Chapter 1: Introduction
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Problem Statement
More than 20 years from the onset of the epidemic, HIV/AIDS remains a global challenge. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), HIV/AIDS has particularly affected sub-Saharan Africa, with 28.5 million people estimated to be living with the virus in the region by 2001 (UNAIDS, 2001). This figure represents approximately 71% of all people living with HIV/AIDS in the world. About 81% of all HIV-infected women and 79% of all HIV/AIDS orphans live in sub-Saharan Africa. In this region, more than half the new infections are occurring in young people aged 15-24 years, with teenage girls being far more likely to be HIV-infected than teenage boys.
Malawi, like its neighbours in sub-Saharan Africa, has been severely affected by HIV/AIDS. The first case of AIDS in the country was diagnosed in 1985. Since then, epidemiological data show an escalating epidemic. For example, in a sample of pregnant women attending antenatal clinics in urban Blantyre, HIV seroprevalence rose from 2.6% in 1986 to over 30% in 1998, decreasing only slightly to 28.5% in 2001. In 2001, Malawi's national adult prevalence (15-49 years) was estimated at 15%, translating into almost 740,000 adults living with HIV/AIDS (National AIDS Commission [NAC], 2001). HIV prevalence is almost twice as high in urban areas, at 25%, as in rural areas, at 13%. Annual deaths due to HIV/AIDS are estimated at over 80,000, amounting cumulatively to 555,000 deaths since 1985.
The epidemic has affected all sectors of Malawian society, especially social services. For example, in the health sector, the maternal mortality rate has more than doubled, in large part due to the HIV/AIDS epidemic. HIV/AIDS patients occupy more than 50% of medical ward beds, and more than 70% of all pulmonary tuberculosis (TB) patients also have HIV infection. In the education and agricultural sectors, teachers and extension workers, respectively, are dying at a faster rate than replacements can be trained. The economic viability of most homes has deteriorated due to loss of breadwinners and the consequent support of orphans by the elderly and older siblings.
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The Context of the Problem
In addition to HIV/AIDS, the Country Development Report (UNDP, 2001) highlights poverty and governance as key development challenges for Malawi. These challenges are reciprocally influenced by prevailing political, social, cultural and economic conditions. For example, Malawi is one of the poorest countries in the world, with 65% of the rural and 55% of the urban population living in poverty. Furthermore, its population is characterised by a high proportion of people below 15 years of age (45% of the 9.8 million people, according to National Statistics Office [NSO], 1998), resulting in a high dependency ratio. The poverty situation is further aggravated by recurrent drought, which disrupts food security in an agriculture-dependent economy. Consequently, inflation rates continue to rise and economic productivity decreases. In order to reduce poverty levels, Malawi has established a Poverty Alleviation Programme and developed a Poverty Reduction Strategy Paper (PRSP). Government is being supported in this effort by donor partners and through the use of funds from programmes such as the Highly Indebted Poor Countries (HIPC) Initiative.
Cultural and religious practices further influence HIV/AIDS, governance and poverty. The population of Malawi is diverse in terms of language, religion and ethnicity. There are about nine indigenous ethnic groups, in addition to Asian and Caucasian groups. Moreover, the majority of the African population is Christian, while the Asian population is predominantly Muslim, resulting in a wide range of practices, some of which are detrimental both to development and to an effective HIV/AIDS prevention programme. For instance, certain traditional norms limit access of women to education, thereby increasing illiteracy, decreasing participation in governance and lowering their socioeconomic status.
Thus, HIV/AIDS presents a major challenge to the individual and collective well-being and security of people in Malawi. Malawi's response to the epidemic began in 1986, initially concentrating on preventing further transmission of the virus. A review of the HIV/AIDS control programme and extensive stakeholder consultations led to the formulation of the National HIV/AIDS Strategic Framework for the period of 2000 to 2004. This framework emphasises the need for an expanded and multi-sectoral response to HIV/AIDS and other sexually transmitted infections (STIs). It incorporates care, support and impact mitigation as integral parts of the national response. Malawi has also committed itself to the fight against HIV/AIDS at the regional and international level through the Abuja Declaration and Framework for Action for the Fight Against HIV/AIDS, Tuberculosis, and Other Related Infectious Diseases in Africa (27 April 2001); the United Nations General Assembly Special Session Declaration of Commitment on HIV/AIDS (27 June 2001) and the Millennium Development Goals. These agreements aim to (1) address the development and implementation of multi-sectoral national strategies and financing plans for combatting HIV/AIDS that are resourced to the extent possible from national budgets, without excluding other sources such as international cooperation; (2) confront stigma, silence and denial; (3) address gender and age based dimensions of the epidemic; (4) eliminate discrimination and marginalisation; (5) strengthen partnerships with civil society and the business sector; (6) encourage full participation of people living with HIV/AIDS (PLWAs) and other vulnerable populations, particularly women and young people; (7) fully promote and protect all human rights and fundamental freedoms, including the right to the highest attainable standard of physical and mental health; (8) integrate a gender perspective; (9) address risk, vulnerability, prevention, care, treatment and support so as to reduce the impact of the epidemic; and (10) strengthen the capacity of the health, education, and legal systems.
HIV/AIDS impacts the economy, the social fabric of society and the ability of the political system to effectively and efficiently perform its mandates. The challenge of HIV/AIDS demands a high level of commitment, strong multi-sectoral collaboration and sustained action, which this policy seeks to facilitate.
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Goals and Objectives
The goals of the National HIV/AIDS Policy are: (1) to prevent the further spread of HIV infection; and (2) to mitigate the impact of HIV/AIDS on the socioeconomic status of individuals, families, communities and the nation.
These goals will be achieved by pursuing the following specific objectives:
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To improve the provision and delivery of prevention, treatment, care and support services for PLWAs.
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To reduce individual and societal vulnerability to HIV/AIDS by creating an enabling environment.
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To strengthen the multi-sectoral and multi-disciplinary institutional framework for coordination and implementation of HIV/AIDS programmes in the country.
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Preamble
The Government and people of the Republic of Malawi, note that:
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HIV/AIDS has reached epidemic proportions in the country.
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HIV/AIDS is a public health issue, as it directly affects the health of large numbers of people in society and reduces the overall health status and well-being of the nation; contributing to the rise in maternal and under-five mortality rates, facilitating opportunistic infections and placing further stress on a health care system that is already overburdened.
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HIV/AIDS is a social issue, as it adversely impacts families and communities; affected or infected individuals and/or families are faced with excessive medical expenses, depleting all their savings and even forcing them to dispose of their assets.
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HIV/AIDS is an economic issue, as it leads to a reduction in economic growth, by reducing the productivity of the labour force; it causes an imbalance between the supply and demand for a range of complex public services, by decreasing the former while at the same time increasing the latter.
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HIVAIDS is a development issue, as it is weakening institutions and destroying institutional memory in both the public and private sectors; it is destroying their capacity to formulate, analyse and manage the public policies, development programmes and strategies essential for economic development and growth, thus hindering sustainable development.
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An effective response to HIV/AIDS requires respect for, protection of and fulfilment of all human rights--civil, political, economic, social and cultural--and upholding of the fundamental freedoms of all people, in accordance with the Constitution of Malawi and existing international human rights principles, norms and standards.
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All people are guaranteed freedom from discrimination on grounds of race, colour, sex, language, religion, political or other opinion, nationality, ethnic or social origin, disability, property, birth or other status including HIV/AIDS status, in accordance with the provisions of the Constitution of Malawi and existing international human rights principles, norms and standards.
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Prevention, treatment, care, support and impact mitigation are mutually reinforcing elements on the continuum of an effective response to HIV/AIDS.
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Certain social, political and economic conditions create and sustain vulnerability to HIV infection, including:
- the unequal position of girls and women in society and the fact that, due to biological, social, cultural and economic factors, women and girls are more likely to become infected and can be more adversely affected by HIV/AIDS than men;
- the reality that people living with HIV/AIDS are discriminated against and marginalised, leading to lack of individual and collective well-being, development and human security.
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Culture and religion have a strong influence on lifestyle choices.
Thus, Government commits to:
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Advancing a public health-based response that integrates principles of prevention, treatment, care and support.
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Promoting and protecting human rights in accordance with the Constitution of Malawi and international human rights conventions which Malawi has endorsed to effectively address the social, political and economic factors that increase vulnerability to HIV infection and negatively affect people living with HIV/AIDS.
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Applying resources transparently, accountably and responsibly, including financial, technical and human resources, as well as infrastructure and community contributions--in cash, kind and time.
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Ensuring that decision-making and delivery of this policy is transparent and accountable.
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Ensuring timely and sustained action.
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Implementing a multi-sectoral response where resources are harmonised for maximum impact.
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Ensuring that resources and programmes of government and partners are equitably distributed to all parts of Malawi.
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Guiding Principles
This policy shall be guided by, governed by and based on the following principles:
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Political leadership and commitment
Strong political leadership and commitment at all levels is essential for a sustained and effective response to HIV/AIDS.
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Multi-sectoral approach and partnerships
An effective response to HIV/AIDS requires the active involvement of all sectors of society. Thus, a multi-sectoral approach is required that includes partnerships, consultations and coordination with all stakeholders, particularly PLWAs, in the design, implementation, review, monitoring and evaluation of the national response to HIV/AIDS.
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Public health approach
A public health approach reduces the risk of transmission by intensive mass education on modes of transmission and ways to reduce risk, widespread and vigorous use of barrier methods, antibody testing, beneficial disclosure or notification of partners, prevention of mother-to-child transmission (PMTCT) services, and medical treatment and management of infected individuals.
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Promotion and protection of human rights
International human rights law and the Constitution of Malawi guarantee the right to equal protection before the law and freedom from discrimination on grounds, singly or in combination, of race, colour, sex, language, religion, political or other opinion, nationality, ethnic or social origin, disability, property, birth or other status. Discrimination on any of these grounds is not only inherently wrong but also creates and sustains conditions leading to vulnerability to HIV infection and to receiving inadequate treatment, care and support once infected.
Groups suffering from discrimination which makes them vulnerable to HIV/AIDS include women and young girls, orphans, widows and widowers, children and young people, the poor, sex workers, prisoners, mobile populations, persons engaged in same-sex relationships, people with disabilities and PLWAs.
An effective response to the epidemic requires that the rights to equality before the law and freedom from discrimination are respected, protected and fulfilled--in particular, in gender relations among women, men, girls and boys.
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The greater involvement of PLWAs
The greater involvement of PLWAs at all levels is crucial for an effective response to HIV/AIDS.
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Good governance, transparency and accountability
An effective national response to the epidemic requires government to provide leadership, good governance, transparency and accountability to effectively mobilise resources--including, but not limited to, financial resources--and to prudently manage resources at all levels and in all sectors.
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Scientific and evidence-based research
It is essential that the national response to HIV/AIDS be based on sound, current, empirically-based research. As aspects of the epidemic continually change and as scientific, medical and programmatic knowledge of the worldwide pandemic progresses, our understanding of the HIV/AIDS epidemic and how best to respond to it must likewise evolve.
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