Kachirombo ka Edzi
Kachirombo ka Edzi. The wee AIDS beast. The beast that came to Malawi as early as the late 1970s and started to take its toll and show its effects in the 1980s. An unknown beast popularly called “the slimming disease” or “kaliwondewonde” since those with it became noticeably very thin. A stigmatizing impact that persists in Malawian culture up to today- that thin means sick and overweight/obesity means healthy. A beast largely spread through heterosexual relationships opposite to many trends seen in the West. A beast that changed the fabric of societies and left many children without their biological parents.
The first hospital case of HIV was reported in Malawi in 1985 at Kamuzu Central Hospital. Kwabwera Edzi- AIDS has arrived. In Chichewa, HIV/AIDS had many names: “magawagawa” (something shared), “chiwerewere” (promiscuity), matenda aazimayi (the disease you catch from women) and mtengano (dying in twos). But Edzi, an onomatopoeic version of AIDS in Chichewa, is what is popularly used in the present time.
Funding for HIV began in Malawi around 1985 and helped establish a National AIDS Secretariat. The National AIDS Commission (NAC) was founded in 1989. But even with such systems established, the government response to HIV under Kamuzu Banda was slow, apathetic and marked by elements of denial. Under Kamuzu Banda the country was highly conservative with family planning even banned until 1982 and by 1994 only 43 out of 756 government health facilities provided family planning services. With discussion of sexual matters taboo and even forbidden, there wasn’t much one could discuss in terms of HIV transmission and prevention. This persisted regardless of the fact that Kamuzu Banda was himself a trained medical practitioner. This led to another name evolving for HIV: matenda a boma (government’s disease). Many thought HIV was invented by the government of Malawi or the West as a family planning measure in Africa.
Even after the transition to mutli-party democracy in 1994, the new administration still initially failed to address the crisis with the urgency it deserved. The International Monetary Fund (IMF) was also largely criticized during this time for encouraging African governments to implement Structural Adjustment Programs (SAP) in return for loans which decreased the amount of state funding for healthcare among other state services which many argue worsened poverty and disease. Because of this, by 1995 one in three of all hospital admissions were due to HIV/AIDS related illnesses and prevalence rates among pregnant women ranged to up to 33% in Blantyre- a large urban district in Southern Malawi. There was an estimated 250,000 new cases and 74,900 deaths in 1995. The virus targeted everyone from government officials to urban and rural men and women with women acquiring HIV at a higher rate. Overall, the Malawi epidemic is a generalized one meaning it affects not only high risk populations but the general population as well.
By 2005, there were 98,000 new HIV infections per year. The wee AIDS beast was out of control and a strong intervention was needed. In 2004, the Malawi government rolled out free antiretroviral treatment prior to which there was very limited accessible treatment options. ARVs are given free of charge in Malawi to anyone living with HIV but is heavily donor dependent. Currently treatment for HIV is funded through the Global Fund to Fight AIDS, Tuberculosis and Malaria. In Malawi, this system of care is known as a public health approach which focuses on task shifting around care to ensure the large population of clients living with HIV are all able to be managed with guidelines clear and simple enough for lay cadres to understand and administer care. All patients follow similar algorithms which guide their care and treatment.
According to UNAIDS, by 2016 approx. 1 million people were living with HIV (Malawi’s projected population is approx. 17.5 million) with 39,000 new infections and 17,000 deaths per year. According to the Malawi Population HIV Impact Assessment Survey (MPHIA 2015/2016), prevalence rates for adults 15-64 years is around 10%. About 1 out of every 5 households is affected by HIV. Of those adults 15-64 years living with HIV, about 77% of them know they are HIV positive and 91% of these people are on antiretroviral treatment. [Note: Numbers vary slightly based on source and sampling methods.]
Our work now focuses on supporting people to stay on treatment and not default, continuing efforts around prevention (especially for vulnerable young girls) and to find the remaining undiagnosed HIV positive populations and encourage them to be started on treatment. And not just treatment but treatment that is responsive to the needs of individual clients including monitoring their viral load status, nutritional status and other opportunistic infections and diseases. Thanks to new research, it has been shown that if a person living with HIV stays on treatment and has an undetectable viral load (basically meaning HIV levels are so low they cannot be detected through standard viral load tests using blood sampling) then they cannot transmit HIV to other people. This information is popularly disseminated through a campaign known as Undetectable = Untransmittable.
In 2014 the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched a campaign called 90-90-90. The targets to be achieved by the year 2020 were to diagnose 90% of all HIV positive persons, to provide antiretroviral therapy (ART) to 90% of those diagnosed and to achieve 90% viral suppression of those on treatment. As seen above, according to MPHIA results, Malawi is well on its way to achieving these ambitious targets. But it doesn’t mean there’s not more work to do. We must maintain vigilance to keep the gains we have made so far. We must ensure prevention remains prioritized. And we must aim to completely eliminate mother to child transmission and injustices that put young girls at a higher risk. As Mark Green (USAID Administrator) stated, on World AIDS Day "we're celebrating progress, not victory. There is much work ahead of us."
In Malawi, HIV is largely diagnosed through a simple rapid blood test which detects antibodies. Just the prick of a finger. And in recent years, HIV self-testing (using an oral sample) has been piloted and is rolling out this year across the country in order to reach more undiagnosed people. While the past may look glim, the future can indeed be one of hope and restoration. The work towards HIV epidemic control and a cure continues on. Although faced with a slow initial response to the epidemic, Malawi has become known over the years for its excellent work in HIV care and treatment and bold policy measures in order tackle mother to child transmission. For example, Malawi was one of the first countries in 2011 to roll out a program known as Option B+. This allowed pregnant women lifelong and consistent access to treatment regardless of their CD4 count or AIDS progression. And in 2015/16 Malawi extended and rolled out this provision to all people living with HIV through a policy called “Test and Treat.” As soon as anyone tested positive they could immediately start treatment for life whereas previously certain thresholds had to be met.
If Malawi continues on this now bold approach the elimination of HIV/AIDS can become more than just a dream. While donor funding and HIV/AIDS program fatigue presents a great threat to Malawi and many other countries around the progress made, the vision for elimination is one that we must jointly remain behind and committed to. May we never fall back into the silence from which we came.
The first hospital case of HIV was reported in Malawi in 1985 at Kamuzu Central Hospital. Kwabwera Edzi- AIDS has arrived. In Chichewa, HIV/AIDS had many names: “magawagawa” (something shared), “chiwerewere” (promiscuity), matenda aazimayi (the disease you catch from women) and mtengano (dying in twos). But Edzi, an onomatopoeic version of AIDS in Chichewa, is what is popularly used in the present time.
Funding for HIV began in Malawi around 1985 and helped establish a National AIDS Secretariat. The National AIDS Commission (NAC) was founded in 1989. But even with such systems established, the government response to HIV under Kamuzu Banda was slow, apathetic and marked by elements of denial. Under Kamuzu Banda the country was highly conservative with family planning even banned until 1982 and by 1994 only 43 out of 756 government health facilities provided family planning services. With discussion of sexual matters taboo and even forbidden, there wasn’t much one could discuss in terms of HIV transmission and prevention. This persisted regardless of the fact that Kamuzu Banda was himself a trained medical practitioner. This led to another name evolving for HIV: matenda a boma (government’s disease). Many thought HIV was invented by the government of Malawi or the West as a family planning measure in Africa.
Even after the transition to mutli-party democracy in 1994, the new administration still initially failed to address the crisis with the urgency it deserved. The International Monetary Fund (IMF) was also largely criticized during this time for encouraging African governments to implement Structural Adjustment Programs (SAP) in return for loans which decreased the amount of state funding for healthcare among other state services which many argue worsened poverty and disease. Because of this, by 1995 one in three of all hospital admissions were due to HIV/AIDS related illnesses and prevalence rates among pregnant women ranged to up to 33% in Blantyre- a large urban district in Southern Malawi. There was an estimated 250,000 new cases and 74,900 deaths in 1995. The virus targeted everyone from government officials to urban and rural men and women with women acquiring HIV at a higher rate. Overall, the Malawi epidemic is a generalized one meaning it affects not only high risk populations but the general population as well.
By 2005, there were 98,000 new HIV infections per year. The wee AIDS beast was out of control and a strong intervention was needed. In 2004, the Malawi government rolled out free antiretroviral treatment prior to which there was very limited accessible treatment options. ARVs are given free of charge in Malawi to anyone living with HIV but is heavily donor dependent. Currently treatment for HIV is funded through the Global Fund to Fight AIDS, Tuberculosis and Malaria. In Malawi, this system of care is known as a public health approach which focuses on task shifting around care to ensure the large population of clients living with HIV are all able to be managed with guidelines clear and simple enough for lay cadres to understand and administer care. All patients follow similar algorithms which guide their care and treatment.
According to UNAIDS, by 2016 approx. 1 million people were living with HIV (Malawi’s projected population is approx. 17.5 million) with 39,000 new infections and 17,000 deaths per year. According to the Malawi Population HIV Impact Assessment Survey (MPHIA 2015/2016), prevalence rates for adults 15-64 years is around 10%. About 1 out of every 5 households is affected by HIV. Of those adults 15-64 years living with HIV, about 77% of them know they are HIV positive and 91% of these people are on antiretroviral treatment. [Note: Numbers vary slightly based on source and sampling methods.]
Our work now focuses on supporting people to stay on treatment and not default, continuing efforts around prevention (especially for vulnerable young girls) and to find the remaining undiagnosed HIV positive populations and encourage them to be started on treatment. And not just treatment but treatment that is responsive to the needs of individual clients including monitoring their viral load status, nutritional status and other opportunistic infections and diseases. Thanks to new research, it has been shown that if a person living with HIV stays on treatment and has an undetectable viral load (basically meaning HIV levels are so low they cannot be detected through standard viral load tests using blood sampling) then they cannot transmit HIV to other people. This information is popularly disseminated through a campaign known as Undetectable = Untransmittable.
In 2014 the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched a campaign called 90-90-90. The targets to be achieved by the year 2020 were to diagnose 90% of all HIV positive persons, to provide antiretroviral therapy (ART) to 90% of those diagnosed and to achieve 90% viral suppression of those on treatment. As seen above, according to MPHIA results, Malawi is well on its way to achieving these ambitious targets. But it doesn’t mean there’s not more work to do. We must maintain vigilance to keep the gains we have made so far. We must ensure prevention remains prioritized. And we must aim to completely eliminate mother to child transmission and injustices that put young girls at a higher risk. As Mark Green (USAID Administrator) stated, on World AIDS Day "we're celebrating progress, not victory. There is much work ahead of us."
In Malawi, HIV is largely diagnosed through a simple rapid blood test which detects antibodies. Just the prick of a finger. And in recent years, HIV self-testing (using an oral sample) has been piloted and is rolling out this year across the country in order to reach more undiagnosed people. While the past may look glim, the future can indeed be one of hope and restoration. The work towards HIV epidemic control and a cure continues on. Although faced with a slow initial response to the epidemic, Malawi has become known over the years for its excellent work in HIV care and treatment and bold policy measures in order tackle mother to child transmission. For example, Malawi was one of the first countries in 2011 to roll out a program known as Option B+. This allowed pregnant women lifelong and consistent access to treatment regardless of their CD4 count or AIDS progression. And in 2015/16 Malawi extended and rolled out this provision to all people living with HIV through a policy called “Test and Treat.” As soon as anyone tested positive they could immediately start treatment for life whereas previously certain thresholds had to be met.
If Malawi continues on this now bold approach the elimination of HIV/AIDS can become more than just a dream. While donor funding and HIV/AIDS program fatigue presents a great threat to Malawi and many other countries around the progress made, the vision for elimination is one that we must jointly remain behind and committed to. May we never fall back into the silence from which we came.
World AIDS Day 2018. WAD30. Know Your Status.
References:
1. HIV & AIDS in Africa: Beyond Epidemiology. 2004. “Politics, Culture and Medicine: An Unholy Trinity? Historical Continuities and Ruptures in the HIV/AIDS Story in Malawi.” John Lloyd Lwanda.
2. AIDS Anal Afr. 1996 Feb;6(1):1. “Malawi wakes up to harsh AIDS reality.”
3. Croat Med J. 2008 Dec; 49(6): 853-855. “Language as Vehicle for Spread and Prevention of HIV in Malawi.” Adamson S. Muula
4. Aidscaptions. 1995 Feb;2(1):40-2. “Visible political commitment sparks renewed effort to fight AIDS in Malawi. Policy profile.” Chirwa I.
5. Anthropology & Medicine. 2015. “Saying ‘No’ to PrEP research in Malawi: what constitutes ‘failure’ in offshored HIV prevention research?” K. Peterson et al.
6. Malawi Population-Based HIV Impact Assessment (MPHIA). 2015-2016. “Final Report October 2018.”
7. Avert.org. 2018 October. “HIV and AIDS in Malawi.”
8. UNAIDS.org. Malawi. Updated 2018.
Comments
Post a Comment