes additional time (ranging from 1 to 4 weeks) for the money to be disbursed. The average time taken for processing proposals decreased from April 2005 to June 2006. The IAWP milestone of reducing average grants processing time to 3.5 months was not reached. 7.4 Research, Monitoring and Evaluation
IAWP milestones: 1.HIV and AIDS M&E plan revised and a decentralized system in place by June 2006 2. Behaviour and biological surveillance conducted 3. Research and M&E results disseminated 7.4.1. HIV and AIDS Monitoring and Evaluation Achievements: 1. Behaviour surveillance was conducted through DHS which was finalized in 2005 2. Biological surveillance was conducted through Sentinel Surveillance and DHS which were finalized in 2005 3. Research and M&E dissemination conference was held in 2006 HIV and AISD M&E system Malawi applies the ‘Three Ones8' in its response to HIV and AIDS: Despite this, some stakeholders do not comply with requirements of the ‘Three Ones Principle'. The National HIV and AIDS Monitoring and Evaluation System has fifty-nine core indicators that are informed by twenty ‘traditional' data sources. Alternative data sources are also used. Almost 85% of the fifty-nine are properly tracked and reported on. Failure to properly track other indicators is mainly due to failure by data source institutions to implement surveys or non-compliance of data source institutions to send data to NAC. Since its inception, the system has successfully managed all data sources that provide impact and outcome level indicators. The major challenge has been to collect programme out put data. Service data collected through quarterly reports/data sets, annual reports/data sets from data source institutions and through the HIV and AIDS Activity Reporting System (ARS). The ARS provides information for 17 of 38 output-level indicators of the M&E plan. M&E challenges and revision of the HIV and AIDS M&E Plan Major shortfalls of the HIV and AIDS M&E plan are inadequate capacity at sector and local levels, poor coordination at local level and most importantly the HIV and AIDS system is not decentralized. The M&E system also faces a unique challenge of noncompliance to report programme data to national level and district assemblies due to lack of legal mandates on M&E. In order to iron out M&E challenges the HIV and AIDS Monitoring, Evaluation and Information System technical working group (MEIS) formed an M&E Review Task Force to manage revision of the M&E plan and to explore solutions to challenges facing the M&E plan. The approach of creating a task force has had its advantages and disadvantages. The major advantage of the approach 8 One National Framework, one Coordinating Agency, and one Monitoring and Evaluation Plan. is its richness in diversity of skills, professional backgrounds and representation from key sectors. The major shortfall has been the slow pace to review the M&E plan and put in place a decentralized M&E system. In future, the MEIS and Task Forces emerging from MEIS should not be asked to implement but to provide technical guidance and recommendations to implementing agencies. Delays in revision of the M&E plan has affected implementation of critical M&E activities in 2005-6 IAWP. The M&E milestone in the 2005-6 IAWP was to have the M&E plan reviewed and a decentralized M&E system in operation by June 2006. Advocacy on HIV activity reporting and capacity building NAC has intensified its M&E and research dissemination and feedback meetings at regional level throughout the country. During these meetings M&E operations issues are discussed and best practices are shared. This has led to more stakeholders participating in the HIV Activity Reporting System. It is encouraging to note that district assemblies are embracing M&E as local level responsibility through DACs and M&E officers. Biannual, annual HIV and AIDS reviews and evaluations by independent reviewers In order to have infallible monitoring and evaluation findings, NAC introduced participatory biannual review and annual reviews of the national response. These are participatory in nature and draws participants from all sectors, that is, public, private and civil society. Participants are also drawn from national, district and community levels. In addition, NAC contracted an independent firm to conduct evaluations of the national response on a six monthly basis. The participatory reviews and external evaluations complement the traditional monitoring and evaluation system in highlighting successes and challenges of the national response. The most recent annual review was conducted in February 2006. After successfully managing reviews at national level NAC is planning to move to zonal level where focus of the review will be at district assembly and community levels. 7.4.2. HIV and AIDS Research Behavioural and biological surveys The first Behaviour Surveillance Survey (BSS), in which 13 high-risk and vulnerable sub-populations were targeted, was conducted in 2004. BSS were introduced to complement data from MDHS and sentinel surveys, which have been conducted almost annually since the 1994. Planning for the 2006 BSS was almost finalized. An HIV testing component would be included in the 2006 BSS. Malawi also conducts demographic and health surveys which collect behavioural and biological data. Results from the 2004 BSS, 2004 Demographic and Health Survey (DHS) and the 2005 Sentinel Surveillance Survey have been disseminated at national and regional level. Research and M&E dissemination conferences and meetings Malawi holds research and M&E dissemination conferences on annual basis the most recent one was done in May 2006. Research studies accepted by a research conference abstracts review committee are presented at the conference and documented in an HIV and AIDS research abstracts book. Summaries of major findings at the research conference and annual reviews were also disseminated at regional level in June 2006. Research Strategy The Malawi National HIV and AIDS Research Strategy was finalized and disseminated in 2005. The document highlights priority areas for HIV and AIDS research in the country. The document has been disseminated to stakeholders in all sectors at national and district level. The document is also distributed to end users on an ongoing basis. Summary on Programme Management, Research, Monitoring, and Evaluation
Malawi has effective and efficient structures in place to coordinate and implement the national response. The country has a sound HIV policy and a comprehensive action framework for guiding programme implementation. Financial resources have been mobilized from multilateral and bilateral donors for managing the national response and the resource have been prudently utilized. The Malawi government also contributes towards HIV and AIDS pool funds, though the contribution has been increasing in the past 2 years the proportion coming form the government is too low. Government contribution towards funding of HIV and AIDS programmes need to increase for sustainability and predictability of programme financing. The country has a robust HIV and AIDS monitoring and evaluation system, which includes routine Monitoring and Evaluation, participatory bi-annual and annual reviews and independent evaluations. The M&E system is complemented by research studies earmarked in the HIV and AIDS Research Strategy. Studies have been conducted to determine HIV prevalence levels and to understand trends in behaviour and practices at national level. Efforts are currently underway to devolve research and M&E responsibilities to the local level. Summary of Key Successes and
7 Challenges
7.1. Successes
1. Noticeable decline in HIV prevalence in some urban areas as evidenced by a decline in prevalence among young pregnant women aged 15-24 years. This finding is complemented with evidence of positive behaviour change in urban areas. 2. Remarkable decline in STI prevalence especially in men. Based on self-reported signs and symptoms of STI, the DHS has also revealed a decline in STI prevalence among male youth from 2000 to 2004. Syphilis prevalence among pregnant women has declined since 2001.
3. Positive changes in sexual behaviour. Primary abstinence among adolescents and youth aged
15-19 years has increased. Proportions of married men engaging in high-risk sex and those having sex with multiple partners have decreased. The proportion of sexually active persons using a condom at last high-risk sex has increased significantly. The proportion of men paying for sex has drastically gone down. 4. Sustained high awareness levels on HIV and AIDS. 5. Effective structures for coordination of the national response have been put in place. Major steps include establishment of the Malawi Interfaith AIDS Association, MBCA and engagement of the Department of the Human Resource Department in the fight against HIV and AIDS. 6. Successful mobilisation and effective management of resources from a wide-range of bilateral and multilateral donors. 7. Significant increase in coverage of HIV counseling and testing and ART services. 8. Sustained high TB cure rate since 2002. 7.2. Challenges
1. There is no evidence of HIV prevalence decline in rural areas. The prevalence and occurrence of new infections remain highest in rural Southern Region, and increasing in rural Northern Region. 2. Gaps in behaviour change still exist for instance condom use at last high-risk sex remains relatively low in rural areas compared to urban areas, and in Southern Region compared to the other two regions. 3. Stigma and discrimination are still widespread in Malawi. 4. Nationally, PMTCT coverage is still very low. 5. Programme coverage remains lower in rural areas compared to urban areas. Such programmes include HIV counseling and testing, ART, mass media and condom distribution. 6. Decentralised district-based responses that are truly multi-sector are not yet fully-fledged. 7. Mechanisms are not yet in place to mobilize resources locally to support and sustain a rapidly expanding response. 8. The number of months taken to process HIV and AIDS grants proposals are still very high to entice would be a grant applicant. 9. Lack of legal mandate at national and district assembly levels to enforce reporting by 8 Major Recommendations
Following the experience that has been gained and lessons learnt in the areas of programme planning, implementation, coordination, monitoring and evaluation of HIV and AIDS activities through implementation of the NSF and NAF, it is recommended that the following should be implemented: - 1. Conduct studies to under stand social-cultural and social-economic issues influencing the spread of HIV in rural and urban areas at all level. 2. Scale up implementation of targeted and evidence based preventive and behaviour change interventions. 3. Evaluate the impact of existing youth programmes including life skills education, and consequently roll out implementation of evidence based youth friendly programmes. 4. Support the health sector to beef up its human resource base to effectively scale-up biomedical HIV interventions in rural areas. 5. Decentralise the HIV and AIDS Grants facility system 6. Explore mechanisms for mobilizing financial resources locally. 7. Enhance capacity building efforts at district level to effectively manage HIV and AIDS interventions based on local data. 8. Establish legal requirements for all implementing agencies of HIV and AIDS activities to report to district assemblies, in a timely manner, using harmonised formats, to ease consolidation of data at national level. Bibliography
BLM. ‘2005 Annual Data': Blantyre: Banja La Mtsogolo, 2006
MOH. ‘National Health Facility Survey' Lilongwe: Ministry of Health, 2002. Kakhongwe, P. ‘Beyond Numbers: Malawi Women in Parliament.' Zomba: University of Malawi Centre for Social Research, 2004. Malawi National TB Control Programme. ‘Annual Report July 2004–June 2005.' Lilongwe: Malawi National TB Control Programme, 2005. MOEST. ‘Education Statistics, 2004.' Lilongwe: Ministry of Education, Science, and Technology, 2004. MOEST. ‘Education Statistics, 2005.' Lilongwe: Ministry of Education, Science, and Technology, 2005. MOEST. ‘Life Skills Study Report.' Lilongwe: Ministry of Education, Science, and Technology, 2005. MOH. ‘HMIS Bulletin: Annual Report, July 2004 to June 2005.' Lilongwe: Malawi Ministry of Health and Population, 2006. MOH. ‘Report of a Country-Wide Survey of HIV and AIDS services in Malawi for the year 2005.' Lilongwe: Malawi Ministry of Health and Population, 2006. MOH. ‘Report on ARV Therapy in Malawi – up to June 2006.' Lilongwe: Malawi Ministry of Health 2006. MOH. ‘Sentinel Surveillance Report, 2003.' Lilongwe: Malawi Ministry of Health and Population, 2003. MOH. ‘Sentinel Surveillance Report, 2005.' Lilongwe: Malawi Ministry of Health 2005. NSO. ‘Malawi Demographic and Health Survey, 2000.' Zomba: National Statistical Office, 2000. NSO. ‘Malawi Demographic and Health Survey, EdData Survey, 2002.' Zomba: National Statistical Office, 2002. NSO. ‘Malawi Demographic and Health Survey, 2004.' Zomba: National Statistical Office, 2004. PSI. ‘PSI Annual Data, 2005.' Lilongwe: Population Services International, 2005. MOH, National Health Accounts and HIV and AIDS Resource tracking Report, 2006 (preliminary findings) MOH, Malawi Logistics System Assessment and Stock Status report SLSASSR, 2006 NSO, Welfare Monitoring Survey, 2005. [1] Excluding blood donors. [2] Generally, access to radio programmes is very high in Malawi (in excess of 90%, although ownership is only 60-70%). [3] OI and STI drugs in the survey included: 2.4 mU vials of benzathine penicillin, 100 mg tablets of doxycycline, 250 mg tablets of metronidazole, 200 mg tablets of fluconazole, nystatin pessaries, and 250 mg tablets of erythromycin. [4] The rest either experienced treatment failure or transferred to other places.

Source: http://www.aidsmalawi.org.mw/index.php/downloads/category/4-monitoring-and-evaluation?download=20:m-e