HIV/AIDS in Malawi: Difference between revisions

The HIV/AIDS epidemic in Malawi began in 1985, when the first case of HIV/AIDS was identified in Lilongwe, Malawi's capital.^[1] Since then, due to a number of policies and initiatives by non-governmental organizations and the Malawian government, HIV prevalence rates in Malawi have gradually decreased.^[2] However, the epidemic is perpetuated by many factors, including unprotected heterosexual sex, discrimination, and gender inequality.^[1] In addition, Malawi faces many other barriers to the prevention and treatment of HIV/AIDS, including a lack of trained health care professionals, limited access to health services, and inadequate physical infrastructure.^[3]

The first case of HIV/AIDS in Malawi was reported at Lilongwe's Kamuzu Central Hospital in 1985.^[1] President Hastings Banda, who was in power at the time, responded with several small-scale prevention initiatives and created the National AIDS Control Programme, a division of the Ministry of Health, to manage the growing epidemic.^[2] Banda believed that issues relating to sex, including HIV transmission, should not be addressed in the public sphere; during this time, it was illegal for Malawian citizens to discuss the epidemic openly.^[4] In 1989, Banda introduced a five-year World Bank Medium Term Plan to combat the epidemic, but HIV prevalence had already increased drastically at this point.^[2]

In 1994, when Bakili Muluzi became president, he addressed the nation's need for a coordinated response to the growing epidemic.^[2] In 2000, Muluzi introduced another five-year policy known as the National Strategic Framework, but, like Banda's five-year World Bank Medium Term Plan, this strategy was largely ineffective.^[2] In 2001, the Malawian government replaced the National AIDS Control Programme with the National AIDS Commission, hoping that the National AIDS Commission would address the epidemic successfully.^[2] Unlike Banda, who had prevented the public from accessing information about the epidemic, Muluzi ensured that information about HIV/AIDS was available on the radio and television, in newspapers, and on billboards.^[4] However, despite Muluzi's efforts, HIV prevalence was already significantly influencing national agricultural productivity during this period, and Malawi experienced an AIDS-related nationwide famine in 2002.^[2]

Malawians gained access to antiretroviral drugs in 2003, and with a donation from the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the election of new President Bingu wa Mutharika in 2004, government interventions increased substantially.^[2] However, soon after his election, Mutharika experienced tensions with Muluzi because of his anti-corruption program, which distracted the government from addressing the nation's food and HIV/AIDS-related crises.^[5] Despite these obstacles, Mutharika successfully implemented a National AIDS Policy and appointed a Principal Secretary for HIV/AIDS during his presidency.^[2]

Various studies have demonstrated that knowledge regarding HIV/AIDS is high among people living in both urban and rural Malawi.^[6] According to a random sampling of 100 households by Barden-O'Fallon et al. in 2004, women in Malawi are most likely to learn about HIV/AIDS through radio and television, local health workers, and their female friends. Among men, the most common sources of information about HIV/AIDS are radio and television; however, some men also gain information from their male friends.^[6] When 57 Malawian men were interviewed in 2003, 100% said they had heard a radio broadcast about HIV/AIDS, 84.2% said they had heard about HIV/AIDS at a clinic or hospital, and 63.2% said that somebody had come to their homes to discuss HIV/AIDS with them.^[4]

Studies have indicated that personal characteristics such as age, gender, and education level correlate, either positively or negatively, with HIV/AIDS awareness levels. For example, older women are more likely to be knowledgeable about HIV/AIDS than younger women.^[6] Because men have greater access to education and other resources, they are typically more knowledgeable about HIV/AIDS than women.^[6] For example, while men are, on average, able to list 2.2 ways to avoid contracting HIV, women are only able to list 1.5 ways; condom use, abstinence, and monogamy are the most commonly known means of HIV/AIDS prevention.^[6] Only 38% of women surveyed in 2003 and 2004 understood that their husbands would be less likely to contract HIV if they used condoms during intercourse with prostitutes.^[5] In addition, for men in particular, place of childhood residence corresponds to HIV/AIDS awareness; men raised in towns or cities are, on average, more informed about HIV/AIDS than men who grew up in villages.^[6] Men and women who have received primary school educations are slightly more informed about HIV/AIDS than men and women who have never attended school.^[6] In addition, men and women who have received secondary school educations are significantly more likely to understand nuanced aspects of the disease, such as the fact that people who look healthy can still be HIV-positive.^[6] People who have lost friends or relatives to HIV/AIDS, been personally tested for HIV, or received treatment for sexually transmitted infections are also likely to be more knowledgeable about the disease.^[6]

The aforementioned study by Barden-O'Fallon et al., which surveyed 940 women and 661 men, indicated that, despite their knowledge and awareness, many people in Malawi do not feel personally susceptible to HIV infection.^[6] On average, only 23% of adults believe that their risk of infection is moderate to high.^[6] HIV/AIDS awareness among men does not seem to correspond to increased perceived risk; on the other hand, although women are typically less informed than men, increased levels of knowledge about HIV/AIDS do cause an increase in perceived risk among women.^[6] Another study conducted in rural Malawi between 1998 and 2001 by Kirsten P. Smith et al. indicated that perceived risk declined during this four-year time frame, probably because the increased use of preventative strategies gave people a sense of control.^[7] According to this study, men are also less likely to express concerns about HIV/AIDS than women.^[7] This could be due to the common belief that men behave promiscuously, making women more likely than men to worry that their spouses will infect them with HIV.^[7] In fact, many men in this study claimed that they were "not at all worried" about HIV/AIDS, which could either be interpreted as a form of fatalism or an indication that they believe their behavioral changes have reduced their risk of exposure.^[7]

Students in Malawi have expressed high levels of dissatisfaction regarding the HIV/AIDS-related education and support they receive at school. According to a survey of secondary students in Malawi, less than one-third of students are satisfied with the HIV/AIDS curricula at their schools.^[8] Although non-governmental organizations and the Malawian government have conducted many education-oriented campaigns, there is still a significant shortage of audio and visual educational materials relating to HIV/AIDS available to instructors, particularly in rural areas; also, these materials are often non-stimulating, so they remain largely unused.^[8] In addition, many schoolchildren are able to identify at least one classmate who is caring for a family member infected with HIV/AIDS, but most teachers are unable to do the same, which suggests that school-based support for HIV/AIDS is minimal.^[8] However, despite this lack of support, according to surveys conducted in Malawi, children from HIV/AIDS-affected families rarely experience stigma or discrimination at school from their teachers or peers.^[8]

Most schools are required to address HIV/AIDS prevention in their curricula, but teachers often address this information briefly or superficially, occasionally omitting it altogether. Although teachers are concerned about the epidemic and willing to serve as leaders in education and prevention, they face many barriers in addressing HIV/AIDS in the classroom.^[9] Instructors face personal barriers such as risky sexual behavior (which undermines their value as role models), discomfort in discussing the disease (traditional values condemn conversations about sexuality), and limited knowledge and awareness (due to a lack of training).^[9] In addition, teachers face several systemic barriers including fatalism, stigmatization, and denial regarding the epidemic; perceived constraints on teaching methods (for example, condoms are viewed as inappropriate for the classroom); and skepticism about support from the community.^[9]

However, despite this reluctance among teachers to discuss HIV/AIDS in the classroom, several techniques have successfully improved knowledge and awareness about HIV/AIDS among students.^[10] A study conducted in 1997 by Maclachlan et al. demonstrated that active learning approaches to AIDS education in Malawi could establish a thorough and accurate knowledge base among students.^[10] As part of this study, the students at one government-run secondary school completed an educational board game about HIV/AIDS once per week for four weeks, while the students at the other secondary school did not. The students at the first school answered more questions about HIV/AIDS correctly every week, and, by the end of the study, they scored significantly higher on a follow-up questionnaire about HIV/AIDS than the students at the second school, who had not played the educational board game.^[10]

The HIV/AIDS epidemic in Malawi is varied and diverse, with notable differences in infection rate between social groups, genders, and age groups. Most HIV infections in Malawi occur through heterosexual sex, but local studies have indicated that 21.4% of men who have sex with men in Malawi may be HIV-positive.^[2] In addition, rates of adult HIV/AIDS prevalence are higher among women than men, suggesting that women are particularly vulnerable to HIV contraction.^[2] Finally, HIV/AIDS has significantly impacted young people; 170,000 children were HIV-positive in Malawi in 2011, and the epidemic has drastically increased the number of orphans in Malawi.^[2]

Due to the vast scope of the HIV/AIDS epidemic, many Malawian men believe that HIV contraction and death from AIDS are inevitable.^[11] Some of these men believe that HIV contraction is preordained by God or other supernatural forces.^[11] Other men refer to their own characters or irresponsible sexual histories when explaining why they believe that death from AIDS is inevitable.^[11] These men often believe that abstinence and condom use "go against nature," making HIV contraction unavoidable. Finally, some men falsely claim that they have already been infected with HIV to justify their sexual histories and unsafe sexual practices, hoping to convince themselves that there is no need to use condoms or reduce their number of sexual partners.^[11] Because of these fatalistic beliefs, many men continue engaging in extramarital sexual relations despite the prevalence of HIV, and this behavior hastens the spread of the disease.^[4]

However, despite these widespread feelings of fatalism, some men believe that behavioral changes can and will protect them from HIV/AIDS. Men who decide to change their behavior to reduce their risk of infection are unlikely to practice strict monogamy, use condoms regularly, or decrease their number of sexual partners; instead, they usually become increasingly selective when choosing their extramarital partners.^[7] For example, they choose their sexual partners based on appearance, marital status, or age, and use their social networks to learn more about their partners' sexual biographies so they can reduce their risk of infection.^[7] Men who practice partner selection commonly believe that bar girls and "town women" who wear non-traditional clothing are more likely to carry HIV, while schoolgirls, who are perceived as sexually inexperienced, are considered "pure."^[11] Because of this perception, there is a growing concern that schoolchildren in Malawi, particularly girls, are contracting HIV as a result of sexual harassment or assault by their teachers and peers.^[11]

Women are particularly vulnerable to HIV contraction in Malawi due to gender inequality and widespread poverty.^[5] Because of their lower status, women often have limited access to education, employment, and productive resources such as land.^[5] Traditional gender roles place men, who are responsible for income generation, in the formal work sector, and relegate women to the domestic sphere; these power structures decrease women's autonomy, thereby increasing their vulnerability to HIV/AIDS. Women who are employed in the formal sector typically earn lower wages than men, giving them less bargaining power in the home.^[5] They are also less likely than men to benefit from government assistance or international aid initiatives.^[5]

Due to their vulnerable position, women are often afraid to discuss HIV/AIDS with their husbands, even if they know that their husbands are engaging in extramarital sex.^[5] The majority of women do not view divorce as an option, even when their husbands are HIV-positive and refuse to wear condoms.^[5] Because they lack the education needed to seek gainful employment, women often depend on their husbands for financial support.^[5] When men are unable to provide for their families, their wives become economically vulnerable; they often resort to commercial sex work to feed their children, but they lack the status to protect themselves by demanding that their clients wear condoms.^[5]

However, despite their vulnerability, some women in rural Malawi believe that they do, to a certain extent, have the ability to protect themselves from HIV contraction. Some women discuss the dangers of HIV/AIDS with their husbands directly, and many are confident that, by appealing to the needs of their children (who may be orphaned if their parents contract HIV), they will be able to convince their husbands to remain faithful.^[12] Others use their social networks as advocates, seeking help and advice from friends, family members, or respected counselors when they believe that their husbands' unsafe practices are putting their lives at risk.^[12] Some will publicly (and occasionally aggressively) confront their husbands' girlfriends as a way to control their husbands' sexuality.^[12] Finally, as a last resort, women might threaten to visit the ankhoswe, or traditional marriage counselor, and get divorced if their husbands refuse to take preventative measures.^[12]

Estimates suggest that 1.2 million children in Malawi had lost at least one parent due to HIV/AIDS by 2000.^[6] In addition, surveys conducted in schools indicated that 35% of students had lost at least one parent to AIDS, and around 10-12% of these children had lost both parents.^[8] Because HIV is transmitted sexually, when parents co-habit, their children are likely to become double orphans when one of their parents contracts the disease. Double orphans usually live in child-headed households, responsible for the care of their younger siblings.^[8] Many double orphans in Malawi do not attend secondary school, presumably because they do not have the financial resources or time (due to their care-taking responsibilities) to do so.^[8] AIDS orphans are often forced to migrate to cities to find work due to the limited earning opportunities available in rural areas, which increases their vulnerability.^[8]

Because men often leave the care of children to grandparents and other extended family members in the event of maternal death, only 19% of maternal orphans in Malawi live with their fathers.^[8] In Malawi, double orphans are usually sent to live in orphanages (21%) or with their grandparents (23%) and other relatives (21%).^[8] Despite common belief, there is no evidence indicating that extended family members commonly discriminate against orphans whose parents died from HIV/AIDS. In fact, it is likely that the role of extended family members in supporting HIV/AIDS orphans has reduced the devastating impact of the epidemic.^[13] However, female orphans are particularly vulnerable to sexual abuse because they are often forced into early marriages to relieve their guardians of extra care-taking responsibilities.^[8] In addition, although primary school absenteeism rates are high in general in Malawi, female double and paternal orphans in Malawi have particularly high rates of absenteeism.^[8]

Evidence suggests that many schoolchildren in Malawi are contracting HIV as a result of sexual harassment or assault by their teachers and peers.^[8] Adolescent boys and girls are often targeted by adults because they are perceived as sexually inexperienced, and, therefore, less likely to be HIV-positive. Schoolchildren are particularly vulnerable to "transactional" sexual advances by adults because, due to their poverty, they are often unable to afford school fees, books, or even food, making them susceptible to sexual exploitation.^[8] Many young girls living in poverty agree to engage in sexual relations with older men, including their teachers, because the men give them money and gifts, which the girls can use to improve their families' quality of life. Interviews indicate that teachers and school administrators in Malawi often do not understand the meaning of sexual harassment: some believe that sexual relations between teachers and students represent consensual sex and "normal" sexual relations, not harassment or assault.^[8] Because of this misunderstanding, teachers in Malawi, particularly male teachers, are unlikely to admit that sexual harassment and assault are problems at their schools. Although regulations for punishing teachers who sexually harass or assault students are in place, they are often ineffective.^[8] In Malawi, allegations alone warrant punitive action, but allegations are uncommon because children are hesitant to accuse adults of wrongdoing. In addition, teachers are often unwilling or unable to investigate the truth behind the accusations.^[8]

Although condom use outside of marriage is growing in Malawi, the acceptability of condom use within marriage does not seem to be increasing significantly. The association between condoms and commercial sex work is widespread, and, therefore, condom use is seen as inappropriate during marital sex, which is supposed to be based on trust and mutual commitment.^[14] Many believe that condom use within marriage violates the purposes of marriage in the eyes of God: sexual pleasure and procreation.^[14] In a study published in 2007 by Agnes M. Chimbiri, only 2.3% of respondents used condoms consistently with their spouses, and only 18.2% used condoms regularly during other "casual" sexual encounters.^[14] Men cited pregnancy prevention as the primary reason why they used condoms with their wives, but they cited protection against sexually transmitted infections as the most important reason why they used condoms during their extramarital sexual encounters.^[14]

Both formal and informal sources of information are important in catalyzing discussions about HIV/AIDS among married couples. When men and women have accessed information about HIV/AIDS from clinics, radio broadcasts, or conversations with peers, they are more likely to discuss the risk of HIV/AIDS contraction with their spouses.^[15] Concerns about being infected with HIV, which are often motivated by concerns about infidelity, play an imporant role in motivating conversations between couples about the risk of HIV/AIDS. Surprisingly, education levels do not significantly impact the likelihood that couples will discuss the risk of HIV/AIDS; however, couples that have discussed family planning issues are more likely to discuss the risk of HIV/AIDS.^[15] In addition, couples are more likely to have discussions regarding HIV/AIDS when wives understand that their husbands can contract the disease from "healthy-looking" extramarital partners.^[15]

Rates of discussion about HIV/AIDS among married couples are higher in the southern matrilineal/matrilocal regions of Malawi, which suggests that female autonomy and status are positively correlated with spousal conversation regarding HIV/AIDS.^[15] On the other hand, in the northern patrilineal/patrilocal regions of Malawi, many women are raised to believe that their husbands have the sole right to make decisions about condom use and sexual relations.^[15] However, in both the patrilineal/patrilocal North and the matrilineal/matrilocal South, women occasionally claim that there is "no point" in discussing HIV/AIDS with their husbands, either because they trust them to remain faithful, or because they do not believe their conversations will change their husbands' desire for extramarital sex.^[15]

A study conducted by CARE International across three districts in the Central Region of Malawi in 2002 examines the impact of the HIV/AIDS epidemic on the productivity and livelihoods of families in rural Malawi.^[16] When skilled laborers are unable to work due to HIV/AIDS, their families must shift away from labor-intensive crops such as tobacco towards less labor-intensive crops, which are often less profitable.^[17] In addition, the sudden disease or death of skilled laborers affects the productivity of their household members and relatives, who must spend time caring for them, accompanying them to the hospital, and acquiring medications for them.^[16] Because of this loss of labor, households are often forced to postpone their agricultural activities, leave their land fallow, sell their produce before maturity for reduced profits, or change their sources of livelihood entirely.^[16] In addition, when family members fall ill, households must use money reserved for agricultural inputs such as fertilizers or seeds to support medical and transportation-related costs, further decreasing economic stability at the household level.^[16] Finally, adults who are burdened by the HIV/AIDS epidemic often withdraw their children from school, threatening long-term national productivity.^[17] In summary, these local changes decrease physical, social, and natural capital in Malawi, and this has negative long-term implications for the national economy.^[17]

CARE International proposes several interventions that might reduce the economic burden of HIV/AIDS on rural households.^[16] They recommend introducing new technologies and less labor-intensive crops to allow households affected by HIV/AIDS to continue supporting themselves through agriculture.^[16] Women in patrilineal/patrilocal villages often experience pressure to leave their villages when their husbands die of HIV/AIDS; therefore, helping women acquire traditionally masculine agricultural skills such as the ability to cultivate tobacco may decrease their vulnerability while improving agricultural productivity at the household and community levels.^[16] CARE International recommends improving community, faith, and kinship-based support networks, which can provide information, advice, and emotional and financial support to affected households.^[16] They also suggest promoting the development of community-based labor and food banks, which can serve as safety nets for families affected by the epidemic.^[16] Finally, CARE International highlights the importance of increasing advocacy and information flow regarding HIV/AIDS in Malawi to help families prepare for and cope with the economic burdens associated with the epidemic.^[16]

The HIV/AIDS epidemic in Malawi has been characterized by increasing demands on health services and drastic declines in the number of health workers available to provide treatment and care. Hospital-based studies indicate that 70% of all admissions to hospital wards in Malawi are due to HIV-related conditions.^[18] However, Malawi currently faces a significant deficit in health workers: according to the national Human Resources for Health census, there were only 159 doctors and 3,614 nurses and midwives working in Malawi in 2007.^[19] The World Health Organization's Essential Health Package recommends placing two nurses or midwives and one clinical officer at every health center in the country, but the vast majority of Malawi's health facilities fail to satisfy this recommendation.^[19]

While migration to more developed countries in search of better opportunities, also known as "brain drain," is partially responsible for the shortage of health care workers in Malawi, many health care workers have been personally affected by the HIV/AIDS epidemic; in fact, an average of four nurses die of HIV/AIDS in Malawi every month.^[2] The HIV/AIDS epidemic has also led to chronic absenteeism among many health workers in Malawi, either due to personal infection or the deaths of family members, and there are no policies in place to hire replacements for people who are chronically absent due to long-term illnesses.^[18] Because of this, the government often takes up to a year to hire new health workers, which creates additional strain for the remaining health workers. These health workers frequently abandon their posts because they are unable to manage the increased workload or because they are afraid of becoming infected, either with HIV or HIV-related infections such as tuberculosis.^[18]

Because of this deficit in health workers, Malawi has adopted task shifting strategies to overcome the shortage of workers available for HIV/AIDS treatment and care.^[19] Task shifting involves training less specialized health workers such as nurses and non-physician clinicians to perform medical tasks that require less knowledge and training, such as the initiation of antiretroviral therapy (ART).^[19] For example, at Thyolo District Hospital, health workers undergo a one-week classroom training course and a two-week clinical attachment before they receive a certificate and are legally (under Ministry of Health guidelines) allowed to initiate ART.^[19] Another form of task shifting involves training counselors in HIV testing and counseling, which relieves nurses of this additional task.^[19]

Malawi has taken many steps towards slowing the spread of HIV, including the implementation of voluntary counseling and testing services, mass media campaigns, life skills education for children and young adults, and mother-to-child transmission prevention services, as well as the promotion of condoms, voluntary medical male circumcision, and blood safety campaigns.^[2] Access to antiretroviral therapy is limited in Malawi, particularly in rural areas, so many interventions have promoted prevention rather than treatment.^[6] However, the Malawian government and non-governmental organizations have faced many structural barriers in implementing these interventions including stigmatization of the disease and limited health infrastructure.^[2]

In 2011, international donors funded over 75% of Malawi's HIV/AIDS interventions.^[2] Malawi's most notable international donors include the World Bank, the Global Fund, the World Health Organization, the President's Emergency Plan for AIDS Relief (PEPFAR), and the Joint United Nations Programme on HIV and AIDS (UNAIDS).^[2] The World Bank has lent $407.9 million to Malawi, the Global Fund has agreed to give $390 million, and PEPFAR has promised to give $25 million towards condom distribution and other prevention-oriented programs.^[2] In 2011, Malawi devoted 65.9% of its national budget towards treatment and care, and only 11% towards prevention strategies.^[2]

Recent studies have suggested that the number of people receiving antiretroviral treatment in Malawi has increased dramatically in the past decade: in 2004, only 13,183 people were receiving antiretroviral therapy, but in 2011, 322,209 people were receiving treatment.^[2] This success stems partially from the fact that Malawi introduced the World Health Organization's treatment guidelines in 2008, which improved the treatment timeline and the quality of the drugs.^[2] However, Malawi's proposals for a new antiretroviral treatment plan in 2011, which would have cost $105 million per year, were rejected by the Global Fund, threatening Malawi's ability to increase national access to antiretroviral treatment.^[2]

In 2000, Malawi's Ministry of Health and Population planned to use the public health system to distribute antiretroviral drugs to the population, and, as of 2003, there were several sites providing antiretroviral drugs in Malawi.^[18] The Malawian government sponsors the provision of antiretroviral drugs at the Lighthouse, a Malawi-registered trust in Lilongwe that fights HIV/AIDS, at a cost of 2,500 kwacha per month.^[18] Queen Elizabeth Central Hospital provides antiretroviral therapy through its outpatient department, and Médecins Sans Frontières distributes free medication in the Chiradzulu and Thyolo Districts.^[18] In cities, many private providers sell antiretroviral drugs for-profit; however, very few patients can afford to receive drugs from the private sector in Malawi.^[18] In addition, private providers are not currently required to obtain certification before selling antiretroviral drugs, and, therefore, this practice is largely unregulated.^[18] Finally, some employees receive access to antiretroviral drugs through their workplaces, but this practice is not widespread.^[18]

Due to the advent of antiretroviral drugs, HIV/AIDS has become a manageable disease for people who can access and afford treatment; however, antiretroviral therapy remains largely inaccessible to most people in Malawi.^[18] Malawi's National HIV/AIDS Policy highlights the need for equitable access to antiretroviral therapy, but this goal has not yet been achieved: 449 clinics offer antiretroviral therapy in Malawi, but the South East region of Malawi has disproportionately limited access to treatment.^[2] In many rural areas, limited transportation, poor health infrastructure, drug shortages, and food crises have made sustained, high-quality antiretroviral therapy difficult or impossible.^[2] In addition, donations from the Global Fund to Fight AIDS, Tuberculosis, and Malaria were used to fund antiretroviral therapy programs that distributed medication on a "first-come, first-served" basis, making the drugs more accessible to the male, urban, educated population.^[18] Because there are no explicit policies regarding the equitable distribution of antiretroviral drugs, individual health care workers often become responsible for deciding who will receive treatment, which inevitably leads to "informal" selection and corruption.^[18]

Although latex condoms, when used correctly, prevent the spread of HIV effectively, several factors have limited widespread condom use in Malawi.^[2] Condoms are often inaccessible to people living in rural areas, and they are rarely provided at bars or other places of entertainment, where they could have a significant impact on HIV prevention.^[2] Many people oppose condom use because they believe condoms make sex less enjoyable, are ineffective, or even cause the spread of HIV.^[2] As mentioned previously, women, both married and unmarried, are often unable to request that their sexual partners use condoms, which increases their vulnerability to HIV/AIDS.^[2] However, despite these factors, many unmarried couples have started relying on condoms more frequently in Malawi, which is probably due to widespread concern about HIV contraction.^[14]

Many non-governmental organizations in Malawi, including Population Services International and Banja La Mtsogolo, have conducted campaigns to increase knowledge regarding condom use and distribute condoms to the public.^[2] Banja La Mtsogolo, an organization founded in 1987 that provides family planning services to women in Malawi, has conducted widespread educational campaigns about female condom use.^[2] Together, Population Services International and Banja La Mtsogolo provided 4.3 million condoms to the public between 2009 and 2010.^[2] Because of their efforts, condoms have become both more accessible and more acceptable to many people living in Malawi.^[2]

In 2000, Malawi's Council of Churches condemned the promotion of condom use by the Malawian government and non-governmental organizations, arguing that condoms encourage promiscuity, which is viewed as immoral by the church.^[4] The Church in Malawi claims that monogamy and abstinence are the only reliable ways to prevent infection, denying the effectiveness of latex condoms.^[4] However, recent evidence has suggested that some faith-based organizations in Malawi have started promoting condom use, particularly among those who have multiple sexual partners.^[2]

People living in areas with high rates of HIV/AIDS, including Malawi, face many psychological barriers when deciding whether to undergo testing for HIV.^[2] For example, people may prefer not to know if they are HIV-positive, have religious beliefs that prevent them from getting tested, not know about the testing services that are available to them, assume that they have already been infected, or believe that they have no chance of being infected.^[2] However, despite these barriers, both mobile and static testing services have become more widely available in Malawi: 1,392 testing and counseling sites existed in 2011, and more than 1.7 million people took advantage of these services.^[1] Certain non-governmental organization such as the Malawi Aids Counseling and Resource Organisation (MACRO) provide door-to-door counseling and testing services, which have greatly improved accessibility.^[1] According to the Malawi Demographic and Health Survey conducted in 2010, 96.9% of women and 96.4% of men between ages 15 and 49 were aware of at least one location where they could receive an HIV test, and 73.1% and 52.2% of female and male respondents, respectively, had actually been tested for HIV.^[1] Among both men and women, respondents with higher incomes and education levels were more likely to have undergone testing for HIV.^[1]

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