Culture Box THE FiGHT AGAiNST HiV/AiDS iN MALAWi
Malawi is a small country in Southern Africa. Its official languages are English and Chichewa, with other dialects of Bantu spoken as well (Rankin, Lindgren, Rankin, & Ng’ona, 2005). According to the Central Intelligence Agency’s World Factbook (CIA, 2013), Malawi was established as a British colony in 1891 and achieved independence in 1964, with the first democratic elections held in 1994. It has a total area of 118,480 square kilometers, making it slightly smaller than Pennsylvania. Women bear an average of five children and have a lower literacy rate than men (69% vs. 81%); however, it should be noted that this literacy rate is substantially higher than in the first edition of this text, then 50% to 76%. Eighty-three percent of the population is Christian and 13% is Muslim, with the rest declaring other (1.9%) or none (2.5%).
It is one of the world’s least developed nations, ranking 170 out of 187 countries on the Human Development Index and 124th out of 148 in gender equality (UNDP, 2013). Approximately half of the population lives below the international poverty line of USD$l.25/day, an improvement from 65% in 1998 (World Bank, 2013). Malawi has been heavily affected by AIDS, but it has made good progress in turning around the epidemic. The current life expectancy in Malawi is 52 years, a substantial increase from the 41 years expected at the time of the first edition of this text (CIA, 2013). The rate of infection was 14.1% in 2005; in 2011, the adult prevalence rate was 10% (UNAIDS, 2006, 2011b). The rate of new infections decreased more than 50% between 2001 and 2011 (UNAIDS, 2012a). Prevalence among young people and pregnant women has also decreased (Malawi Government, 2012).
The primary method of HIV transmission in Malawi is heterosexual sex (Malawi Government, 2012). Mother-to-child transmission had been quite high, but it has been substantially reduced. The number of sites providing PMTCT services increased to 544 in 2011 from 152 in 2006. In 2011, 82% of pregnant women who tested positive for HIV received ARV drugs; all women who are pregnant now receive them regardless of how far the illness has progressed (Malawi Government, 2012). About 20% of men are circumcised, but it varies widely by region and ethnic group (Malawi Government, 2012).
The previously discussed risk factors, such as orphanhood, condom use, circumcision, MSM, and low levels of knowledge, are all evident in Malawi. While awareness of HIV/AIDS is universal, comprehensive knowledge remains low—under 50% (Malawi Government, 2012). Orphans are more likely to have sex earlier than non-orphans (Mkandawire, Tenkorang, & Luginaah, 2013). Homosexuality is illegal in Malawi with a punishment of 14 years of hard labor (“Queer Malawi,” 2011). Interestingly, HIV continues to be correlated with higher wealth in Malawi; it is also more common in urban areas as opposed to rural ones. High-risk groups have included truck drivers (14.7% 2006 prevalence rate), police (28.3%), schoolteachers (23.4% primary, 17.2% secondary), sex workers (70.7%), and MSM (21.4%) (Malawi Government, 2012).
Stigma against those with HIV/AIDS has been decreasing, although it does still exist. Half of those living with HIV reported being gossiped about and 35% stated they had been verbally insulted, harassed, or threatened; one-third had been excluded from a social gathering (Malawi Government, 2012). Condom distribution remains below target. While traditionally faith-based organizations have denounced the use of condoms, recently some are now privately advising their members to use them (Malawi Government, 2012).
Economic migration assisted in the spread of AIDS in Malawi as it did in other nations. Between l985 and l993, the Malawian Army fought in Mozambique to defend a railway line. This army, consisting primarily of single men, took its “rest and relaxation” with sex workers in Malawi and Mozambique. Similarly, Malawian men emigrated to work in the South African gold mines and visited sex workers while there. Upon their return to Malawi, these gold miners were favored as husbands due to their comparatively high income. When both groups of these men returned to Malawian society, they transmitted the disease they had obtained while working outside of the country (Lwanda, 2004).
The government was reluctant to acknowledge the AIDS crisis at first. Even in 1994, when 20% to 30% of those hospitalized had HIV-related illnesses, the government continued to deny the crisis (Lwanda, 2005). There is a strong taboo in Malawian culture against speaking about sexual subjects not only in public but also within the family, even between husband and wife (Rankin, Lindgren, Rankin, & Ng’oma, 2005). In 2012, Joyce Banda became the president of Malawi after the sudden death of the previous president, Bingu wa Mutharika. Malawi had a series of proposals rejected by the Global Fund due to lack of faith in the fiscal management of the Mutharika administration, and Banda set out to increase international confidence in Malawi again. She also pledged to decriminalize homosexuality, but as of this writing, that has not yet occurred (“Where is HIV/AIDS,” 2012).
The cycle of AIDS increasing poverty can be seen easily in Malawi. The nation is dependent on its agriculture. As adults of working age are disabled or killed by the disease, familial poverty increases. Children are pulled from school for caretaking or farming duties. On a macro level, the decreasing agricultural output due to the disabled workforce increases food insecurity. In addition, the structural adjustment policies of the World Bank mandated that Malawi switch its agriculture to more exportable goods, as opposed to those that would feed its nation, again resulting in greater food insecurity. These policies also mandated the elimination of the subsidy for fertilizer (Bryceson & Fonseca, 2005), reducing its accessibility and thus lowering agricultural output. Food insecurity is an ongoing problem due to overuse of fields, natural occurrences such as floods and droughts, and rising inflation (World Food Programme, n.d.). This lack of food further weakens those infected with HIV and AIDS, pushing the cycle to start again.
Under colonial rule by the British, health care was highly segregated. “European-only” hospitals were in existence until 1972 (despite independence in 1964), and many of the qualified medical personnel focused on the care of the small European population. Therefore, people living in rural areas continued to rely on traditional medicine for their health care. In the early days of the AIDS epidemic, Malawians believed that talk of an epidemic was a family planning plot of the Americans, family planning being contrary to the values of their culture. Early public health interventions, with their reliance on condoms, violated both these values and the economic realities of the nation (Lwanda, 2004).
John Lwanda (2003, 2005), a physician from Malawi, notes the following cultural practices among ethnic groups in Malawi that can lead to HIV infection: nthena. when a widower is given his deceased wife’s younger sister; m'bvade. a practice in which the abstinence after childbirth of an unmarried woman is ceremoniously ended by surrogate sex with a designated man; chokolo. widow inheritance; and the use of fisi (surrogates) in infertility rites and in initiation ceremonies. There is also a strong faith in traditional medicine to protect against and heal HIV. However, he states that the strongest cultural contributor to the spread of HIV is the weak position of women in Malawian society. Rankin et al. (2005) noted that the Chichewa term for sexually transmitted infections translates as “women's disease.” If a man discovers he has an infection, he will tell his wife he has a “women's disease,” thus blaming her for the infection.
In Malawian society, women are expected to be subordinate to men. A woman is socialized never to refuse having sex with her husband, even if she suspects him of being unfaithful or of being infected with HIV (National AIDS Commission, 2003). It is seen as unnatural for men to go without sex: “manhood without sex is considered incomplete” (Lwanda, 2005, p. 134). This social inequality translates to increased infection rates for women. Among younger people, females have a much higher infection rate than males. Among those aged 15 to 24 years, approximately 1.9% of males are reported to have AIDS compared to 5.2% of females. This disproportion is true for every age group except those 40-44 years (Malawi Government, 2012).
Women living with HIV in Malawi have also reported marriage to be a risk factor. Women who never married have a much lower infection rate (4.2%) than those who are currently married (11.7%), divorced/ separated (24.8%), or widowed (50.1%) (Malawi Government, 2012). They report often getting married in a search for companionship but also due to poverty. Many were orphaned and lacked basic necessities
such as food, which led them to accept marriage proposals. However, once married, they reported high levels of infidelity and forced sex, as well as other forms of abuse and abandonment. Once abandoned, they were once again faced with the choice of poverty or a new marriage (Mkandawire-Valhmu et al., 2013).
Despite its struggles, Malawi has been a leader among African nations in many areas, including the care of the children left orphaned by AIDS. In 1992, it became the first nation in the region to develop guidelines for the care of these children, recommending that orphans be kept within their home communities (Mutume, 2001). Malawi has eliminated school fees and other educational costs to enable more students to attend schools (UNICEF, n.d.b). Education still remains problematic, however, due to familial poverty. Children are often needed to help bring money into the family rather than attending school, and Malawi has had difficulty retaining teachers due to the high number of deaths among working-age adults.
Malawi has developed child care institutions for children whose families are unable to care for them, community-based child care centers, and a cash transfer program. Similar to other nations, the cash transfer program has had very promising results to date. Health outcomes include increased food security and reduced malnutrition, as well as increased school enrollment and retention. Program recipients also have lowered dropout rates, reduced early marriage, and reduced sexual activity (Malawi Government, 2012). Another initiative has provided vocation skills training to orphans and other vulnerable children, such as carpentry or tailoring, skills in high demand (Rowan & Kabwira, 2009).
Malawi was the first nation in the region to develop and implement a national system for monitoring and evaluating the responses to HIV/AIDS within its borders (UNAIDS, 2004). ARV treatment is free and this access has greatly increased the life span for those living with HIV. However, drug shortages have become an ongoing problem (“Malawi’s never-ending,” 2013). There is also a severe shortage of health workers, facilities, and equipment to care for the affected population.
Therefore, organizations from around the world have been assisting the government of Malawi. Doctors Without Borders has been working with the government on “task shifting,” in which routine duties are shifted from doctors to other health workers. These duties include HIV tests and dispensing ARV medications (Doctors Without Borders, 2011; “Solving health worker,” 2008). Patients who are medically stable also need to see a medical worker only every 6 months rather than every 3 months, a 50% increase in available time for health workers (Doctors Without Borders, 2011).
The US Centers for Disease Control (2012) has also been assisting in training of health care workers, as well as supporting the improvement of laboratory services. Partners in Health, Dr. Farmer’s organization, has adapted its accompagnateur model. Its worker has a dirt bike, due to the poor roads and expense of fuel, and makes home visits to those who have stopped taking their medication. He is able to help determine why they have stopped (e.g., food insecurity or depression) and to talk with them about the consequences. This approach helps increase medication adherence (Partners in Health, 2013c).
The Coalition of Women Living with HIV/AIDS (COWLHA) in Malawi has been a major force in fighting against some of the factors that have particularly affected women (http://www.cowlhamw.com). They work on issues relating to women’s rights and sustainable livelihoods in order to address social and economic empowerment, as well as issues directly related to HIV/AIDS, such as gender roles in Malawian society. Their “Stepping Stones” program separates participants by sex and then helps them explore issues relating to relationships such as love, intimacy, violence, and decision-making, in order to help them move to a model where they make decisions as a couple rather than having the man make the decisions (UNAIDS & The Athena Network, 2011).
Malawi offers a microcosm of the global epidemic of AIDS. The disease is furthered by poverty, discrimination, and certain cultural traditions, but targeted, culturally relevant interventions have stemmed the tide and offer hope for the future.
What Can I Do Now?
- • Advocate to reduce the impact of HIV and AIDS on women and girls:
- • Remove financial barriers that keep girls out of school.
- • Reduce violence against women.
- • Secure women’s rights to own and inherit property.
- • Provide equal access to treatment, care, and prevention.
- • Develop an effective microbicide (a gel, cream, sponge, or suppository that women can use to protect themselves from HIV).
- • Call on leaders—politicians, religious leaders, corporate managers, community leaders—to get engaged in the fight against AIDS. Make a call, write a letter, or go to a meeting. Ask them to advocate for support to the Global Fund to Fight AIDS, Tuberculosis, and Malaria.
- • Advocate for low-cost access to life-saving medicines.
- • Give your time to an organization or program that helps people affected by HIV and AIDS.
- • Donate money to an organization that is working to reduce the impact of HIV and AIDS.
- • Become knowledgeable about how the disease spreads, and then spread the word. Ignorance is the enemy.
What Can I Do as a Professional Social Worker?
- • Work for an organization within the United States such as PSI (www.psi.org) that works to promote health in the Global South. They use social marketing techniques to address a broad range of health issues, including HIV/AIDS, malaria, and safe water.
- • Work for an international organization in the countries that are directly affected. Doctors Without Borders (Medecins Sans Frontieres) (www.doctorswithoutborders.org) seeks mental health workers, including social workers, to assist in its work. Save The Children operates a number of projects in affected countries. Partners in Health is another option.
• Work against stigmatizing those with HIV/AIDS, as this creates a barrier both to testing and to treatment.