Malawi - Aids Assessment Study (Vol. 1 of 2)

CONFIDENTIAL 17740-MAI VOL. 1 MALAWI AIDS ASSESSMENT STUDY Volume I FILE COPY MALAWI AIDS ASSESSMENT STUDY Volume I August 1998 This study was prepared jointly by the Government ofMalawi and the World Bank. ACRONYMS AND ABBREVIATIONS ADRA Adventist Development and Relief Agency MTEF Mid-Term Expenditure Framework AIDS Acquired Immune Deficiency Syndrome MTP Mid-Term Plan - BLM Banja La Mtsogolo MOWYCS Ministry of Women, Youth CAPAR Canadian Physicians Agency for Refugees Affairs and Community Services CBD Community Based Distributors MOLGS Ministry Local Government and Sports CCA Community Change Agents MYP Malawi Young Pioneer CEP Community Empowerment Process NAC National AIDS Committee 'CBC Community-Based Care NACP National AIDS Control Program CHAM Community Health Association of Malawi NAS National AIDS Secretariat CHSU Community Health Services Unit NFWC National Family Welfare Council CNA Community Nexus Approach NGO Non-Governmental Organization CIDA Canadian International Development Assistance PSI Population Services International DAAC District AIDS Coordinating Committee PLWA Person Living with AIDS DAC District AIDS Coordinator RAC Regional AIDS Coordinator DFID Department for International Development RHO Regional Health Offices DHO District Health Officer RHU Reproductive Health Unit EU European Union SADC Southern African Development FLEP Family Life Education Program Community GDP Gross Domestic Product SCF Save the Children Fund GMS Government Medicine Stores STAFH Support to AIDS and Family Planning GNP Gross National Product STDs Sexually Transmitted Diseases GOM Government of Malawi SWCD Social Welfare and Community HBC Home Based Care Development HRMD Human Resources Management Development TB Tuberculosis HSA Health Surveillance Assistants UNAIDS United Nations Program on AIDS IEC Information, Education, Communication UNESCO United Nations Education, Scientific IEF International Eye Foundation & Cultural Organization LCH Lilongwe Central Hospital UNFPA United Nations Population Fund MACRO Malawi AIDS Counseling Resource UNICEF United Nations Children's Fund Organization USAID United States Agency for International MASAF Malawi Social Action Fund Development MBC Malawi Broadcasting Company VCT Voluntary Counseling and Testing MCH Maternal Child Welfare WHO World Health Organization MDHS Malawi Demographic Health Survey MK Malawi Kwacha MKAPHS Malawi Knowledge, Attitudes, Practices Health Survey MOE Ministry of Education MOR Management, Overhead and Recurrent Costs MOHP Ministry of Health and Population ACKNOWLEDGMENTS The Malawi AIDs Assessment Study was written by Wendy Roseberry, Senior Health Specialist of the World Bank based on contributions received from a team of consultants during a June 23-July 18, 1997 mission: Jim Chin, Clinical Professor of Epidemiology, University of California at Berkeley and Consultant Team Leader; Sainiu M. Samu, Professor, College of Agriculture, Bunda; George Liomba, Professor, University of Malawi; Sam Okware, Commissioner of Health, Uganda Ministry of Health; Mary Bassett, Senior Lecturer, University of Zimbabwe; Anne Martin, Adjunct Professor, Princeton University; David Kalomba, Health Planning Unit, Malawi Ministry of Health and Population; Clement Chela, Deputy Director of the National AIDS Control Program, Zambia; and Amusaa Inambao, Executive Director, Management Development Assistance for Health and Population, Kenya. Several people from the World Bank contributed to the report. Venanzio Vella assisted the team in the literature search, development of terms of reference and analysis of data. Mead Over assessed the impact AIDS is expected to have on health expenditures and per capita income growth in Malawi. Tshiya Subayi wrote the first draft of the plan of action and helped design the cover. David Maurer created many of the graphs and formatted the document, with assistance from Eva Ngegba. Comments on drafts were received from Barbara Kafka, Ok Pannenborg, Ruth Kagia, Norbert Mugwagwa, Bert Voetberg, Peter Moll, Ahmad Ahsan, Mead Over, Martha Ainsworth, Michele Lioy, Debrework Zewdie, Linda English, Venanzio Vella, Shiela Dutta, Surendra Agarwal and Marguerite Salah. Revisions of the report have been made under the direction of officials of the National AIDS Secretariat, Ministry of Health and Population: Rosemary Chinyama, Senior Program Officer and Owen Kaluwa, Monitoring and Evaluation Officer. FOREWORD This report summarizes the findings of a study undertaken by the Malawi Ministry of Health and Population and the World Bank. The objective of this study was to assess the AIDS epidemic and the strategy to stop its spread in Malawi. Three outcomes were envisaged: 1) consensus on a) the factors influencing the spread of HIV; b) the impact AIDS is having and will have on individuals, communities, and selected sectors and; c) the interventions that are working best to prevent HIV and mitigate the adverse consequences of AIDS; 2) active participation of representatives from the public and private sector in the assessment; and 3) design of a proactive AIDS plan of action for subsequent government, World Bank and donor support. The Study's terms of reference can be found in a separate document of annexes (Annex A) to this report. Although the Study has looked in depth into a number of issues relating to the cause of the epidemic and the nations' response, this report only focuses on the Study's main findings. The report summarizes the magnitude of the problem (Chapter One); reviews the human and financial resources committed to respond to the epidemic (Chapter Two); provides a brief analysis of sexual attitudes and practices in the country and the priority intervention, changing sexual behavior (Chapter Three); describes the current efforts to provide STD and AIDS care (Chapter Four); and sets forth an AIDS plan of action that encompasses the Study's recommended actions for the immediate future (Chapter Five). TABLE OF CONTENTS EXECUTIVE SUM M ARY ............................................................................................................i Chapter One: The Magnitude and Impact of the Epidemic..................................................1 Chapter Two: The Resources Committed to the Nation's Response.................................. Chapter Three: The Priority Intervention: Changing Sexual Behavior.............................18 Chapter Four: The Other Important Interventions: Providing STD and AIDS Care....36 Chapter Five: The ActionPla ............................................................................................. 46 BIBLIOG RAP Y ....................................................................................................................... 53 EXECUTIVE SUMMARY 1. The HIV/AIDS epidemic in Malawi has reached crisis proportions. The ever- increasing numbers of AIDS deaths among productive adults in the public and private sectors are depleting the country's capacity and deterring developmental efforts. The_ epidemic is now killing more adults than any war would, and still the response has yet to reach a level of commitment, one would expect during a time of war. The evidence that HIV prevalence continues to be high among young adults means prevention activities must be intensified. The expected doubling of AIDS cases and deaths over the next decade means the coping mechanisms of individuals, families, and communities must be fortified. Such intensification and fortification require a refocusing of the nation's response and urgent mobilization of human and financial resources from within and outside the country. 2. Priority actions in policy, strategy and in operations to refocus the nation's response and to mobilize resources proposed by the Assessment Study are abbreviated below in this Executive Summary. The actions include the establishment of a Cabinet Committee to oversee a mobilized response; reorganization of the National AIDS Secretariat (NAS) with increased expertise in multisectoral coordination, behavior change, and evaluation; significant strengthening of capacity for care ofSexually Transmitted Diseases (STD) and AIDS in the Ministry of Health and Population (MOHP), and the development of cost-effective strategies that first focus on high risk behaviors, ensure quality of STD and AIDS care within facilities and communities, and factor the impact ofAIDS into the plans ofselected sectors. Magnitude of the Epidemic 3. The HIV/AIDS epidemic in Malawi is one of the most severe in the region and in the world. The most recent HIV prevalence surveys suggest that the incidence of HIV infection is still very high, especially in adolescent women and young adults. Thirty five percent of women attending antenatal facilities in Blantyre in 1996 were HIV positive; an increase from the thirty percent rate found in 1990. This means that a significant change in high-risk sexual behaviors has not yet occurred. About one third of the 15-49 year olds in Blantyre and Lilongwe, and over 13 percent of this age group throughout Malawi, are estimated to be HIV-infected. Twenty percent of women under the age of 20 attending antenatal the Queen Elizabeth Central Hospital in Blantyre, are HIV infected. 4. The personal loss experienced by individuals and families due to illness, death and orphanhood caused by AIDS is only beginning. Modeling used for this Study project the annual number of AIDS cases to double from 34,000 in 1996 to 70,000 in 2005. Annual pediatric AIDS cases will rise from 12, 000 in 1996 to 25,000 in 2005. Annual maternal AIDS orphans estimated at 39,000 in 1996 will increase to 70,000 in 2005. 5. In addition to increased death and orphanhood, the impact of AIDS on the family will be to increase poverty, as poor households use limited income to pay for medical care. Analyses of data from a longitudinal study in Tanzania (Kagara District) concluded that expenditures on food and consumption of food among poor households decreased by 32 and 15 percent respectively after an adult died from AIDS. Recent Demographic and Health Surveys in the Central African Republic showed school enrollment at rates over 60 percent for children 7-14 whose parents were alive verses 39 percent for children whose parents were dead. 6. With respect to human capital, both public and private sectors in the nation are affected by AIDS. Because of such high HIV infection rates in urban adults, a minimum of one quarter, and up to one half of 1996 urban-based personnel in development sectors, such as education, health and the military, can be expected to die of AIDS by the year 2005. The Department of Human Resources and Management Development is already reporting an annual death rate among health personnel of three percent, six times the expected .5 percent. A recent study for the Makandi Tea Estate also showed a six fold increase in mortality among employees between 1991 and 1995, from 4 per 1000 employees to over 23 per thousand employees. 7. Lastly, AIDS has a devastating impact on the overall development goals of a society because of its enormous effect on life expectancy. Life expectancy in Malawi today is estimated to be 43 years, 9 years less than the 52 years expected without AIDS. Furthermore, the lost years in productivity due to AIDS further exacerbate the problem of limited capacity to support the country's development agenda. Financial and Human Resources Committed to the Nation's Response 8. Since development capacity is limited in Malawi, capacity to respond to the AIDS epidemic is most likely to be limited. Building on this assumption, committed national leadership will be reflected in how well existing financial, human and institutional resources are mobilized, strengthened and supplemented, and how well these resources are utilized. 9. Financial Support to the Response: Total expenditure for AIDS prevention, STD care and community-based AIDS care by the major government and non-governmental organizations was approximately $10.5 million in 1996. Over 95 percent of resources expended on these categories was by donors. 10. Little direction has been given to donors or NGO's in the placement of their respective contributions. Prevention activities, the key to slowing the epidemic, account for only about 24 percent of total expenditures. Of this amount, approximately two and nine percent were expended on education and activities targeted for sex workers and youth, respectively. UNFPA's new five year program begun in 1997, will most likely increase the amount of financial support to these two populations. About ten percent of total expenditures were attributed to reducing the personal and social impact of HIV -ii- infection; primarily through the development of community based care programs. Eighteen percent of the expenditures supported STD and AIDS care. Only five percent of expenditures were attributed to the NAS and regional offices, and 44 percent, the largest share, to other miscellaneous costs. These miscellaneous costs for travel and training, could not be attributed to the major interventions for prevention and care. 11. Human and Institutional Capacity: Misconceptions heard during the Assessment Study--that AIDS is the responsibility of the health sector, that malaria is still the number one cause of adult mortality, that HIV is transmitted by women only, and that the military need not, because of security reasons, monitor in a transparent but confidential manner its soldiers' high levels of infection--strongly suggest many leaders have yet to internalize AIDS as a threat to the country's development agenda. 12. Concurrently, the evidence is limited as well, that much real adjustment has been made to institutional systems--in the way of policy, strategy and operations--to significantly address the cause of the problem. Unlike governments in Uganda, Thailand, and other severely-affected countries, the Government of Malawi at the time of the Study, had yet to make it a pWJ!gy to elevate the responsibility of planning and directing the AIDS response to the highest levels of government as well as to encourage significant national leadership for AIDS-matters within civil society. The advisory body to the NAS, the National AIDS Committee (NAC), had no budget, and rarely met. Consequently, its "voice" from civil society had not been heard or involved in the making of policy. 13. As to strategy, the multisectoral nature of the response is weak. Since slowing the epidemic is dependent on changing individual sexual behavior and social norms, and most behavior change occurs outside institutions of the health sector: in homes, schools and communities; AIDS prevention needs to occur outside the institutions of the health sector as well. However, most AIDS focal points persons in the ministries have no budget, workplan or support from their management to factor AIDS into their respective programs. The NAS still resides in the Ministry of Health and Population (MOHP) and the salaries of its top professionals are funded by donors. Furthermore, investment in expertise and studies to better understand what approaches are successful in changing behavior has been minimal. 14. Lastly, in the way of operations, attempts have been made to decentralize the response by designating Regional AIDS Coordinators (RACs) and District AIDS Coordinators (DACs). Unfortunately, the RACs.and DACs are expected to carry out AIDS-related activities in addition to their full time workload and few provisions have been made to improve the attitudes and skills of health personnel in the promotion of condoms. Although numerous local and international organizations perform HIV/AIDS- related interventions throughout the country, little guidance is given as to where and what models of interventions should be employed and how they should be evaluated. Unlike National AIDS Control Programs in Burkina Faso, Chad, Kenya and Uganda, no government sponsored grant facility exists in Malawi to broaden the role of the non- governmental sector and to monitor the nations focus. -iii- 15. In summary, much more could be done to put forth an increased sense of urgency, ensure adequate multisectoral coordination mechanisms for HIV/AIDS efforts, and encourage efficient mobilization and utilization of available human capacity at the local community level to fight the epidemic. 16. The Study recommends five priority actions to address management of human, institutional and financial resources for the nation's response. Responsibility to undertake these actions lies within the Government of Malawi and its partners. * ACTION: Create a Cabinet Committee to Lead and Monitor the Nation's Multisectoral Response The Cabinet Committee on AIDS, made up of the Vice President and Ministers of key ministries would meet monthly to provide the needed leadership and authority to mainstream HIV/AIDS-related activities in selected government ministries and institutions. The Committee would urgently address issues to strengthen the capacity and roles of the NAS and NAC, establish NAS posts, and increase government resources to AIDS- related activities.' * ACTION: Empower and Reorganize the NAC The empowered NAC would need an increased budget and mandate to allow members to play greater advocacy and advicnry roles in the community and to the NAS. Additionally, the NAC would need to limit its size to approximately 12 members from a variety of public and private organizations, in order to facilitate decision- making. * ACTION: Establish the NAS as an Independent Body The NAS needs a high and visible profile and an appropriate level of authority and autonomy that would allow for urgent decision-making and multisectoral coordination of nation-wide HIV/AIDS activities. NAS leadership would report to the Cabinet Committee and serve as the secretariat to the NAC. This option provides an opportunity for integration of HIV/AIDS in the national development and socio-economic planning processes. * ACTION: Launch a NationalAIDS Planning Exercise To Prepare a Strategic Plan for the Next Five Years A transparent and participatory process is required to prepare a comprehensive national AIDS five year (1999-2004) multisectoral plan. The Strategic Plan would define program direction optimally and guide planning and implementation of HIV/AIDS activities nationwide. * ACTION: Allocate, Pool and Monitor Resources Based on Strategic Planning and Cost-effectiveness. Adequate funding to support prevention activities targeted at high risk behaviors, would be secured first, before This action has already been taken. The Cabinet Committee on AIDS, chaired by the Vice President, met for the first time February 11, 1998. -iv- national AIDS program allocations are made elsewhere. Government, private and donor grant funds ould be mobilized and pooled into one budget. A World Bank loan could then be designed to cover any gaps. A standardized format would be developed by the NAS to monitor financial and programmatic contributions made by all partners. Key Intervention--Changing Sexual Behavior 17. Although much progress has been made by the NAS and its partners in initiating information, education and communication (IEC) interventions, these efforts lack i) a focus first on those behaviors most likely to facilitate transmission of the virus; ii) depth in assuring all elements and conditions for behavior change exist; aid iii) breadth in reaching all target communities (those must likely to transmit the virus) throughout the country. Promotion of free condoms--essential in all of the above--is grossly inadequate in the public sector because health personnel are poorly trained and persistent problems exist in distribution. 18. The challenge of AIDS prevention in Malawi is to move beyond awareness to behavioral change: abstinence, partner limitation and condom use. Only 22 percent of women aged 15-19 and 37 percent of women aged 30-34 surveyed in a 1996 national study, who had heard of AIDS, knew of at least two valid ways of avoiding HIV transmission. Such low levels of knowledge of preventive measures help explain why many youth, particularly girls, are becoming infected with HIV before the age of 20. For men, knowledge of prevention in the 1996 study was higher (but still not high enough), with 48 percent of men aged 15-19 and 56 percent of men aged 30-34 citing at least two valid ways of avoiding HIV. 19. As anticipated from the national data above, and even though 92 percent of Malawians surveyed in 1996 claimed to have changed their behavior, sexual partner exchange rates remain too high and condom use too low throughout the country, to expect a significant slowing of the epidemic. Nineteen percent of married women and men reported sexual relations within the last four weeks with an extra-spousal partner in the 1996 survey. From here, the sexes diverge in practice when it comes to non-regular sexual partners. (Non-regular sexual partners are often a source of HIV infection.) Two percent of women and 16 percent of men reported having at least one-non-regular partner during a 12 month period. In repeat surveys of youth commissioned by UNICEF, 46 percent of primary school and 66 percent of secondary school youth are sexually active, a proportion more or less unchanged since 1994. Eighty percent of boys reported more than one partner, compared to 60 percent of girls. 20. In reference to condom use, six percent of men and three percent of women in the 1996 national survey sample, reported condom use for their most recent sexual encounter. Less than two percent of married couples reported condom use, unchanged since 1992. Noteworthy is the higher condom use reported in 1996 with a nonregular partner, at 41 percent among men and 24 percent of women. Again, these rates of condom use need to be higher to expect a significant slowing of the epidemic. -v- 21. The most efficient strategy for reducing the spread of HIV is to prevent transmission (by condom use or decrease in numbers of partners) among those with the highest rates of partner change. This creates a "multiplier" effect in terms of preventing many more subsequent, secondary infections. Ensuring that a majority of those most likely to transmit the virus (i.e. the above women and men in Malawi reporting multiple partners, particularly non-regular sexual partners) benefit from behavior change interventions will require the targeting of prevention efforts. The objective however, is to target and even stigmatize the practice of having unprotected sex with multiple partners and not the individuals. 22. Data from sub-populations and communities is especially needed to supplement the national data cited above. Formative and evaluation research will provide answers to questions such as: "Who in the community is practicing high risk behaviors, what factors influence their behavior, and how they can be effectively reached and involved?" While some of these answers are known now by persons working on community intervention projects (i.e. peer education projects among sex workers, truckdrivers, plantation laborers, soldiers and youth) in a few places in Malawi, their experience plus additional research need to be repeated in far more locations throughout the country to have a significant affect on slowing HIV transmission. Involvement of the target communities in designing the required research and interventions is essential to ensure individuals are empowered with their change toward preventive behaviors. 23. The strategic shift from providing information to promoting and influencing individual and community norms, values and beliefs on the reduction of high risk behaviors (unprotected sex with multiple partners) means capacity to do this at the national and local levels will need to be greatly expanded and strengthened. Experience in Uganda and Thailand suggest this is possible in the developing country setting. True investment in strengthened human and institutional capacity in behavior change in Malawi will however, require a reprogramming of public, private, and donor funding and actions: * ACTION: Strengthen NAS Capacity to Facilitate Behavior Change. The focus of the NAS must be on creating a social movement in behavior change. Thus, the personnel in the NAS would be leaders in developing strategic direction and technical approaches and in evaluating impact related to behavioral and social change. At the present, these skills in the NAS are limited. Evaluation must include surveillance of risk behaviors (and if possible, HIV and STD rates) among the target communities. * ACTION: Develop a Strategy to Strengthen the Community's Capacity to Change Behavior with Emphasis on High Risk Behavior. A behavior change strategy that promotes and influences safe sexual behavior to close to 100 percent of target communities and that significantly increases the promotion and use of condoms would be developed and coordinated by the NAS, in close consultation with representatives of the target communities, NGO's and persons living with AIDS (PLWA's). The NAS would emphasize -vi- educating the youth on prevention skills through a variety of modem and traditional channels and promoting HIV voluntary counseling and testing, (VCT) to all target communities. Most likely a grant facility will be needed to increase and coordinate the involvement of partners from NGO's, agencies, institutions and the workplace. Lastly, the community empowerment process as an element of the community nexus approach outlined in the Population and Family Planning Sector Review document, could well serve AIDS prevention through the mobilization of a variety of community cadres. Providing STD and AIDS Care 24. Preventing individuals from acquiring HIV or other STDs through safe sexual practice is the most cost-effective intervention in reducing further spread of the epidemic in Malawi. However, ensuring that those individuals already infected receive appropriate care early and information and skills to prevent future infections, is also important. 25. STDs account for a significant burden of care in Malawi. About 500,000 cases of STDs will be treated at the country's health facilities in 1998. Actual number of cases in the country are most likely two to four times this figure. Patients with STDs in Malawi are often also infected with HIV. HIV prevalence among STD patients ranges from 37 percent in Rumphi to 70 percent in Blantyre. Studies have shown that a person with an STD has a seven times greater chance in transmitting HIV. 26. Thus, ensuring that persons with STDs receive effective treatment could have a significant impact on slowing HIV transmission in Malawi. This task however, is neither easy nor simple. STDs are often not recognized by infected persons (especially women) and ensuring their effective treatment and ability to prevent further infections is dependent upon a public and private network of interrelated components such as access to trained personnel and appropriate antibiotics. 27. Despite this challenge, much progress has been recently made in several areas of STD control in Malawi. Policies for integrating care for STDs and family planning, guidelines for STD syndromic management, and manuals for counselor training now exist. A variety of materials on STD Control for national, regional and district managers have been developed and distributed together with manuals for the training of trainers and supervisors. Pilot sites have been established to try new approaches. 28. As to AIDS, a generalized AIDS epidemic in any country increases the cost of care and total health expenditures and reduces overall access. The severity of the epidemic in Malawi suggests a severity in its impact, one that will only increase as AIDS cases peak in the next decade. First, AIDS increases the demand on health care; thus increasing use of hospital beds, drugs and supplies. Second, AIDS reduces the supply of health care available at a given price; through the increased cost of maintaining a given level of safety for medical procedures (i.e. increased screening of blood for transfusion and provision of gloves) and increased absenteeism, illness and deaths among health -vii- personnel. Data from the Ministry of Human Resources shows annual death rates to be three percent--six times what it would be without an epidemic. Taken together, increased demand and reduced supply makes health care become scarcer and thus more expensive, and makes national health care expenditure rise. The World Bank estimates health care expenditures have risen over.80 percent since the epidemic began in Malawi. 29. Not only is health care scarcer and more expensive in Malawi, but the quality is unacceptable as well. Personnel are overworked, communication between provider and client is minimal and drugs are often unavailable, and if available, administered inappropriately. Although no data exist on quality of AIDS care, quality of STD care studies show that the accuracy of STD treatment is 67 percent in pilot sites and only 17 percent in non-pilot sites. Only 29 percent of staff interviewed at both pilot and non-pilot sites said they had any supervision at all from unit managers or coordinators. 30. +Health institution care, whether for STDs, AIDS or other conditions in Malawi needs urgent attention and reform. The Government's first step in this direction is the Strategic Framework Planning Process for Health Reform. In addition to giving serious consideration to the impact AIDS has had, and will have on the demand, and cost of health care in Malawi, the reform process should give equal consideration to the following three actions: * ACTION: Develop National Policies and Strategies for both STD and HIVIAIDS Care. These strategies would define the type, scope and standard of services to be carried out effectively at different levels of the health care system, and the indications for referral between the levels. * ACTION: Strengthen Leadership in STD Control and AIDS Care in the MOHP. The MOHP would need to create the positions and assign several senior officials to the Reproductive Health Unit for STD care, and the Communicable Disease Unit for AIDS care, to guide implementation of the above recommended STD and HIV/AIDS policies and strategies. This leadership would help assess the adherence to the clinical, counseling and home care - guidelines available on AIDS. As done with STD case management, the MOHP would perform baseline and follow-up studies to monitor quality of care. Particular attention to finding acceptable ways to care for the ever increasing cases of AIDS in and outside the public sector would be needed. Adequate levels of trained staff, drugs, and supplies would need to be assured for appropriate STD and AIDS care. * ACTION: Strengthen the Community's Capacity to Cope with AIDS. Several ministries and actors in civil society would need to help formulate and coordinate a social mobilization strategy to increase the involvement of Malawians in coping with AIDS and caring for those infected and affected. PLWA's must play an instrumental role in these efforts and living with AIDS positively, must be a central theme. New and innovative incentives to sustain the contribution volunteers are making would have to be found. -viii- Chapter One THE MAGNITUDE AND IMPACT OF THE EPIIEMIC 1.1 The HIV/AIDS epidemic in Malawi is among the most severe in Africa and in the world. As with other countries in the region, HIV began to spread silently during the early 1980s. Within one decade HIV prevalence among pregnant women attending i antenatal facilities in Blantyre rose from three percent in 1,986 to close to, 35 percent in 1996 (Kaluwa et al. 1996). As a result of the long interval of eight to ten years average from HIV infection to AIDS, the. annual toll of AIDS and other HIV-related conditions such as TB cases, maternal AIDS orphans, and pediatric AIDS cases, have only become visible during the early 1990s. The full impact of AIDS-deaths and other. HIV-related conditions, under the best case scenario, is not expected,to peak until about the middle or latter part of the next decade. A. Estimates and Projections of HIV/AIDS 1.2 Constraints exist in the ability of public health programs to'measure the prevalence and especially the incidence of HIV infections and AIDS cases in a given population with any substantial degree of precision. Reported cases of HIV infections and AIDS are unreliable as an indication of the magnitude of the problem, surveys on prevalence are few and studies on incidence non-existent. As-a result, epidemiologists have used many methods and models to develop reliable estimates and projections of HIV/AIDS. 1.3 The HIV/AIDS estimates and projections used for this report are the most conservative (i.e., the lowest) of the several estimates and projections that have been developed for Malawi. (See Annex B for a discussion about the previous models used to make estimates and projections of HIV infections and AIDS cases in Malawi). The estimates and projections in this report are conservative because: (1.) the lower range of possible HIV prevalence estimates was used; (2) it was assumed that the HIV epidemic in Malawi has peaked and that the incidence of new infections will be decreasing after 1997; and (3) in the modeling of AIDS cases, the slower median progression rate of 10 years was used. Why use the conservative parameters? The AIDS problem is of such magnitude in Malawi, that its severity is apparent, even with the lowest estimates and projections. HIV Infection Estimates 1.4 Reasonable working estimates of the prevalence, general distribution, and trends of HIV infection for Malawi have been developed by the Malawi NAS based on an analysis of all available HIV survey data. Most of the data derive from sentinel surveillance surveys begun in 1992 of women attending 19 antenatal service sites throughout the country. Figure 1.1 below shows the very high age-specific HIV prevalence among women attending the Queen Elizabeth Central Hospital (QECH) in Blantyre (Liomba and Taha, 1996). For women under the age of 20 (aged 15) to age 34, prevalence rates now exceed 20 percent and reach as high as 43 percent. The highest age- specific HIV prevalence has shifted over time from younger to older age groups, suggesting an aging cohort of infected women who are still giving birth. (See Annex C for a summary of other HIV surveillance data collected in Malawi and issues concerning reliability and biases). Figure 1.1 Age-Specific HIV Prevalence in Antenatal Females by Year (QECH) Thousands 40- 01990 01993 gl996 ------------ ------------- 30 - ---------------- .----- -------.- -----..-.---- 20-4 10 IA 10- <20 20-24 25-29 30-34 35+ Age Group 1.5 Using HIV prevalence rates among antenatal women throughout Malawi, and taking into consideration the population size of different areas and regions, an estimate of the HIV prevalence rate in the 15-49 year old population throughout Malawi, as of the end of 1996, was calculated by the authors of this report and the NAS, to be over 13 percent or about 600,000 young and prime-aged Malawians. -2- AIDS Cases Estimates 1.6 As of July 1997 about 50,000 AIDS cases have been reported to the NAS (Kaluwa, 1997). However, it is recognized that these reported cases are a gross underestimate of the actual number of cases that have occurred. Total under-estimation of AIDS cases (due to poor access to health care facilities, under or inaccurate diagnosis, and nonreporting of diagnosed cases) in most developing countries can be more than seven to ten fold lower than the number of AIDS cases that actually occur (UNAIDS, 1996). The requirement for a positive HIV-antibody test result before an AIDS case can be reported, adds to the general problems of under-estimation of AIDS in Malawi as well. (See Annex D for a brief discussion of the burden of AIDS in comparison to other major causes of illness in Malawi). Figurel.2 Estimated and Projected Annual Adult HIV Infections and HIV related Diseases and Conditions In Malawi Thouande Thounnde =Adut HIV G000 EAdultoAIDS s EOGrph- 15 yre ..o. CAdult H IV/T B -40 100 Pd itr AIDS20 800 *0 25.0.00 20 0 82 84 86 88 90 92 94 96 980 2 4 6 8 10 u...s ,Year JTc 1.7 Figure 1.2 above shows annual adult AIDS cases and other HIV-related conditions, including HIV-induced adult TB cases, maternal AIDS orphans, and pediatric AIDS cases as estimated by using Epimodel.2 Epimodel's outputs were based on the HIV prevalence estimate of 13 percent derived by the NAS. The model calculates that annual AIDS cases in Malawi began to increase markedly in the mid-to-late 1980s, and in 1996 reached a cumulative total of 150,000 with annual cases reaching about 34,000. In 1996, the annual total for maternal AIDS orphans <15 years old was about 39,000; for adult TB cases related to HIV infection, about 18,000; and for pediatric AIDS cases, about 12,000. - A simple computer model developed by the former Global Program on AIDS (GPA), World Health Organization (WHO). The model used data believed most accurate by the NAS. -3- Projection of HIV Infections and AIDS Cases 1.8 The HIV scenario used in Epimodel to project AIDS and other HIV-related conditions assumes that the annual incidence of HIV will decrease from a peak level of 90,000 in 1996 to about 50,000 in the year 2010. However, because of the eight to ten year incubation period from HIV infection to the development of AIDS, the vast majority of projected HIV-related conditions up to the year 2010 will occur regardless of whether HIV incidence increases or decreases after 1997. All HIV-related conditions according to the model, will increase in Malawi steadily over the next decade. Adult AIDS may peak at about 70,000 cases per year during the middle of the next decade. Figure 1.2 below presents estimated adult AIDS cases for 5-year periods from 1985-89 to 2005-09. The clinical burden of AIDS will increase markedly through the next decade. Similarly, annual maternal AIDS orphans are projected to peak at about 70,000; adult TB cases related to HIV infection at 35,000; and pediatric AIDS cases at about 25,000. Whether the annual toll of HIV-related conditions will actually peak towards the end of the next decade depends on whether the current rates of high-risk sexual behavior in Malawi can be significantly reduced during the next few years. A recent review of available epidemiological data on both disease and behaviors (discussed in Chapter Three) suggest that high risk behaviors have as of this writing, yet to be reduced to significantly in Malawi to slow HIV transmission. B. Impact of AIDS on Demographic Parameters 1.9 AIDS is having and will have a significant, measurable impact on mortality rates in Malawi. HIV/AIDS as the Major Cause of Adult Death in Malawi 1.10 The 1996 HIV prevalence data and the most conservative modeling of AIDS cases indicate quite clearly that AIDS is the major cause of death among those aged 15-49 in Malawi. Data taken from sibling histories in recent Demographic Health Surveys in Malawi also support these findings (Annex D). 1.11 As seen in other severely-affected countries, considerable misunderstanding and/or nonacceptance of AIDS as the major cause of adult death exist among the general public and some policy makers. Part of this misunderstanding is due to the official disease reporting system, which as described above, grossly underestimates the AIDS cases and deaths. Reports of TB cases typify this problem. Since the mid-to-late 1980s, there has been a three to four fold increase in reported TB cases in Malawi. Before 1985 and before the HIV/AIDS era, about four to five thousand TB cases were reported annually. This figure has grown to about 20,000 TB cases reported for 1996 in Malawi. Virtually all of the increase in TB cases can be attributed to HIV infections, yet the vast majority of these persons with TB have not been tested for HIV, and thus officially, these infections are reported as TB cases. Simple modeling of HIV-related TB in Malawi -4- indicates that about three-quarters of all current TB cases in Malawi are occurring in persons infected with HIV. These modeling results are corroborated by a recent study of a large sample of TB patients (both sputum positive and negative) by the Malawi TB Program, where 66 percent of TB patients were HIV positive (Ministry of Health.and Population, 1995).. Figure 1.3 Estimated and Projected Annual Deaths In the 15-49 Year Old Urban Population - Malawi Thausands I Thousands 20 O All Othere-er- MAIDS Deathe 15 - . . ... -. --.-.-.16 10 ... .. ...... ... 10 5 6111 0 O 1986 1990 1996 2000 2006 2010 1.12 Figure 1.3 presents estimated and projected annual deaths in urban adults from 1985 to the year 2010. AIDS deaths began to increase markedly during the early 1990s - and by 1995 AIDS deaths were about double total deaths due to other causes. By the year 2005, urban adult AIDS deaths will be 4 to 5 times greater than deaths due to other causes. AIDS as Major Determinant of Life Expectancy in Malawi 1.13 AIDS deaths will be the single largest determinant of life expectancy in Malawi. A Malawian was expected to live 45.2 years in 1985. Life expectancy was projected to- rise to 57.4 years by 2010. However, because of AIDS, life expectancy is expected to decrease to 44.1 in 2010, or by more than 13 years compared to projected life expectancy in the absence of AIDS. 1.14 Figure 1.4 (next page), shows the impact of AIDS on life expectancy as estimated by Epimodel used with another model, DemProj from The Futures Group International. Projections from the Interagency Working Group AIDS model, a model used by the US Bureau of Census is also shown for comparison. The demographic impact of AIDS projected by the US Bureau of Census is in general about two to three times greater than that obtained by use of Epimodel and DemProj, primarily because the HIV prevalence levels used for the U. S. Bureau of Census were two to three time higher than the -5- conservative HIV scenario developed using Epimodel. (Again, see Annex B for information on the different models used in Malawi.) 1.15 The rate of natural increase for Malawi is projected to decrease more rapidly in the presence of AIDS: the population growth rate is projected to decline from 3.3 percent in 1985 to 2.5 percent in 2010 . In the absence of AIDS, the growth rate would have declined more slowly from 3.3 percent in 1985 to about 3.1 percent in 2010. The 1997 population size of about 10 million was expected to increase to 16.7 million in the year 2010. However, because of the increase in AIDS deaths, the conservative HIV/AIDS scenario projects that there will be 14.8 million persons or close to 2 million less persons in the year 2010. Figure 1.4 Projections of Life Expectancy - Malawi Life expectancy Life expectancy 20. USBO 0 0 86 88 so 92 94 86 98 00 02 04 06 00 10 Mae6/al97 Yey AIDS as a Major Cause Of Premature Death of Urban-Based Work Force 1.16 The HIV infection rate among urban-based personnel in development sectors can be estimated roughly from HIV prevalence data obtained from routine HIV sentinel surveillance of antenatal women. As of 1996, the average HIV prevalence rate among antenatal women aged 15-49 years in Blantyre was 34 percent and in Lilongwe, 27 percent (Ministry of Health and Population, 1997). The HIV infection rate among women in Blantyre in the 30-34 year age group is over 40 percent. Recent data from Uganda and Zambia suggest these rates approximate those for the general adult population (Wawer et al., 1998). Cumulative AIDS deaths expected in a 1996 cohort of Even with the impact of AIDS, population growth in Malawi will still be rapid at 2.5 percent annual rate. -6- sector personnel (military, education, or health care) in urban areas were thus calculated based on an HIV infection rate of 40 percent (Figure 1.5). Figure 1.5 Estimated and Projected Cumulative AIDS Deaths In a Cohort of Young and Middle-Aged Adults - Malawi Cumulative percent Cumulative percent 70 70 - -O - --- * ------ -------- *0 MFV peveneT so inthi.hort ------- -- .0 wee4096 In 199o8 40 ---***-*- *--- - -40 10 ..0 1995 2000 2005 2010 Yomar JIG 1.17 By 1997, over 10 percent of the cohort in these sectors will have died from AIDS. By the year 2005 (less than 10 years from now) about 40 percent of this cohort are projected to die of AIDS. This loss in personnel does not include "normal" attrition such as early retirement, relocations, and deaths from other causes, that may be expected for any sector. C. Impact of AIDS on Development 1.18 The decrease in life expectancy and premature loss of productive adults in the sectors noted above, illustrate how AIDS impedes development in Malawi. Although most communicable diseases pose a threat to development, AIDS is unique in that it strikes the educated and skilled, as well as the uneducated (USAID, 1993; Dallabetta and Miotti et al. 1994.) In Malawi, AIDS is fatal, often kills more than one breadwinner in a family and has yet to peak in the number of persons affected. Effects of AIDS on the Economy 1.19 Most studies estimating the impact of AIDS on the economy in Malawi were performed in the early 1990's. Forsythe's work determined that on average, a person infected with HIV was estimated to work only 9.7 years out of a potential 25.3--a loss of 15.6 productive years (Forsythe, 1992). Over's work, estimated that per capita gross domestic product (GDP) in a moderately-affected country could be reduced by as much as half a percentage point per year due to AIDS (World Bank, 1997). A half of a - 7- percentage point would be significant in Malawi, since the country's average annual growth of per capita GDP Wvas only 0.2 percent between 1986-96 (World Bank, 1997). Figure 1.6 Crude Death Rate for One Private Company Deaths per 1,000 employees 25 2 0 . ..--- ..-- .-- .....-------.-..-t---- ----- ------ - 15 . ...-.-.- - ....--- -- .- ..-- .--- .- --------- 10 - ----------------------------- --------------- 5 - -- ---- -- --- - ------------ - _ -- - - 0 I II 1991 1992 1993 1994 1995 Year (Jones, 1994) 1.20 A more recent study for the Makandi tea estate and tea processing factory, performed by Jones in 1996, reported a six fold increase in mortality between 1991 and 1995, from 4 per 1000 employees to over 23 per thousand employees (Figure 1.6 above). Over 70 percent of these employees were between the ages of 36 and 45. The annual cost of HIV/AIDS to this company in Malawi was 6 percent of operating profit (Jones, 1996). 1.21 For many countries, Malawi included, the epidemic will result in serious consequences in public health spending and in poverty. Discussion of the impact of AIDS on the country's health sector is provided in Chapter Four, and on poverty, below. Effects of AIDS on Poverty 1.22 At the individual and household level, AIDS causes personal pain and loss, and cuts into,income, human capital and time available to families. People with AIDS need physical care, counseling for, coping and help in making arrangements for the future care -8- of their dependents. AIDS also creates large numbers of survivors--spouses, elderly parents and orphaned children. 1.23 In Malawi, reliable data on reported cases of pediatric AIDS and maternal AIIS, orphans are not available for estimating and projecting the current and future numbers of these children. The Study used Epimodel to calculate the total children bom to,HIV infected women - including those children born before these women were infected by HIV - and calculates the age of these children at the time their mothers aie of AIDS (i.e., when they become maternal AIDS orphans). Figure 1.7 Estimated/Projected Prevalence of Maternal AIDS Orphans Less than 15 Years of Age - Malawi Thousands Thousande .............................. ... 17 O Prior years U Now 176 . 150 .,. ...................... ............................. . 125 12 .. . . 100 100 76 7 0 600 25 1_4 00 0 84 86 86 87 88 89 90 91 92 93 94 89 96 97 Year Ma-7/13/9 Y 1.24 Figure 1.7 presents the number -f matearnil AIDS orphans under the age of 15 years by year - from 1984 to 1997. These annual totals include those maternal orphans from previous years who are still less than 15 years,bf age as well the new niaternal orphans that year under the age of 15 years. By 1997, this total annual prevalence of orphans was about 180,000 and this annual prevalence can be expected to gradually increase to about 300,000 during the next decade. 1.25 In addition to orphanhood, the impact AIDS has on poverty can be measured by the impact of adult death on such social indicators as child'nutrition and schooling. By- worsening these measures and widening the gap between the poor and others, HIV can exacerbate poverty and delay attainment of national economic development goals. -9- 1.26 Little data however, on the impact adult deaths is having on these social indicators, particularly nutrition and schooling are available in Malawi. Studies performed by other African countries suggest that to minimize the impact of an adult contracting HIV with consequent death, households make changes in food expenditure and consumption. For example, in Tanzania, expenditures on food and consumption of food among the poor households decreased by 32 and 15 percent respectively after an adult died from AIDS. Stunting (very low height for age) among children under 5 was substantially higher for orphans (51 percent) than for children whose parents were both alive (39 percent) (Over, and Mujinja et al. forthcoming). 1.27 Besides increasing childhood malnutrition, a prime age adult death in a household is likely to reduce school enrollment. Children may be withdrawn from school to work outside the home, help with chores and farming, or care for an ailing family member. And children who have lost one or more parents are likely to have lower enrollment rates than those whose parents are alive. Recent Demographic and Health Surveys in the CAR showed school enrollment at rates over 60 percent for children 7-14 whose parents were alive verses 39 percent for those with both parents dead (World Bank, 1997). 1.28 This chapter has summarized the magnitude of the AIDS problem in Malawi. With one third of the sexually active population in the urban areas infected with HIV, with fatality certain among those infected and the educated as affected or even more likely to be so, AIDS has become one of the most important obstacles to Malawi's goals in building capacity for development. What investments has the country committed to deter any further spread of the virus and its adverse affects? The next chapter, Chapter Two addresses this question. -10- Chapter Two THE RESOURCES COMMITTED TO THE NATION'S RESPONSE 2.1 Limited capacity is a serious problem in Malawi. Existing financial, human and institutional resources to support the country's development agenda, are few. Forty-three percent of the adults in Malawi are illiterate and average annual growth of per capita GDP was only 0.2 percent between 1986 and 1996 (World Bank, 1997). Thus, resources to respond to the AIDS epidemic in Malawi are most likely to be limited. Country leadership will need to find ways to mobilize, strengthen and supplement existing resources for AIDS prevention and mitigation and to utilize these limited resources in the most cost-effective manner. A. Financial Capacity 2.2 The data for this Study collected from sixteen donors, the World Bank and numerous implementing organizations on expenditures for AIDS control activities in 1996 have two major limitations. First is the lack of uniform financial formats, which make it difficult to compare donors or categorize their spending patterns. Thus, some judgments had to be made by the Study Team in assigning expenditures to different program component categories, such as prevention activities for youth or community- based care activities for those infected and their families. 2.3 Second, no data exist on expenditures associated with the provision of services to persons with HIV or AIDS opportunistic infections within the public, private or traditional health systems. The adoption of a standardized reporting format drafted during the Study would resolve the first problem and the ongoing Mid-Term Expenditure Framework (MTEF) undertaken by the Government, may provide some cost estimates on facility care to address the second limitation. 2.4 Figure 2.1 (next page) shows the relative financial support to AIDS control less the financial support to facility care for persons with HIV and AIDS. Total expenditure for AIDS prevention, STD care and community-based AIDS care was approximately $10.5 million in 1996. How does this compare to budgets or expenditure data from other SSA countries? The findings of a 1997-98 study sponsored by UNAIDS to provide these data, are not yet available. However, information from neighboring Zimbabwe, a country with a similar population size (11.2 million compared to Malawi's 10 million) reports a similar budget commitment (not expenditures). -11- Figure 2.1 Total Expencil ture (1996) on AIDS Control by Donors and the Government of Malawi Total = $1 0.5 million UNICr=F %J2 P 3 % DFID 4A EU/MC 13% _CQM 3% USAID/STAFH- 68% - 2.5 Over 95 percent of resources expended on these categories for AIDS control in Malawi derive from donors. (See Annex E for expenditure breakdowns). Donors contributing the majority of financial resources to AIDS control programs in SSA is common. Again in comparison to Zimbabwe, up until and including 1996, the donor community has contributed a similar amount, 94 to 95 percent of the total funds budgeted for AIDS control (Government of Zimbabwe, 1998)4. 2.6 As shown in Figure 2.2 (next page), prevention activities, the key to slowing the epidemic, account for only about 24 percent of total expenditures. Of this amount, approximately three percent were expended on information, education and communication (IEC) activities, one and a half percent on sex worker-related activities, and 10 percent on condom promotion activities. UNFPA's new five year program, just beginning in 1997 will most likely increase the amount of financial support to these two populations. Eighteen percent of the expenditures support STD/AIDS care. About 10 percent of total expenditures are allocated to reduce the personal and social impact of HIV infection; primarily through the development of community based care (CBC) programs. 2.7 Of the total money expended on AIDS, a small proportion, 5 percent is administered by or supports the NAS. Far too high a percentage, 44 percent, of AIDS- related expenditures in travel, research and training could n=t be attributed to the essential program categories in prevention (IEC, activities targeting youth, commercial sex workers and clients and condom promotion) or care (STD/AIDS care and CBC activities). In 1997 however, the Government of Zimbabwe increased its share to 8.4 percent for an 18 month budget. -12- Figure 2.2 Percent of Total Expenditure (1996) on AIDS Control by Activity Category Total Expenditure = $10.5 million OTHER NACP/RHO 44% 5 CBC 10% CONDOMS 10.7% ____COM SEX STDIAIDSWORKER STDIAIDS IEC YOUTH 1.5% 18% 2.8% 9% 2.8 The review of expenditures for 1996 demonstrates the government's success in attracting funds from donors, with less success in developing a system to monitor the contributions or to guide the contributions towards supporting the essential prevention and care intervention activities. Since financial allocations and expenditures reflect decisions made in policy, strategy and operations, the Study reviewed the human and institutional resources committed to the response. B. Human and Institutional Capacity 2.9 Like the three percent share of expenditures supporting AIDS control, the. commitment of human and institutional resources by the government to the AIDS response has been minimal. Public appearances and sponsored meetings by the President and his Cabinet have been frequent (more details on advocacy efforts in the country are provided in Chapter Three) and visible but have not given way to much real adjustment-- in the way of policy, strategy and operations--to significantly harness the nations AIDS response. 2.10 Unlike governments in several countries such as Uganda, Thailand, and the United States, the Government of Malawi at the time of the Study, had yet to make it a -13- policy to elevate the responsibility of planning and directing AIDS control efforts to the highest levels of government as well as to encourage significant national leadership for AIDS-matters within civil society. Thus, up until recently, no formal cabinet body in the Malawi Government has been overseeing the nation's response. Although a direct correlation between high level government oversight in the form of a formal body and reduced HIV incidence has not been documented, many involved in AIDS-related activities believe the existence of a formal body located in the highest levels of a government contributes to improved program effectiveness (UNAIDS, 1998; World Bank, 1997). 2.11 The public and private sector leaders who make up the Malawi National AIDS Committee (NAC), have rarely met as a group and are rarely heard or seen individually as spokespersons for AIDS. The NAC has no budget, no yearly program of tasks, and its membership is too large to make decision-making possible. 2.12 Since slowing the epidemic is dependent on changing individual sexual behavior and social norms, most AIDS prevention occurs outside the institutional setting of the health sector: in homes, schools and communities. Thus, international consensus exists that AIDS must be addressed by all sectors (World Bank, 1997; UNAIDS 1996a). However, the multisectoral strategy in Malawi has yet to catch momentum. Most government ministries in Malawi still regard the AIDS response as the direct responsibility of the MOHP. Too few services of the Ministry of Women, Youth and Community Services (MOWYCS), curricula of Education and operations of Defense have factored in AIDS. (Chapter Three summarizes the activities in these ministries, including those in the MOHP). Most AIDS focal points persons in the ministries have no budget, strategy or support from their management to factor AIDS into their respective programs. AIDS-related issues and concerns rarely make the agenda of the national socio- economic planning processes led by the National Economic Council. 2.13 Even within the MOHP, the several years devoted to the Strategic Framework Planning Process for Health Reform has done little to prepare the health system for the increases in new cases of AIDS or been able to, through education, prevent significant loss of its own personnel or those of the other ministries to the virus. Within the MOHP's Community Disease Unit or newly established Reproductive Health Unit no one person is responsible for coordinating STD or AIDS care within facility services. Nor has the NAS benefited from much MOHP commitment in terms of positions. Funding for the top three to four decision-making positions in the NAS has had to come from external sources (WHO, DFID, USAID, UNDP). The lead position in the NAS has been vacant over eight months, from November, 1997 to June, 1998. The status of the NAS has remained unclear since its establishment and a proposal to transform its status into one of autonomy has yet to be acted upon formally by the rarely convened NAC. 2.14 Lastly, in the way of operations, the priority intervention--changing sexual behavior--needs more emphasis. Not enough investment has been made in expertise and studies to better understand what approaches are successful in changing behavior within -14- the Malawi context. Furthermore, programmatic and technical strategies for all of the main interventions: behavior change, STD control, community-based care and AIDS care have yet to be developed. 2.15 It is worthy to note that decentralization of AIDS-related activities has been supported by the NAS through the identification and support of Regional and District AIDS Coordinators. The Coordinators, however, must carry out AIDS-related activities in addition to their full time workload. The government has also encouraged numerous local and international organizations to perform HIV/AIDS-related interventions throughout the country. More guidance should be given by the NAS and sector ministries as to where and what models of interventions should be employed and how they should be evaluated. Unlike National AIDS Control Programs in Burkina Faso, Chad, Kenya and Uganda (World Bank 1996) no government sponsored grant facility exists to broaden the role of the non-governmental sector and to monitor the nation's focus. C. Lessons Learned and Proposed Actions 2.16 The magnitude and severity of the HIV/AIDS problem in Malawi requires urgent intervention by the government and civil society. The meager allocation of local resources, failure to assign high level leadership responsibility for AIDS oversight, inactivity among members of the NAC, lack of a comprehensive multisectoral approach and operation efforts barely emphasizing the key intervention to change behavior has led to an AIDS control effort that is led by a well-intentioned few, with support from a half- hearted all. Steps taken by the Government (establishing the NAC, identifying focal point persons for each ministry, and encouraging contributions by donors and NGO's) now need to be harnessed and intensified to deliver specific outcomes. 2.17 The outcomes required in policy include strengthened political commitment and leadership at the highest level in government and civil society. Outcomes required in strategy include improved institutional capacity to lead a multisectoral response. Outcomes required in operations include investment in the most cost-effective interventions (behavior change, condom promotion, and treatment of STDs) to slow the epidemic. The Study identified five priority actions to harness and intensify the response towards attaining the above outcomes: * ACTION: Create a Cabinet Committee to Lead and Monitor the Nation's Multisectoral Response: The Cabinet Committee on AIDS, made up of the Vice President and Ministers of key ministries would provide the needed leadership and authority to mainstream HIV/AIDS-related activities in selected government ministries and institutions. The Committee would urgently address issues to strengthen the status, capacity and roles of the NAS and NAC, establish NAS posts, and increase overall government resources to -15- AIDS-related activities.5 Key ministries in the Cabinet Committee would include the Minister of Finance, Minister of the MOWYCS, Minister of the MOLGS, Minister of the MOHP, Director General of the National Economic Commission, Minister of Education, Minister of Information and Minister of Defense. The Committee would report regularly to the President on the progress in slowing the epidemic's spread. * ACTION: Empower and Reorganize the National AIDS Committee (NAC) The empowered NAC would need a budget and increased mandate to allow members to play greater advocacy roles in the community and increase its impact on advising the Cabinet Committee on AIDS and NAS on policies and strategies affecting government and civil society. Members would be supported to serve as spokespersons for the nation's response and advocates of behavior change. The NAC would need to limit its size from 38 to approxiniately 12 members from a variety of public and private organizations, to facilitate decision-making. * ACTION: Establish the NAS as an Independent Body The NAS needs a high and visible profile and an appropriate level of authority and autonomy that would allow for urgent decision-making and multisectoral coordination of nation-wide HIV/AIDS activities. NAS leadership would report to the Cabinet Committee and serve as the secretariat to the NAC. This option provides an opportunity for integration of HIV/AIDS in the national development and socio-economic planning processes. A thorough institutional analysis of AIDS Control in the government and its relationships with other partners would be undertaken as one of the steps in the reorganization of the NAS. Based on this analysis, functions within the NAS would be redefined, and positions created and advertised. * ACTION: Launch a National AIDS Planning Exercise to Prepare a Strategic Plan for the Next Five Years A transparent and participatory process is required to prepare a comprehensive national AIDS five year (1999-2004) multisectoral plan. The Multisectoral Strategic Plan would define program direction optimally and guide planning and implementation of HIV/AIDS activities nationwide. The plan would build on lessons learned and actions proposed in the AIDS Assessment Study and 1996 External Evaluation. The Multisectoral Strategic Plan for AIDS would be developed within the overall Strategic Framework Planning Process for Health Reform. For the interim, an enhanced work plan and budget for 1998 would be developed by the NAS. Some of the urgent issues and actions highlighted in this Study and 1996 External Evaluation would be piloted in the interim plan. 5 This action has already been taken. The Cabinet Committee on AIDS, chaired by the Vice President, met for the first time February 11, 1998. -16- Government, donor and World Bank funding would be mobilized to support the work plan. * ACTION: Allocate, Pool and Monitor Resources Based on Strategic Planning and Cost-effectiveness Adequate funding to support prevention activities (at close to 100 percent coverage levels) targeted -at high risk behaviors, would first be satisfied, before national AIDS program allocations are made elsewhere. The establishment of a grant facility to broaden sector and community involvement in cost-effective interventions, would be piloted. Government, private and donor grant funds would be mobilized first and pooled into one budget. Donor financial support going directly to NGO's would contribute eight to ten percent to the NAS budget for the documentation and dissemination of best practices and lessons learned. A World Bank operation could then be designed to cover any gaps. A standardized reporting format would be developed by the NAS, to monitor financial and programmatic contributions from all major partners. -17- Chapter Three THE PRIORITY INTERVENTION: CHANGING SEXUAL BEHAVIOR 3.1 In Malawi and many other countries throughout the world, AIDS is first and 6 foremost a consequence of sexual behavior . Far too many barriers in attitudes, beliefs and the social conditions to reducing the number of sexual partners and increasing use of condoms still exist in Malawi to significantly slow the epidemic's spread. The likes of a social movement will be required to change these barriers. A. Sexual Behavior and its Influencing Factors 3.2 Unprotected sex with multiple partners is the specific sexual behavior fueling this epidemic. This behavior can be changed. Recent data from projects and programs in Uganda, Thailand, Australia, United States and Switzerland suggest that due to reduction in number of sexual partners and increased condom use, transmission of HIV in these countries has been reduced (Stonebumer and Carballo, 1997; Choi and Coates, 1996; UNAIDS, 1996). Sexual Education and Knowledge in Malawi 3.3 Among many Malawians, an initiation ceremony provides a setting for sex education for adult life. Girls may have two or more ceremonies; boys have one. Participation in initiation appears widespread in rural areas. In a study conducted by Helitier-Allen in 1994, 84 percent of rural girls had been initiated (Helitzer-Allen, 1994). 3.4 The effectiveness of these ceremonies in instilling safe sexual behavior remains untested, and appears limited. Timing of the ceremonies is crucial. Fifty-eight percent of rural girls reported sexual activity before menarche in Helitzer-Allen's study and initiation usually occurred after the onset of sexual activity. Also important is content. The discussion of sex appears quite variable, with those ceremonies conducted by the church, brief in sexual content. 3.5 Among the young and older adults, AIDS is the most common STD known. Knowledge of STDs is higher for men than for women. In the 1996 Malawi Knowledge, 6 Heterosexual transmission accounts for some 90% of HIV infections in Malawi -18- Attitudes, Practices Health Survey (MKAPHS)7, 85 percent of women and 92 percent of men reported that they know of AIDS. By comparison, 57 percent of women and 73 percent of men reported knowledge of syphilis. With regard to age, awareness of STDs and ways to avoid them is lowest in the youngest age group for both sexes. Only 22 percent of women aged 15-19 and 37 percent of women aged 30-34, who had heard of AIDS, knew of at least two valid ways of avoiding HIV transmission. As mentioned in Chapter One, over twenty percent of women under the age of 20 attending QECH antenatal services were already infected with HIV in 1996. 3.6 For men, the rates of knowledge are higher, with 49 percent of men aged 15-19 and 56 percent of men aged 30-34 citing at least two valid ways of avoiding HIV. The percentage of both sexes knowing preventive measures appear however, too low to expect significant change in individual behavior and community norms. Figure 3.1 below shows the percentage of all men and women (who have heard of AIDS) reporting various ways to avoid,AIDS. Figure 3.1 Among Women and Men Who Have Heard of AIDS, the Percentage Reporting Various Ways to Avoid AIDS ,Abstain from Sex 37 Use condoms V W "___ __47 One partner 47 67 Avoid prostitutes 0 Avoid injections 19 Avoid sharing razors 33_ Men aEWomen 0 10 20' 30 40 50 60 70 Ministry of Economic Planning & Development, Percent National Statistical Office (MKAPHS) 1996 The MKAPH (conducted by the National Statistics Office) was a nationally representative sample survey of 2,683 women aged 15-49, 2,658 men aged 15-54, and 2,418 children aged 0-59 months designed to provide estimates of family planning and health indicators for the three administrative regions of the country: urban and rural areas, and Malawi as a whole. -19- Changing One's Behavior 3.7 A high percentage of Malawians (92 percent) claimed in the 1996 MKAPH Survey to have changed their behavior in response to AIDS. How they did so varied in predictable ways. Among effective changes, large proportions of women-and men reported that they had restricted their sexual activity, stopped all sexual relations or postponed starting sex. Sixty-nine percent of women and 58 percent of men claimed'they had limited sex to one partner as a means of reducing their risk. Nine percent of women and 11 percent of men stopped sexual relations all together. Similar percentages--nine percent of women and. 10 percent of men--did not start sexual relations. Three percent of women and 16 percent of men began using condoms. Numbers of Sexual Partners 3.8 As can be seen in Figure 3.1 above, 65 percent of women and 47 percent of men who know about AIDS, cited "staying with one partner" as a way to reduce risk of HIV. In marital practice, the sexes were similar; nineteen percent of married women and nineteen percent of married men reported sexual relations with an extra-spousal partner within the last four weeks of the 1996 MKAPHS. One percent-of unmarried women and 9 percent of unmarried men reported more than two sexual partners.in the last four weeks of the survey. 3.9 Overall, men reported having more sexual partners than women. In terms of non- regular partners, 2 percent of women as compared with 16 percent of men reported having at least one-non-regular partner during a 12 months period. Non-regular partners is often a source of HIV infection and other STDs (Over and Piot, 1993). As might be expected, there is a difference in prevalence of non-regular partners in terms of marital status. Less than 1 percent of currently married women reported at least one non-regular partner compared with 6 percent of currently married male respondents. Among unmarried respondents, 11 percent of women and 46 percent of men reported a non- regular partner. Acceptance and Use of Condoms 3.10 Condoms are seen by many in Malawi, as a symbol of immoral sexual activity for both men and women. Condom use for reasons other than birth control within marriage, "represents infidelity" and is widely viewed as unacceptable (Kornfield and Namate, 1996). As seen in Figure 3.1 above, three times (65 percent) as many women knew that limiting numbers of partners could reduce risk, as compared to 22 percent who knew condom use could protect against AIDS. 3.11 Not surprisingly therefore, overall condom use remains low. In the 1996 MKAPHS sample, six percent of men and three percent of women reported condom use for their most recent sexual encounter. Less than two percent of married couples reported condom use, unchanged since the 1992 Demographic and Health Survey (Ministry of -20- Economic Planning and Development, 1992). Higher, however, was condom use in 1996 with a nonregular partner, at 41 percent among men and 24 percent of women. As mentioned earlier, from an epidemiological perspective, increasing condom use among nonregular partners is a priority, since HIV and other STDs are often spread among nonregular sexual partners. Social context of personal risk 3.12 Contextual factors such as socio-economic status, gender and culture influence the sexual practices discussed above. Level of education and urban location were positively associated with one's level of knowledge about ways to avoid AIDS and where to find condoms, as well as use of condoms, for both sexes surveyed in the 1996 MKAPHS. Thus, those most educated in Malawi are also likely to be the most educated about AIDS and its prevention. Surveys of HIV prevalence and socio-economic status performed in Malawi, although few, have suggested the opposite, that it was those most educated who were most at risk of acquiring HIV. 3.13 A 1987 to 1990 study in the Mangochi District on the effects of malaria on pregnancy and birth outcomes found women with higher levels of education and socio- economic status significantly more likely to be HIV positive (USAID, 1993). A 1992 study among blood donors (Table # below) showed higher HIV prevalence rates among the military/police, Malawi Young Pioneer (MYP), the educated and skilled workers. Table 3.1 HIV Prevalence Among Blood Donors by Occupation Occupation HIV+/total sample % Military/police 23/37 62 MYP 15/53 28 Educated 64/231 28 Skilled 118/486 24 Unspecified 104/510 20 Unskilled 86/483 18 Farmers/villagers 261/1592 16 Housewives 110/670 16 Students 38/297 13 TOTAL 819/4359 19 (USAID 1992) -21- 3.14 Women attending antenatal clinics at Queen Elizabeth Hospital in 1994 whose husband had more than eight years of school, were twice as likely to be HIV positive than women with less educated husbands (Dallabetta and Miotti et al., 1994). The association between socioeconomic status and HIV infection however, is not so clear in other studies. HIV prevalence among university students in Blantyre has decreased from 5.2 percent in 1993 to 2.2 percent in 1994, suggesting behavior may be changing--at least among university students--due to information about AIDS and prevention (Liomba and Taha et al., June 1996). Sentinel surveillance data of women attending antenatal facilities throughout the country in 1995 (Table 3.2 below) showed professional occupations and unemployment status to have high rates of HIV infection. Table 3.2 HIV prevalence among antenatal care attendees by husband's occupation. Husband's Occupation Woman's Occu-ation HIV+/Sample HIV+ prevalence HIV+/Sample HIV+ prevalence Professional 158/727 21.8 34/96 35.4 Skilled 186/788 23.6 29/55 52.7 Military 23/59 39 1/2 50 Student 5/45 11.1 6/25 24 Unemployed 143/684 20.9 14/33 42.4 Farmer 207/1,694 12.2 13/113 11.5 Unknown 13/44 29.6 1/7 14.3 Housewife 637/3,709 17.2 TOTAL 735/4040 18.2 735/4040 18.2 (NACP 1995 Sentinel Surveillance report) 3.15 The reasons behind the higher prevalence of HIV among some occupations include higher urbanization, better economic conditions and mobility that are associated with a higher frequency of having multiple sexual partners. Additional surveys with larger sample sizes subjected to a variety of statistical analyses are needed to better understand the dynamics between infection, behavior and socioeconomic status in Malawi. 3.16 Gender roles and cultural traditions place both women and men vulnerable to HIV. Most woman are socially subordinate to and economically dependent on men, even though large areas of the country are matrilineal. For a woman who is widowed or divorced (six and a half percent of Malawian women between ages 20-39), few options -22- exist to generate an income (Ministry of Economic Planning and Development, 1995). Not surprisingly, most women who engage in commercial sex are divorced and have children to support (Chiwaya, 1995). As for males, the dominant male role in society also carries its own risk to HIV. Societal norms "enable" men to engage in multiple sexual partners, whether encouraged formally in polygamist unions, or "tolerated" informally through casual and commercial sex relations (Mason, 1993). Furthermore,.demands for casual and commercial sex increase as men migrate in searcl if jobs. B. Behavior Change Leadership and Strategy 3.17 Although behavior change is recognized as the key intervention to slowing the epidemic, the means to lead an effective behavior change strategy in Malawi has yet to be found. The current skills, staff positions and structure that make up the NAS are significantly deficient in this regard. The mandate to facilitate behavior change and mobilize communities to address the epidemic is lost in the many responsibilities of the NAS and weakened by frequent change in personnel and lack of a clear strategy. 3.18 The IEC and Social Mobilization Unit of the NAS is responsible for promoting behavior change to reduce sexual transmission of HIV. The role of the unit is to lead and coordinate an array of activities described and funded by donors in the nation's Medium Term Plan (MTP) II . Donors are numerous, including UNFPA, EU, UNICEF, UNESCO, UNAIDS, WHO and CIDA. 3.19 Personnel within the IEC and Social Mobilization Unit acknowledge their limitations in the skills and experience to launch the social movement necessary to change sexual behavior in Malawi. Only one Information and Communication Officer and one Assistant Health Education Officer are managing the unit. Additional staff members awaiting recruitment include an Information and Resource Officer and an Assistant Librarian. At the time of the AIDS Assessment Study, the unit had no discretionary budget. Use of Behavior Change Models 3.20 In general, no explicit theoretical model of behavioral change has been promoted by the IEC and Social Mobilization Unit to guide research and intervention activities in the country . Observers in Malawi and elsewhere do agree however, that knowledge alone is not enough to motivate individual change. 8 Although, there are intentions to formulate a Health Communication Plan. -23- Box 3.1 Models for Behavior Change A number of interrelated factors affect the way in which people use knowledge to assess the costs and benefits of risky behavior and to internalize them.. These interrelated factors, often found in specific models for individual behavior change, include the extent to which: 1) they understand how HIV infection would affect them personally and that they perceive their behavior to be risky (perceived risk); 2) they believe that the positive consequences to change would outweigh the negative consequences (positive attitude to change); they have the confidence and skills necessary to avoid unsafe behavior, or negotiate safer behavior with partners and to resist social pressures (self-efficacy) and; 3) how they perceive what others in the community are doing (perceived norms). 3.21 Three international organizations in Malawi use models to guide interventions. UNICEF advocates the Behavior Change Continuum (BCC) model. This approach stresses behavioral skills (self-efficacy) and the enabling environment (perceived norms). Interventions supported by Project Hope and the EU use-theories stressing the importance of perceived norms and community activation. Project Hope promotes the Training for Transformation approach. This mode, which draws on the teachings of Paulo Friere, stresses problem identification and problem solving as the essential process in community change. The EU's peer education interventions targeting sex workers are fashioned on social diffusion theory. This theory states that people change not because of a precise rational theory, but because of the behavior of valued peers. 3.22 Whatever behavioral theories are used, an important next step for the nation (with the NAS playing a lead role) is to ensure that the major behavioral interventions are monitored to indicate what works, and that these observations are documented and shared with therelevant parties to guide decisions in strategic planning. Sorting Out Strategic Priorities 3.23 Risk of HIV infection in Malawi can be almost entirely attributed to unprotected intercourse with an infected partner. An individual who has unprotected sex with his/her infected spouse can be at high risk of acquiring HIV. An individual who has unprotected sex with multiple partners is at high risk of acquiring HIV as well. Although the risk for acquiring HIV may be similar for these individuals, from an epidemiological and public economic viewpoint, it is the number of HIV infections subsequently transmitted by these individuals that fuels the spread of the epidemic and thus determines the target communities: who should be targeted first to receive and benefit from prevention interventions. The greater number of infections prevented among these individuals, the more efficient approach to protect everyone. (See Annex F; World Bank, 1997). Communities to Target and Benefit First from Prevention Interventions 3.24 Individuals in Malawi engaged in unprotected sex with multiple partners for the most part, can be categorized for the sake of convenience, into three target communities: female sex workers, male clients to commercial sex/mobile men, and youth. Although -24- data supporting these groups' at-risk status is limited in Malawi, the evidence from other countries strongly suggest these groups are at risk of acquiring and (particularly the first two) transmitting HIV. As will be discussed later, youth have been selected as a target community because a high percentage of youth in Malawi report unprotected sex with multiple partners and by the sake of their young age, long term gains may be made by modifying (or delaying) their sexual practices early in their lives. 3.25 Sex Workers and Bargirls. Studies among sex workers and bar girls--women who live and work at the bar--show a rapid rise in HIV prevalence, reaching about 86 percent in 1994 (Ministry of Health and Population, 1995). Baseline behavioral data show sex workers as mainly single mothers. The majority of the women are between 20-29 years and are highly mobile. Under ten percent of the women had worked from the same establishment (bar) for three or more years and over half for under six months. Experience shows that these women can be reached through peer education networks and discreet contact tracing. In surveys, about half of the sex workers report no clients in the past week, and the rest report under five clients (Chiwaya, 1995). These data suggest that their income is dependent on steady clients who pay on a monthly basis, rather than per encounter. 3.26 Targeting High Risk Behaviors of Sex Workers and Bargirls. The 1975 Public Health Act requires that bargirls be registered as food handlers and seen monthly at the government public health clinic, where they are tested for syphilis and other STDs. Monthly records are kept and are tracked by the Health Surveillance Assistants (HSAs). 3.27 The most ambitious activity targeting the behaviors of sex workers is the EU project, which began in three pilot areas expanded to 24 districts and is now being revised based on lessons learned. Peer educators from in and outside the sex work community were identified and trained, with each peer educator expected to cover 10 bars. Over 1800 peer educators were trained within the EU project alone over a seven year period. Condom use among sex workers for the EU-funded project increased from 51 percent in 1991 to 70 percent by 1996. However, focus group discussions among the workers appear not to support these data, reflecting perhaps a social acceptability bias in reporting. Other efforts to target high risk behaviors in sex work have been limited to plantations or resort areas (e.g. Project Hope on Tea Estates and Save the Children Fund in Mangochi). No systematic mapping of commercial sex networks has been performed throughout the country. 3.28 Commercial Sex Clients/Mobile Men. As the 1996 MKAPHS showed, it is not uncommon for both married men and women to engage in sexual relations with a regular partner in addition to their spouse. However, the study also shows that men engage in more casual or commercial partners than women. Fifteen percent of men reported at least one casual partnership over a 12 month period compared to only 1.8 percent of women. Eight and a half percent of men reported at least one commercial sex act over a year's time compared to only 4. 5 percent of women. Studies in and outside Malawi show that the number of sexual partners reported increases with increased mobility (Quinn, 1994). -25- 3.29 Targeting High Risk Behaviors of Clients to Sex Work and Mobile Men. Very little data in Malawi exist on men who are clients to sex work or who are mobile. Only one project, funded by the EU targets men in the transport industry. Baseline data from 1991 about truck drivers indicate that multiple partners are common and condom use is below 50 percent (Chiwaya, 1995). No HIV prevalence data are available. As to the military, no recent data on behavior or prevalence exist. In 1991, 62 percent of blood donors from the armed forces in Malawi were HIV positive (Table 3.1 on page 21). Military personnel are hesitant to monitor HIV prevalence (via anonymous screening) for reasons of security, although other countries have found these concerns to be unfounded. Success in changing behavior among the military in a transparent manner has been achieved in Thailand (World Bank, 1997) 3.30 An EU-funded AIDS project promotes prevention activities at two barracks in Kamuza and Moyare. The Adventist Relief and Development Agency (ADRA) through the John Snow Inc. (JSI) STAFH NGO grants program, also conducts education activities at the Kobi barracks. The armed forces have an AIDS Unit Secretariat managed by personnel with other full time responsibilities, with little project funding. 3.31 Youth comprise a large segment (about 30 percent) of the Malawian popuiation. As mentioned above, youth are a target community because a significant percentage of youth begin practicing unprotected sex early, with multiple partners. Two-thirds of adolescents (67 percent) in recent focus group discussions declared that "monogamy was impossible" (McAuliffe, 1994). In repeat surveys of youth commissioned by UNICEF, 46 percent of primary school and 66 percent of secondary school youth are sexually active, a proportion more or less unchanged since 1994 (see Annex G). Among the sexually active, most initiated sexual activity between ten and 14 years of age. Eighty percent of boys reported more than one partner, compared to 60 percent of girls in 1994. This percentage was only marginally lower in 1997. Out-of-school youth are more likely than youth in-school to be sexually active and to have multiple partners, with about 20 percent of boys reporting more than five partners. 3.32 Targeting High Risk Behaviors of Youth. By delaying sexual practices among the youth or by modifying their sexual behaviors, healthy sexual practices it is believed, may be instilled for a lifetime. A national youth policy adopted in 1996 identifies adolescent sexual health and HIV/AIDS as priority areas for action. In April 1997, two committees on youth were merged into one--the National Youth Sexual Health and HIV/AIDS Coordinating Committee. Because youth make up a large target community, many partners and numerous avenues (school, sports, clubs, assistance programs) are required to support the behavior change interventions. 3.33 As mentioned in Chapter Two, of the interventions involving the three target communities, youth-related interventions receive the largest amount of financial support. The largest donors for youth activities are UNFPA (mainly youth out of school), UNICEF (mainly youth in school), DFID (school AIDS curriculum), EU (tertiary -26- education), USAID (via the STAFH project support to NGO's targeting school and out of school youth). Smaller donors include Canadian Physician Relief Agency (CAPAR), Project Hope and SCF. 3.34 In 1995/96 an AIDS curriculum, first developed in 1991, was introduced by the MOE in collaboration with UNICEF and USAID in all government primary and secondary schools. Success in implementing the AIDS-related courses has been mixed. The content of the curriculum was found to be too oriented to biological facts, thus students performed well on biological exam questions but poorly on prevention measures. Of the 30 percent of teachers who were trained, most were likely not to teach the subject because of embarrassment or other reasons (UNICEF, 1996). See Annex H for a more detailed discussion on reaching students with AIDS information. 3.35 Since many Malawians receive only two or three years of school, the possibilities for reaching youth through school is limited. At present, over half of students between 15-19 are not enrolled in school and substantial numbers (30 percent of girls, 20 percent of boys) never attend (World Bank, 1997). This pattern is likely to change in the future. The new free primary school initiative has already led to a dramatic increase in enrollment, from pre-1994 enrollment figures of 645,000 students in Standard one enrollment to 1.3 million students in 1994-95. Total primary enrollment is estimated to have grown from 1.9 million in 1994 to around three million in 1997 (World Bank, 1997). 3.36 However limited, the opportunity to access and involve youth through the school system nationwide, can be capitalized much further. Targets for reaching all teachers with training on AIDS and reaching close to 100 percent of all students should be set and attained. The monitoring of this coverage will require program managers to frequently estimate the number of teachers to be trained--approximately 50,000 in 1997; with 42,000 teachers for primary level alone, and number of students to be reached--approximately 3,200,000 in 1997; with 3 million for primary level, 108,844 for distance education centers and the remaining from secondary level and private schools (World Bank, 1997). The involvement of youth as trainers and peer educators would improve behavior outcomes as well. 3.37 Out of School Youth. The responsible ministry for youth out of school is the MOWYCS. Efforts to target behaviors of out of school youth include the MOWYCS's Family Life Education Program (FLEP) which covers a few AIDS-related issues. Additional youth NGO's such as Youth Arm, Youth Ambassadors for HIV Positive Youth, Youth Voices and a few "drop-in-centres" have formed as well. 3.38 Reaching and involving out of school youth is much more difficult than youth in school, especially those aged 10-19 years. FLEP and Youth Arm appear to have been more successful at reaching older youth between 20-24 years than the younger 10-19 age group. Drop in centers for youth out of school operate mainly on weekends and falling participation seems to be related to the lack of a variety of activities and services. -27- Improving Coverage 3.39 As mentioned earlier, the most efficient approach to slowing HIV transmission is to decrease the number of secondary infections resulting from unprotective sex with multiple sexual partners. Thus, the nations' response must make sure that those persons who have the most number of sexual partners are first as beneficiaries of prevention measures. Experience in and outside Malawi suggests much more systematic attention to ensuring complete coverage of these target communities in the country is needed and possible (Wilson, 1997; Chiwaya, 1995; Moses, et al. 1991). Identification of where the greatest number of commercial sex clients/mobile men.(such as transport drivers and soldiers), sex workers and youth can be reached, mobilized and empowered, how many there are and how their sexual behavior can best be influenced, needs to be performed on a countrywide basis. Targets for reaching close to 100 percent of these communities, including-the uniformed forces with AIDS prevention efforts and attaining close to 100 percent of these individuals reporting healthy sexual behaviors should be set by the NAS, with assistance from the MOD and MOE and other ministries. Monitoring of prevalence HIV or other STD should be undertaken when and where possible. C. Interventions to Change Sexual Behavior 3.40 To reduce sexual transmission of HIV, the IEC/Social Mobilization Unit promotes safer sexual practices through mutual fidelity, nonpenetrative sex, partner reduction, condom use, and avoidance of risk-conducive situations. Messages and skills on safer sexual practices are communicated through a variety of channels, including media, counseling, peer education and community mobilization at national and local levels. 3.41 The beneficiaries of messages and skills on these safer sexual behaviors have been "prioritized" by the 1996 External Evaluation to include too many groups--the three target communities already mentioned plus workers in the public and private sector; women and STD patients: * Youth in and out of school; * Mobile men (truck drivers, military, paramilitary); * Commercial sex workers and clients (bargirls, prostitutes, freelancers); * Workers in the public and private sector; * Women (housewives, TBAs, community women's groups); * Patients with sexually transmitted diseases. Messages and Media 3.42 The main message of prevention is presented in the three tiered 'ABC' --Abstain, Be faithful, Use Condoms--format. Targeting messages around these actions to specific -28- audiences such as youth or women in bars, has occurred. Little data exists on how effective this approach has been. 3.43 Print media--posters, pamphlets, T-shirts--usually provide information, while radio and some videos address social norms (including community attitudes) and beliefs. Radio is the medium with the highest coverage. Although only 17 percent of rural households have radios, the 1992 Malawi Demographic Health Survey reported listenership at 70 percent, with music programs the most popular. Two radio programs with AIDS-related content target youth, the radio soap opera Tinkanena supported by UNICEF and Straight Talk, produced by Youth Arm. Although the listenership has not been quantified, surveys conducted by UNICEF show that nearly all youth report having heard Tinkanena Such issues as empowerment of girls have not been highlighted, although the Sarah Initiative, a multimedia campaign initiated by UNICEF, about the young adolescent girl child, is being considered. 3.44 The Malawi Broadcasting Corporation (MBC) attempts to devote two hours of air time weekly to health issues. MBC charges for all air time devoted to programming, there is no provision for public service announcements. Thus, access to radio and TV is greatly limited by cost in Malawi. 3.45 With the exception of the ongoing radio soap opera Tinkanena, that strives to portray condom use as a normal behavior for sexually active youth, few messages have addressed the beliefs and attitudes about condoms--condom breakage, condoms causing pain, or ulcers or loss of pleasure--that are identified in community surveye nne group discussions. Condom Availability, Distribution and Promotion 3.46 Experience in other countries suggest that condom availability, distribution and promotion in Malawi could be substantially increased (World Bank 1997; World Bank 1996;). In 1996, a total of 10 million male condoms were available free of charge through the public sector in Malawi, and an additional 8 million through social marketing by Population Services International (see Box 3.2 below) and other NGO's, mainly Banja La Mtsogolo (BLM). Only about 275,000 condoms are sold commercially. This brings total condom availability in Malawi to about 18.7 million annually. Zimbabwe, with a similar population size, imports three times this amount, about 65 million condoms annually for public sector distribution alone (World Bank, 1997). 3.47 The principal problem in ensuring availability of condoms throughout the public sector in Malawi is that of distribution and promotion. Condoms are distributed to facilities irregularly because of lack of space on the GMS (Government Medicine Stores) transport vehicles and frequent transport breakdowns. The extension of the USAID sponsored STAFH Project to 2001 will most likely look into this problem. Promotion of condom use by providers in non-project sites is low. Among providers giving STD care -29- in a recent study, condom use was promoted and condoms given in only 44 percent of provider-patient consultations (STAFH, 1997). Box 3.2 Marketing the Chishango ("Shield") Nationwide The Malawi condom social marketing program was launched by Population Service International (PSI) with support from the government, in September, 1994 Sales have increased gradually. Over 4.6 million condoms were sold in 1995, rising to 5.8 and 5.7 million for 1996 and 1997 respectively. Most of these condoms (64 percent) are used for disease prevention. PSI hopes to double sales this year by upping the percentage (currently at 31 percent) of condoms sold from nontraditional outlets (bottle stores, petrol stations, grocery stores) nationwide. An increase in sales will also depend on increasing the percentage of men and women who believe they are at risk of HIV. The 1995 KAP (Knowledge, Attitudes and Practice Survey) performed by PSI showed only 44 percent of men and 62 percent of women thought they were at risk of acquiring HIV (Gode, PSI; personal communication). Voluntary HIV Counseling and Testing 3.48 The active promotion of voluntary counseling and testing (VCT) as both a public service and potential prevention measure has yet to be realized in Malawi. A recent randomized controlled trial of the efficacy of VCT conducted- in Kenya and Tanzania showed that individuals randomized to VCT reduced risk behaviors to a significantly greater degree than individuals randomized to health information, and that the intervention was cost-effective (Family Health International, 1997). For example, males who received VCT reported a decrease in unprotected intercourse from 30 percent to 18 percent, compared to males who received health information reporting a decrease in unprotected intercourse from 30 percent to 26 percent. 3.49 The study concluded that VCT appears to attract high risk individuals and to result in reduced risk behaviors at 6 months with no adverse psychological consequences. The cost of providing counseling and testing per client was estimated at US $27 in Kenya and US $29 in Tanzania. The average cost per HIV infection averted by the intervention in Kenya came to US $241 and in Tanzania at US $245. (For additional information see Annexes I and J). 3.50 Counseling about the disease and knowledge of HIV status can guide an individual in his/her decision-making about a variety of areas--from prevention to care of loved ones. A positive test in one partner can be a strong incentive for condom use, and a negative test may help reinforce responsible sexual behavior. Knowledge of HIV status may make the use of condoms within marriage less difficult. 3.51 Two VCT sites, one in Lilongwe (LACE) and one in Blantyre (BASE) are operated under the auspices of MACRO. The greatest demand is for counseling, with demand for testing still quite low. For example, in Lilongwe, only about 25-35 people are tested monthly. Recently, a VCT unit has been established in Lilongwe Central Hospital. Tests are provided free of charge. -30- Community Mobilization at the National and Local Levels 3.52 Change of community norms occurs in the community. Whether the community is made up of national leaders, village workers, or both, the potential for mobilizing human and financial resources within the community in Malawi is great. Lacking are the mechanisms to undertake this, effort at the required intensity to slow the epidemic. 3.53 Since 1994, the willingness by government to address AIDS publicly has been evident. The President has personally led a walk against AIDS. The First Vice President/Minister of Defense had organized a national and a regional conference dealing with AIDS and the Armed Forces. Most recently, the government and the EU hosted a meeting for SADC member countries, to develop a regional action plan for AIDS. These gatherings have concluded with a number of practical recommendations. Actual implementation of the recommendations however, has been less than evident. 3.54 As to the local level, several cadres (see Annex K) within the line-ministries are involved in the multisectoral response and could increase their involvement if given additional support. The AIDS Coordinator of the District AIDS Coordinating Committee (DACC) is a part time position and often held by someone with clinical commitments. Members of technical committees such as the Youth Technical Subcommittee and High Risk Technical Subcommittee vary in levels of involvement and face similar constraints. 3.55 Teachers make up the largest potential cadre at the local level to assist in AIDS- related activities. As mentioned earlier, 46,000 teachers alone, teach primary levels. HSAs report to the Health Inspector and are the largest group with 3,500 paid health cadres at Traditional Authority level. Several AIDS prevention projects rely on HSAs. In Project Hope, HSAs are trained as facilitators for the Training for Transformation approach in changing behavior. In the EU projects, some HSAs supervise and support peer education activities involving bargirls. 3.56 Community-based extension workers often live in the same communities where they work, and thus they are well placed to serve as agents of behavioral change. The disadvantage in trying to utilize this cadre is that they may be overburdened by many duties, have weak supervisory structures for undertaking the many tasks requested of them, and lack the skills for the tasks required. Volunteer workers have high turnover rates in the range of 25-50 percent. One important lesson learned is that incentive structures must be in place, and in some settings cash incentives are needed. Efforts are made to avoid presenting incentives as salaries, but it is clear that program stability demands investment in incentives. 3.57 Community based distributors (CBDs) are an important source of information for communities. CBDs are supported by the National Family Welfare Council (NFWC) and are recruited in approximately 26 family planning activities around the country. CBDs have been trained in promotion of reproductive health, including contraception and STDs -31- by BLM. They have also been recruited into condom social marketing activities by PSI. Some CBDs are paid (by BLM and other donor supported programs) and others are not. 3.58 Mobilizing communities to undertake social change will require strategies for the different communities, investment in training and materials, and incentives to support the cadres of leaders and educators. Building capacity in this area is a priority. Investments in training and provision of incentives, whether in salary or in-kind goods, should not be shortchanged. Individuals influencing behavioral change areessential to slowing the epidemic; the greater the investment in their capacity, the greater the return. D. Program Evaluation 3.59 Several surveys have been undertaken in Malawi to measure HIV/AIDS prevention related priority indicators. Two surveys, the 1992 MDHS and the 1996 MKAPS have measured knowledge of preventive practices, condom availability at the peripheral level, reported number of sexual partners, reported condom use with non- regular sex partners and reported STD incidence among men. Malawi is one of few SSA countries with information on quality.of STD case management (see Chapter Four). Several studies,have assessed STI and HIV prevalence among pregnant women, although none have surveyed a sample size large enough to ascertaiix incidence or to detect statistically significant changes in behavior or STD/HIV status. An assessment (Annex L) of patterns of HIV incidence in East African countries and reported behaviors concluded that unlike in Uganda, little evidence in Malawi suggests changes in behavior has slowed HIV frequency rates (Stoneburner and Carballo, 1997) 3.60 The next step in Malawi is to aevelop an evaluation strategy that will identify what additional indicators need to be measured with plans indicating who will do the surveys, among what populations and how often. An obvious need identified during the Assessment Study was information on behaviors (and HIV status if possible) among the high-risk groups targeted by individual projects and interventions. Intervention Evaluation and Project Monitoring 3.61 Since baseline'studies are often not mounted before interventibns take place and there are no behavioral surveillance data routinely collected, trends in behaviors of the target communities have not be monitored over time in Malawi. The school AIDS curriculum intervention plans to measure performance on examination questions over time in a defined, measurable population,'but this will provide information only about knowledge. Only one project directed at individuals practicing high risk behaviors--the previously mentioned EU-supported peer education project,,is monitoring knowledge and practice. Thus, too few data on the,impact of interventions to change behavior, or to decrease STD or HIV rates exist in the country. -32- 3.62 As mentioned above, data to measure coverage of populations in the major geographical areas is also very limited. Indicators typically measure project inputs (e.g., number of radio broadcasts, posters produced, number of condoms distributed), but not against demographic or geographical targets. For example, a project may target youth out of school, but not have calculated the denominator of youth out of school that will need to be reached, in the defined project catchment area. 3.63 In summary, evaluation of national indicators on prevention has been consistent and well planned. Available data on project impact and limited data on number of target communities to be reached throughout the country suggest that behavior change interventions could improve depth (quality of service in promotion and monitoring of risk reduction, condom use and VTC) and breadth (coverage of target communities in all major geographical areas). E. Lessons Learned and Proposed Actions 3.64 Malawi has for the most part, achieved high levels of HIV/AIDS awareness, but behavior change has not occurred to the degree needed to significantly slow HIV transmission. The strategic focus must shift from providing information to promoting and influencing community norms, values and beliefs on reduction of high risk behaviors and to greatly expanding and strengthening capacity to do this at the national and local community levels. Ensuring that a majority of those most likely to transmit the virus are involved in and benefit from, behavior change interventions will require the targeting of prevention efforts. The objective however, is to target and even stigmatize the practice of having unprotected sex with multiple partners and not the individuals. Interventions such as peer education, condom promotion , and VCT to encourage protective behavior among these target communities and to create enabling environments, will need much more support. 3.65 True investment in behavior change will require the government and its partners to reprogram public, private, and donor resources and actions to strengthen capacity in human, institutional and strategic resources: * ACTION: Strengthen NAS Capacity to Facilitate Behavior Change The focus of the NAS must be on creating a social movement in behavior change. Thus the personnel in this body would need to be leaders in developing strategic direction and technical approaches and in evaluating impact related to behavioral and social change. Personnel to lead, evaluate and coordinate multisectoral activities to change behavior and to develop policy on behavior change would be identified and assigned to a reorganized and NAS structure. Descriptions, responsibilities and qualifications for positions, strategies and budgets would be focused on changing behavior and mobilizing communities. * ACTION: Develop a Strategy to Strengthen the Community's Capacity to Induce and Sustain Behavior Change with Emphasis on Target communities The NAS would develop and coordinate a behavior change strategy that promotes and influences safe sexual behavior to close to 100 percent of the target communities (sex workers, commercial sex clients/mobile men and youth) and that significantly increases the use and availability of condoms. The country would need to be mapped to identify geographical locations of high HIV prevalence and concentrated numbers of the target communities. Numbers of these populations would be estimated and realistic targets sets for coverage. Implementing agents would then be assigned areas. Once these communities have been reached, involved and mobilized, other communities would then be reached. (See Chapter Four on patients with STDs). Cost-effectiveness studies in the form of operations research would need to be performed to find out what works best. The NAS would emphasize educating the youth on prevention skills through a variety of modem and traditional channels, promoting VTC to all community groups, and compiling and sharing lessons learned. Surveillance systems to frequently monitor change in sexual behaviors and HIV/STD status among the community groups would be developed. The disciplined forces have an excellent environment to undertake such monitoring. * The NAS would formulate and coordinate a social mobilization strategy to increase the involvement of Malawians in a social movement to change behavior. An advocacy component will involve leaders as positive role models and spokespersons at the national, regional and local community levels. The advocacy component will assist leaders to increase their involvement in guiding the change in national community norms, through the provision of knowledge and skills training and materials. The mobilization component will empower individuals and groups to develop supportive environments for behavior change at the local community level. In addition, some policies governing the management of bars, entertainment places and hotels as well as the sale of alcohol need to be reviewed by community leaders to minimize high-risk behaviors, especially with regard to young women. The involvement of the target communities, NGO's, and persons living with AIDS (PLWA's) will be essential in the development and implementation of this strategy. Most likely a grant facility will be needed to increase and coordinate the involvement of partners from NGO's, agencies, institutions and the workplace. * The community empowerment process (CEP) as an element of the community nexus approach (CNA) outlined in the Population and Family Planning Sector Review can serve well AIDS prevention. The CEP would: -34- * Utilize extension Workers at community level. * Recast a subset of Community Based Distributors (CBDs) as Community Change Agents, who would be trained in contraception promotion, STD/HIV prevention and social marketing of condoms. * Build in incentives for promoting condoms for disease prevention. * Target communities: youth in school; youth out of school; commercial sex clients/men in the workplace and women who sell sex. -35- Chapter Four THE OTHER IMPORTANT INTERVENTIONS: PROVIDING STD AND AIDS CARE 4.1 Preventing individuals from acquiring HIV or another-STD through safe sexual practice is the most cost-effective intervention in reducing further spread of the epidemic in Malawi. However, ensuring that those individuals already infected receive appropriate care early and information and skills to prevent future infections, is also important. 4.2 Because STDs facilitate the transmission of HIV, STD control can be viewed as a preventive measure against AIDS. Because care of persons with STDs is highly dependent on a vast network of interrelated components including recruitment, training and placement of personnel, maintenance of infrastructure, and management of drugs and commodities that make up facility-based services, STD service concerns must not be separated from planning and management of overall facility-based services. A. Burden of STDs 4.3 STDs account for a significant burden of care in Malawi. About 500,000 cases of STDs will be treated at the country's health facilities in 1997. Actual number of infections in the country are most likely two to four times this figure for three reasons. First, most men with an STD seek care first from traditional or private practitioners, where cases are often not reported. Second, many women are asymptomatic for most STDs and do not seek care. Third, Zimbabwe, a country with a similar population size but better reporting system, reports close to double--900,000 or more--cases a year than Malawi (World Bank, 1997). 4.4 Several studies in Malawi show that a large number of persons can be infected with an STD without their knowledge. Twenty-two percent of general medical inpatients in Blantyre unknowingly had an STD in 1995 (Maha, 1995). Forty-two percent of ANC women at QECH were infected with at least one STD--gonorrhea, trichomoniasis, syphilis, chancroid or chlamydia--in 1993 (Dallabetta, 1993). Both urban and rural areas show consistent high prevalence of often undetected STDs. Syphilis prevalence averages 13.4 percent among pregnant women at urban and rural HIV sentinel sites throughout the country. Among STD patients, syphilis prevalence ranges from five percent at LCH in Lilongwe to 23 percent at Mangochi district and Mulanje mission hospitals. -36- Sorting Out Strategic Priorities 4.5 HIV infection and other STDs are synergistic in transmission and acquisition. Studies have shown that an HIV-infected person with an STD has an increased viral load of HIV and seven times the risk in transmitting HIV (Clotty and Dallabeta, 1993). Having an STD can increase the chances of acquiring HIV, thus patients with STDs in Malawi are often also infected with HIV. HIV prevalence among STD patients ranges from 37 percent in Rumphi to 70 percent in Blantyre. Women with syphilis in 1996 were more likely to be positive for HIV than women without syphilis (Kaluwa. 1996). A study in Mwanza, Tanzania also showed that treating STDs can reduce the incidence of HIV in a community by 40 percent (Grosskurth and Mosha, 1995). 4.6 Thus, ensuring that persons with STDs receive effective treatment could have a significant impact on slowing HIV transmission in Malawi. This task is not easy in any setting. As mentioned above, STDs are often not recognized by infected persons (especially women) and ensuring their effective treatment and ability to prevent further infections is dependent upon a private and public network of interrelated components such as access to trained personnel and appropriate antibiotics. Providing STD Care 4.7 Not surprisingly therefore, STD clinical and laboratory services in Malawi come short to ensuring that all persons with STDs receive effective care nationwide. No national STD control strategy exists and no one is responsible for STD Control in the MOHP's Reproductive Health Unit (RHU) or Communicable Diseases Unit. Trained staff are scarce throughout the country. One clinical officer and one nurse at the Lilongwe Hospital outpatient STD clinic provide care to approximately 35 - 70 patients a day, totaling a workload of 500 to 700 patients per month. In addition to a poor provider to patient ratio, privacy in this setting for counseling and examination of STD patients, especially women, is substandard. Few STD activities are integrated with the family planning unit of the MOHP and the NFWC. 4.8 In reference to treatment, routine drugs for treatment of STD syndromes are inadequate in many institutions, especially at district and community levels and reagents for syphilis and sensitivity testing are also in short supply. Promotion of early treatment of STD symptoms is limited and no incentives are offered to patients to stimulate compliance with STD treatment. Lastly, health education materials (flipcharts and leaflets) on STD prevention and care are too few in numbers. 4.9 Much progress has been recently made, despite the above, in several areas of STD Control in Malawi. The National STD Coordinator's post in the NAS has been temporarily filled with funding from the USAID/JSI STAFH Project. Policies for integrating care for STDs and family planning, guidelines for STD syndromic management, and manuals for counselor training now exist. Pilot clinics are providing improved care and quality of care has been assessed (see Box 4.1). A variety of materials -37- on STD Control for national, regional and district managers have been developed and distributed together with manuals for the training of trainers and supervisors. A wide range of print and audiovisual messages have also been developed and produced. Knowledge Attitudes, Practices and Behavior (KAPB) studies related to STD transmission and behavior change have been successfully conducted as well. Box 4.1 Assessing Quality of STD Care A July 1997 evaluation sponsored by the STAFH Project selected 26 health units (health centers and hospitals that included STAFH-supported pilot sites) to assess quality of STD case management. The evaluation methodology included observations of client-provider interactions, questionnaires completed by service providers, interviews with clients both before and after being seen by a service provider, and interviews with non-clinical staff at the units and managers (see Annex). In summary, the evaluation found that in-service training on syndromic management of STDs seems to have been successful in preparing for an adequate management of the STD approach in only the pilot sites. The pilot sites performed far better than non-pilot sites in almost all instances. Following of diagnostic algorithms was accurate and thorough in only 56 percent of observations in pilot sites (25 percent in non-pilot). The accuracy of STD treatment was only 67 percent overall in pilot sites compared to 17 percent in non-pilot sites. Partner notification was seen as a difficulty by most staff, but the issue was discussed with clients and slips for partners given in 87 percent of observations in pilot sites (compared to 43 percent in non-pilot sites). The availability of condoms was very high (96 percent of pilot sites, 89 percent of non-pilot sites). However, as mentioned earlier, while condoms were given to clients in 86 percent of pilot site observations, they were only given in 44 percent of non-pilot site observations. The only factor that might explain this difference in performance between pilot and non-pilot sites was the constant support and attention in frequent visits and feedback provided by the STAFH project to the pilot clinics. Only 29 percent of staff interviewed at both pilot and non-pilot sites said they had any supervision at all from unit managers or coordinators outside the STAFH project. Other factors (drugs, equipment, staff, reference materials etc.), previous experience or other training were not different between pilot and non-pilot sites (see Annex M: STAFH, 1996). B. Burden of AIDS 4.10 A generalized AIDS epidemic in any country increases the price of care and total health expenditures and reduces overall access. The severity of the epidemic in Malawi has already had an overwhelming and direct impact on these factors and will only increase as AIDS cases peak in the next decade. The impact is manifested in several ways. First, AIDS has increased the burden to already overloaded health services culminating in increased bed occupancy and use of drugs and supplies. Second, absenteeism, illness and deaths from AIDS has increased shortages of health personnel. Increased Demand for Care 4.11 Because most people who get AIDS are prime-aged adults, and because the illness and death of a prime-aged adult in Africa typically generates more health care demand than illness and death in another age group (Over and Randall, 1992), AIDS increases the -38- demand for health care more than the increase in mortality alone would suggest. Without AIDS, the 15-50 age group accounts for only 10-20 percent of all deaths in a country like Malawi, but those deaths typically generate more than their share of the total health care demand. 4.12 How much demand for care increases depends on the increasing prime-age adult death rate, which in turn depends on the level of HIV prevalence and the median time from infection to death. In Malawi, where mortality rates in this age group were estimated as high before the epidemic, a 13 percent infection rate among this age group increases the adult death rate by 200 percent. Given these parameters and a median 10 year period between infection and death, the World Bank estimates that the epidemic has already caused a 50 percent increase in the overall demand for health care at every price, from the start of the epidemic to the present (Figure 4.1 below). Figure 4.1 Estimated Percentage increase in the Demand for Health Care in Malawi as a Result of the AIDS Epidemic 250% r- I-- ncreased Adult Mortait -Increased Demand 200% -Adult Prevalence 150% Percentag 100%. 500/6- 0% 1985 1990 1995 2000 2005 2010 Year (World Bank, 1997 Annex N) 4.13 What do these projections mean for government and health personnel facing this increased burden? How many individuals have AIDS in Malawi, what percentage will need care from health personnel and of those seeking care, what percentage will be diagnosed as AIDS? Although the answers to these questions are not readily available, one can estimate the number of AIDS patients in the country and the burden on the health care system with the additional use of modeling, and anecdotal evidence in and outside the country. -39- 4.14 How many Malawians have AIDS? A large number of Malawians have symptomatic HIV disease and AIDS and these numbers will increase. The Epiniodel used by the NAS for this Study calculates that annual AIDS cases in Malawi began to increase markedly in the mid-to-late 1980s, and in 1996 reached a cumulative total of 150,000. Annual cases in 1996 reached 46,000, with adult cases at about 34,000, of which 18,000 are TB cases, and pediatric AIDS cases, at 12,000. 4.15 How many Malawians with AIDS will seek care? No one knows for sure. It is, known from studies in other countries of the region that not all persons with AIDS seek health care. Data from Zaire and Tanzania suggest that anywhere from 57 to 82 percent of persons with AIDS symptoms actually seek care (World Bank, 1992). Those who do seek care in Malawi, seek care from several sources: traditional healers, government/mission health care facilities, and private practitioners (Ministry of Economic Planning and Development, 1996). The majority of patients depending on their ability to pay for services, seek help from all these sources at different times during their illness. In most cases the first point of contact is the traditional healer. 4.16 Based on the Epimodel used by the NAS, one could expect 34,000 adults a year to have succumbed to AIDS in 1996 and potentially have sought care from a traditional or modem health practitioner. Since not all of these persons will seek care however, and based on experience from other countries, one could expect 57 to 82 percent of the, 34,000, or about 19,380 to 27,880 persons with AIDS seeking modem health care a year. How do these figures compare with figures of current demand for services? The most recent available data from the MOHP show 21,100 out-patient attendances were reported for 1994, of which approximately a third were due to malaria, a third to diarrhea and respiratory infections and another third to other causes, including AIDS (MOHP, 1997b). Thus, one can expect the number of AIDS patients seeking care (reported as out-patients and in-patients) in 1996 to have at least equaled or exceeded the total number of out- patient attendances reported for all causes. These numbers are projected to double in the next decade as the epidemic of AIDS peaks. 4.17 Of those seeking care--what percentage are diagnosed as AIDS? Not all persons with AIDS seen by health personnel are reported or diagnosed as HIV or AIDS. As mentioned earlier, underreporting of AIDS cases exists for a number of reasons: staff failure to recognize HIV disease; fear of stigmatizing the patient; and lack of HIV kits for diagnostic testing. As of July 1997, about 50,000 cumulative AIDS cases--only a fourth of the cumulative 200,000 AIDS cases estimated by the model--were reported to the NAS. Reduced Supply of Health Care 4.18 In addition to increasing the demand for care, the AIDS epidemic will reduce the supply of health care available at a given price. The epidemic has most likely reduced and will continue to reduce the supply of care in Malawi in two major ways. First and largest is the increased cost for maintaining safety: screening blood transfusions and -40- provision of gloves9. Second is the increased attrition of management health care workers who die of AIDS. The Department of Human Resources and Development (HRMD) calculates current annual death among all health care workers to be three percent: a six fold increase from the .5 percent annual adult mortality rate believed to have existed in Malawi before the epidemic (HRMD, 1997). The World Bank estimates that the sum of the two effects--increased cost of maintaining safety and increased attrition--will increase the cost of obtaining care of a given quantity and quality in Malawi by about 10 percent (World Bank, 1997). 4.19 Quantity and quality of care in Malawi is often hampered by shortages. Health centers run by the city councils in Lilongwe and Blantyre report critical shortages of both drugs and staff. These shortages result in patients by-passing the health centers to obtain care at the already overcrowded central hospitals, despite a policy requiring patients to obtain a referral from the health center before proceeding to the central hospital. The problem is further compounded by the lack of a district hospital in Lilongwe and Blantyre districts, so that the district health centers refer patients to these hospitals. Central hospitals are perceived as having a better supply of drugs and staff, thus patients from other parts of the country, who are dissatisfied with care in their districts, often travel to these hospitals for treatment. (See Annex P for further discussion of health care in Malawi.) Scarce Care, Higher Expenditures 4.20 Taken together, increased demand and reduced supply have two related impacts: first, health care becomes scarcer and thus more expensive: second, national health care expenditure rises. The size of the increases in health care prices and national health care expenditure depends partly on the price-responsiveness of the demand and supply for care. Drawing on assumptions of elasticities of the demand and supply responses, and assuming that patients pay approximately half the cost of health care in Malawi, total national and government expenditures, have increased by about 81 percent, already since the beginning of the epidemic (see Annex N.) 4.21 Again, what does this mean for the nation and government in current spending for health care? The lifetime hospital cost of a person (adult) living with AIDS (PLWA) is estimated by the Study Team to be MKl 166 ($78), or 43 percent of GNP per capitalo Based on a life-time cost of MK 1166 per adult patient and the assumption that only 75 percent of AIDS patients are able to access health care services, the cost of treating PLWA's in Malawi in 1996 is estimated to cost MK 29;733,000 ($1,995,503) a year. This was seven percent of the MOHP's health budget for 1995/96. See Annex 0 for assessment of blood safety in Malawi. 10 Figure of MKl 166 was based on previous studies by Tabia and Forsythe (FHI, 1992), adjusted for 1997 price in consultation and discussions with clinicians in Malawi. This assumes one year of life after AIDS diagnosis and two hospital admissions per year 41- 4.22 The burden of caring for PLWA's on the Malawi's health system is likely to be much greater (as estimated by the model above) on actual health expenditures. Such data on actual health expenditures were not available for the Study, but will be collected as part of the ongoing MTEF review. Information collected during the Study did suggest that cash flow to health and other institutions has recently slowed since the introduction of a cash budget by government. This is likely to continue and poses a challenge for health managers to offer quality care at lower costs. Providing AIDS Care and Support for Coping 4.23 As articulated in the 1994 - 1998 MTPII, the NAS commits to implementing the following activities to reduce the personal and social impact of HIV infection and AIDS: * provision of HIV/AIDS counseling and education; * improvement of care in and out of health facilities; * promotion of safer practices in traditional and heath care settings; * support to communities to care for those HIV infected and ?LWAs; and * care for surviving family members. 4.24 Some progress in these areas has been made. AIDS coordinators have been appointed in all hospitals. Clinical management guidelines to ensure medical staff offer optimal treatments for AIDS opportunistic infections, have been developed and promulgated. Counseling guidelines have also been formulated to train health staff and others in helping patients cope with the news of a positive HIV test result. A home care training manual is available for the over 85 home-and community-based programs established by public and private agencies in an attempt to meet the needs of the growing number of AIDS patients. 4.25 Nevertheless, many deficiencies still remain. There is no national care strategy outlining the type and quality of care for AIDS patients that should be delivered at the different levels of the health care system. The lack of strategy has led to the development of different models of care, some of which are not efficient. As mentioned above, shortages in staff, drugs, and supply exist in many health facilities at all levels and so prevent the effective development of a care service. Counseling services in some hospitals are not provided on a regular basis due to trained staff being assigned other duties. This is further complicated by a lack of strong links with organizations offering counseling services in the community. 4.26 Referral systems between hospitals and health centers, and among health centers of the same catchment area need to be developed. Guidelines for care are not readily available at lower levels of the health care system and few health facilities have a discharge policy that promotes home based care. -42- 4.27 Concomitantly, the community level lacks a strategy for caring for persons with AIDS. The existence of several effective community based care initiatives show that the community is willing to support community based care initiatives in both rural and urban settings, especially if these are developed from within their own areas and training and incentives are provided. A strategy could build on these successes and help other communities get started. 4.28 The strategy would definitely have to address the challenges of recruiting volunteers and staff to perform these community services. The assumption that all services can be performed by volunteers with minimal incentives and opportunities for training or remuneration will hardly sustain these initiatives for the long duration of this epidemic. The challenge, key to the success of these programs, is identifying the right type of incentives for the particular group or area. Material support in the form of uniforms, blankets, fertilizer, seed, flour and second hand clothes have been used as incentives. Opportunities in training in home care and meeting in groups to exchange experiences boost expertise and team work and use of bicycles for visiting patients and reimbursement of transport costs can augment volunteers' efficiency. 4.29 Another potential source of support to sustain the care initiative at the community level is the inclusion of income generating projects. A number of community-based care initiatives helping to meet the needs of orphans are not only providing guardians, food, clothing, shelter, skills training, but also setting up schemes in growing vegetable gardens and keeping pigs and chickens. 4.30 The Study examined the costs of eight of the 85 CBC programs existing in Malawi. The annual cost of these programs are highly variable, from US $1,883 for a small hospital based program to $184,232 for a larger program. This variation is due largely to difference in the size of the population served and the wide variety of services provided among the programs. Figure 4.2 (next page) shows total.expenditures for three home based care (HBC ) programs. As would be expected, the largest proportion (62 percent of money goes toward operating costs such as salaries and management overhead and recurrent costs (MOR). Direct care accounts for 18 percent of expenditures. Transport shares would rise significantly than the eight percent shown here if the programs were hospital based. 4.31 As seen in prevention activities, the community based initiatives often suffer from limited coverage and limited evaluation of cost-effectiveness and impact. No data exist on the number of communities needing the continuum of care nor what model works best. (See Annexes Q, R and S for additional information on community care in Malawi.) -43- Figure 4.2 Percentage of Total Expenditure (1996) for Three HBC Programmes by Input Category Total Expenditure = $285,570 Salaries Direct Care 32% 18%' Transport 8% Training MOR 12% 30% C. Lessons Learned and Proposed Actions 4.32 Health institution caie at all levels is rapidly rea.ching a crisis point and urgent measures need to be initiated to reverse the trend. It is recognized that health care reforms as proposed under the Strategic Framework Planning Process will address these concerns. However, in the iriterim, there is a need to establish national STD and HIV/AIDS care policies and leadership to address the current difficulties. * ACTION. Develop National Policies and Strategies for STD and HIV/AIDS Care Strategies for STD and HIV/AIDS care would define the type, scope and standard of services to be carried out effectively at different levels of the health care system, and the indications for referral between the levels. Policies that facilitate HIV/AIDS care at lower levels of the'health care systemto reduce overcrowding at central hospitals would be elaborated. Roles of the different cadres of workers in STD and HIV/AIDS care would need to be defined across both continuums, and, where possible, incorporate these roles into cadre job descriptions. Methods to improve care--particularly STD care--in the private sector would be found. 44- * ACTION: Strengthen Leadership in STD and HIVIAIDS Care in the MOHP The MOHP would need to create the positions and assign several senior officials to the Reproductive Health Unit for Sl D care, and the Communicable Disease Unit for AIDS care, to guide implementation of the above recommended STD and HIV/AIDS policies and strategies. This leadership would help assess the adherence to the clinical, counseling and home care guidelines available on AIDS. As done with STD case management, the MOHP would perform baseline and follow-up studies to monitor quality of care. Particular attention to finding acceptable ways to care for the ever increasing cases of AIDS in and outside the public sector would be needed. Adequate levels of trained staff, drugs, and supplies would need to be assured for appropriate STD and AIDS care. * ACTION: Strengthen the Community's Capacity to Cope with AIDS Several ministries and actors in civil society would need to help formulate and coordinate a social mobilization strategy to increase the involvement of Malawians in coping with AIDS and caring for those infected and affected. PLWA's would play an instrumental role in these efforts and living with AIDS positively, must be a central theme. New and innovative incentives to sustain the contribution volunteers are making would have to be found. -4:-*) Chapter Five THE ACTION PLAN Discussions among the NAS, MOHP, UNAIDS, World Bank. donors and implementing agents about this Study's findings, have concluded in the plan of action, provided below. All of these actions and the processes required for their accomplishment are included in the 1998 Interim Plan of the NAS or marked for inclusion in the Five Year Plan of 1999-2004. The actions are a mix of reforms at the policy, strategy and operations level. The creation of the Cabinet Committee and NAC, and reorganization of the NAS are changes in the country's policy' as to the importance given to the epidemic. The greater involvement of the non-health sectors and emphasis on a behavior change thrust concern the nation's strategy to slow the epidemic. Lastly, the increased MOHP leadership in STD and AIDS care with a focus on the provision of quality care, establishment of a sector and community grant facility mechanism to broaden the response and pooling of donor and government financial resources are modifications in operations. Financial and human resources to undertake these actions will be provided collectively, by the GOM, UNDP HIV and Development Project, USAID extended STAFH project, UNAIDS support, EU extended Peer Education Project, and if needed a World Bank loan. The Action Plan TIM 1 M.~1 11.&BE.1 I N I' Create a cabinet onmilee (CC) to lead and GOM Completed monitr the"nadefIds response Context: To urgently address issues to strengthen the capacity and roles of the NAS and NAC, establish posts, increase government budget allocations to the program, and assist in mainstreaming HIV/AIDS-related activities in government and society Actions taken" CC created in 1997, first meeting held in February, 1998. GOM, CC, NAS CC members were briefed on issues by NAS. Next steps 1. CC and NAS to develop agenda of decisions and 1 1) GOM, CC, NAS 1) World Bank 1) April actions to be taken for the year. 2. CC establishes task force to: a) review models for new 2) GOM, CC 2) UNDP 2) May NAS and NAC organigrame and selects model; b) identify new NAS and NAC positions; c) develop multisectoral Actions taken since the AIDS Assessment and in response to the Study's findings 46- Actions Responsible Agency Partner: Due date response in and outside the government 3. CC identifies new sources of financing for AIDS 3) GOM, CC 3) UNAIDS 3) July response in and outside government. Issues Risk exists that CC members will not be available to meet regularly. Serving as secretariat will require considerable time from NAS. CC members will need substantial background material in to make decisions. Empower and Reorganize the National AIDS GOM, CC September, 1998 CamMIttee (NAC) Context The empowered NAC will need an increased budget and mandate to allow members to play greater advocacy roles in the community and to increase its influence. The NAC shall advise the NAS in the making of policy and the implementation of the AIDS response. Actions taken No actions have been taken to date. Next steps 1. CC members approve new NAC structure and terms of 1) GOM, CC 1) World Bank 1) July reference and authorize funding. 2 CC members select NAC members (total number 12). 2) GOM, CC 2) UNAIDS 2) August 3. NAC members convene: members and NAS develop 3) NAC & NAS 3) September agenda of decisions and actions to be taken for the year. Issues Same issues as above: Risk exists that NAC members will not be available to meet regularly. Briefing NAC I members will require considerable time from NAS. NAC members will need substantial background material to make decisions. Estabisk lheNAS as an indepeient body GOM, CC September, 1998 Context The NAS needs a high and visible profile and an appropriate level of authority and autonomy that will allow for urgent decision-making and multisectoral co- ordination of nation-wide HIV/AIDS activities. Action taken New organizational chart for NAS drafted. NAS Next steps 1. CC establishes task force to: a) review models for new 1) GOM/CC 1) World Bank 1) May NAS organigrame and selects model; b) identify new NAS positions and begin recruitment process; c) develop multi- sectoral response in and outside the government. 2. Organizational management specialist hired to assist 2) MOHP 2) UNAIDS 2) June GOM make institutional changes. 47- .Aos Revponsible Aaency Partner Dute date 3 Establish public sector and NGO grant facility to 3) MOHP, NAS 3) UNDP 3) October support AIDS prevention and mitigation in government and communities. Issues Clarifications are needed on: a) what legal form NAS structure will take (government, parastatal or autonomous body; b) origin of funds to support structure; c) multv- sectoral relationships between NAS and ministries. Personnel responsible for coordination in the NAS will need to be experienced and senior to effectively coordinate activities in and outside the government. Launch a national AIDS planning exercise to NAS Launched prepare a strategic plan for the next ive years Context Initiate a transparent and participatory process to prepare a comprehensive national AIDS five year multi-sectoral plan to begin in 1999. Actions taken Proposal describing strategic planning process has been NAS UNAIDS developed. Temporary office established and personnel UNDP being recruited. Some funding from government and World Bank donors has been secured. USAID Next steps 1. Finalize proposal and initiate assessment methodology. 1) NAS, NEC 1) UNDP I) June 2 Secure outstanding funds. 2) NAS 2) UNAIDS 2) June 3 Collaborate with ongoing Strategic Planning Process for 3) MOHP, NEC 3) World Bank 3) Entire year Health Reform, World Bank and government preparation of a loan, extension of USAID project STAFH and EU re- programming or peer education project. Issues 1998 preparation of loan, USAID and EU projects may not benefit from solutions identified in 1999 during the strategic planning process Strategic planning process will significantly consume time from NAS. Allocate, pool and monitor resources based on NAS. NEC 1998-99 strategic planning and cost-effectiveness Context Resource allocation decisions within program interventions will to be based on strategic planning and cost-effectiveness. Action taken Strong partnership with other donors established; NAS, MOHP UNAIDS, USAID, preparations for loan have begun and coordinated to cover UNDP, EU, DFID gaps not addressed by project grants proposed from USAID, UNDP, EU and UNAIDS Next steps 1. Availability of government and donor resources will be 1) MOHP. NAS, Donors ])June determined MOF 48- AC-tion0"S Resiponsible Agenle% Partner Due dlale 2. Look into the feasibility of donor financial support 2) NAS Donors 2) August going directly to NGO's would contribute eight to ten percent to the NAS budget for the documentation and dissemination of best practices and lessons learned. 3. NAS to contract out mapping exercise of country for 3) NAS World 3) June target communities and AIDS vulnerable areas Bank/USAID 4. NAS to direct human and financial resources towards 4) NAS, NEC Donors, NGO's 4) August most cost-effective interventions. 5. GOM to launch STAFH, UNDP, and EU projects, (and 5) GOM, NAS, 5) World Bank, 5) August if necessary, World Bank loan). MOHP, NEC USAID, UNAIDS, UNDP, EU 6. GOM to perform additional cost-effectiveness studies 6) GOM, NEC, MOF, 6) Donors, NGO's 6)1999 and feasibility study on pooling resources (including NAS, MOHP experience gained in other countries, i.e. Zambia) 7. NAS to develop MIS to monitor financial and 7) NAS 7)1999 programmatic contributions from all major partners. Issues GOM provides limited human and financial resources to AIDS response. Mapping exercise will be initiated immediately and will require significant amount of collaboration with other partners particularly the NEC. Feasibility study on pooling resources will most likely require study tour to Zambia. Strengthen,' NAS Capacity ' to Facilitate GOM/NAS December, 1998 Behavior Change Context The focus of the NAS must be on creating a social USAID, DFID movement in behavior change. Thus the personnel in this body must be leaders in developing strategic direction and technical approaches and in evaluating impact related to behavioral, and social change. Action taken NAS organigrame drafted. CC briefed on need for new CC, NAS World Bank, NAS organizational structure. UNAIDS Next steps 1. Hire behavioral change specialist for interim period. 1) NAS 1) USAID 1) June, 1998 2. Strengthen behavior change skills among existing NAS, 2) NAS 2) USAID, 2) 1998-2001 MOHP and other sector staff. World Bank Issues Professionals with behavioral change skills are limited in GOM; Biomedical approach might continue to dominate AIDS response; Pressure to care for patients will consume resources for prevention (behavior change). Develop a Strategy to Strengthen the NAS December, 1998 Community's Capacty to Induce and Sastain Behavior Change with emphasis on Target Camnrities Context Develop and coordinate a behavior change strategy that -49- Actirms ~Responsible A2ency P Dedt promotes and influences safe sexual behavior to close to 100 percent of target communities--those most likely to acquire and transmit HIV (sex workers, commercial sex clients/mobile men and youth) and that significantly increases the use and availability of condoms. Action taken Several discussions have occurred centered on the NAS NFPC challenge of targeting high risk group. PHRD There has been recognition that the EU-peer education project will require a rigorous evaluation component. Next steps 1. Develop behavior change strategy; engage in consensus 1) NAS 1) USAID, World 1) September, building among appropriate interest groups. Seek Bank 1998 approval from NAC 2. Undertake research to better understand factors 2) NAS 2) USAID 2) 1999-2001 influencing high risk behavior Emphasize prevention skills among the yout promote VCT to all target communities and compile and share lessons learned 3. Identify solutions to address problems in condom 3) NAS, MOHP, 3) NFPC, USAID, 3) 1999 distribution and barriers to acceptability and use of i PHRD DFID condoms 4. Develop a surveillance system to frequently monitor 4) NAS 4) USAID 4)1999 change in sexual behaviors and disease status among the target communities. 5. Initiate routine (anonymous and unlinked) surveillance 5) NAS, MOD 5) USAID, World 5)1999 of the disciplined forces. Bank 6. Formulate and coordinate a social mobilization strategy 6) NAS, MOHP, 6) NGO's, 6) 1999-2001 to increase the involvement of Malawians in a social MOWYCS, MOYSC Communities movement to change behavior. Develop supportive environments for behavior change at the local community level. 7 Develop an advocacy component to involve leaders as 7) CC, NAS, MOHP, 7) USAID, NAC 7) 1999-2001 positive role models and spokespersons at the national, MOWYCS, MOYSC, regional and local community levels. Apply the NAC community nexus approach. 8. Explore policies to govern the management of bars, 8) NAS 8) Communities 8) 2000 entertainment places and hotels as well as the sale of alcohol. Issues Discipline forces hesitant to publicize magnitude of AIDS problem Current condom distribution problem is product of government medical stores (GMS) distribution problem. Increasing acceptability and use of condoms will require substantive behavior research. Pevejop NWonal Policies and Strategies fir NAS, MOHP 1999-2001 both STD and III V/AIDS Care Context These strategies will define the type, scope and standard of services to be carried out effectively at different levels of the health care system, and the indications for referral -50- between the levels. Policies that facilitate HIV/AIDS care at lower levels of the health care system to reduce overcrowding at central hospitals should be elaborated. Action taken None Next steps 1. Identify consultants to develop national policies and 1) NAS, MOHP 1) USAID, World. 1) August, 1998 strategies for both STD and AIDS care. Engage in Bank, NGO's consensus building among appropriate interest groups. Seek approval from NAC. 2. Ensure coordination of responsibility for STD and 2) NAS, MOHP 2) World Bank 2) Entire year AIDS care among the NAS, reproductive health unit, 1999 communicable disease unit and CHSU. 3. Evaluate quality of AIDS care provided in facilities and 3 NAS, MOHP 3) NGO's 3)2001 communities. UNAIDS, World Bank 4. Study impact of AIDS on health care system. 4) NAS, MOHP 4) World Bank 4) 1999-2001 5. Explore role of the private sector in STD and AIDS 5) NAS 5) World Bank 5) World Bank care. Issues Resources in AIDS and STD care could overwhelm those for prevention (behavior change). Recent advances in therapy suggest operations research in mother to child transmission may be warranteu. Practice of not diagnosing AIDS patients makes determination of the impact of AIDS on the health system difficult. StreNgthen Leadership in SM CoMVW and, NAS, MOHP 1999-2001 AIDS Care in she VORP Context Create the positions and assign several senior officials to MOHP, UNAIDS, World Bank, 1999 the Reproductive Health Unit for STD care, and the NAS UNAIDS, USAID Communicable Disease Unit for AIDS care, to guide implementation of the above recommended STD and HIV/AIDS policies and strategies. Action taken Several positions have been identified to be financed by NAS, MOHP USAID USAID. Next steps 1. Creation of STD unit with several positions in 1) MOHP, NAS 1) USAID, World 1)1999 communicable diseases, at least one position in Bank reproductive health unit 2. Recruit qualify persons for these positions. 2) MOHP 2) USAID, World 2)1999 Bank 3. Strengthen leadership and experience in STD/AIDS 3) NAS 3) USAID, World 3) 1999-2001 care in the NAS. Bank Issues Lack of coordination of health care delivery among reproductive health unit, communicable diseased unit, curative unit and NAS. -51- SbVaVthet the COMMrnity's Capacity to COpe NAS 1998-2001 with AIDS Context Formulate and coordinate a social mobilization strategy to increase the involvement of Malawians in coping with AIDS and caring for those infected and affected Persons living with AIDS (PLWA's) will play an instrumental role in these efforts and living with AIDS positively. Create an enabling environment. Action taken Strong component of community based care (CBC) is NAS World Bank envisaged in the World Bank loan Next steps _ 1. Develop a CBC strategy 1) NAS 1) MOHP 1)1999 NGO's World Bank 2. Introduce new strategies for home based care and 2) NAS, NGO's, 2) MOHP, 2) 2001 community empowerment to cope with the epidemic MOWYCS . . MOWYCS 3. Undertake research to: 3) NAS, NGO's, 3) MASAF 3)2001 * Explore microfinancing initiatives. MOWYCS NEC Donors * Strengthen collaboration between community based care and poverty alleviation efforts. * Compare cost and effectiveness of on going CBC models. * Explore ways to increase involvement of men in care giving. 4. Develop a strategy to factor AIDS into planning, 4) CC, NAS, NEC 4) World Bank, 4) 2001 implementation and evaluation in all major sectors: , UNDP, UNAIDS disciplines forces, education, private industry, agriculture etc. Issues - Resources in the country are severely limited to provide * care to all persons with AIDS. 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