HIV/AIDS in Malawi

It’s been hard for me to realize that death, especially at a young age, has become commonplace in Malawi. Since the first documented case of AIDS in 1985, the life expectancy has dropped over 10 years, from 52 to slightly over 40. The adult HIV prevalence rate is estimated to be a staggering 12-14%, meaning approximately 900,000 people are living with HIV, the majority of whom don’t even know they are infected. HIV/AIDS accounts for 70% of hospital deaths, with 80,000 people dieing every year of AIDS related illness. Over 400,000 children under 15 have lost one or both parents to AIDS, leaving countless AIDS orphans left in the care of extended family members who are already struggling to survive.
Sometimes, when there is no one to care for them, orphans are left to a worse fates, forced onto the streets or into prostitution to survive.

Girls and young women, in particular, are disproportionately burdened by the disease. This is not just because women are biologically more susceptible to contract HIV; cultural practices, poverty, insufficient education, rape, and a patriarchal society have all increased the risks for young women. Culturally, women are taught to be subversive to men and they must always obey their partners on issues of sex and sexuality, and for the most part the man makes the decisions regarding condom use. Cultural initiation practices and education emphasize to the males their position of dominance and to females their position of powerlessness and servitude. The initiation defines the ultimate goal in life for girls is for them to be good wives and mothers, whereas for boys they are to be participants in society, engaging in sexual conquests with multiple sex partners, even if they have a wife or girlfriend.

Furthermore, men have control of money. Even if the wife has a job, she is expected to give most of her income to her husband. Men also do most of the profitable labour; they engage in business, they sell their cash crops, and they make and sell products on the market. Women, on the other hand, partake in all the “unproductive” but essential labour; they make food, fetch water, tend to the livestock and garden, maintain the house, take care of children and partake in various other necessary household activities. The women are rewarded with very little money of their own and as a result must submit to their man and his every desire in order to ensure that they can acquire everything they need to survive, live healthily, and care for their children. Because of this reliance, Women often don’t have the ability to get out of abusive relationships or escape unfaithful husbands.

When it comes to caring for those who have become sick with an AIDS related illness, the burden usually falls on women. They must forgo any profit making activities or schooling that they may be involved in and are required to stay at home and care for their brothers, sisters, mothers, fathers, children, husbands or other family members. This further exacerbates poverty among women and contributes to their reliance on men, or even worse, their engagement in risky behaviour.
They may perform sexual favours for gifts or engage in prostitution as a quick source of income while caring for their relative, putting themselves at further risk of becoming sero-positive.

For those single women engaged in the labour force, it’s harder for them find jobs, and as a result many resort to promiscuous or risky behaviour for sustenance. It’s common for women, especially young women, to provide sexual favours to older men in exchange for gifts, services and money. Some engage in prostitution or other risky behaviour in order to support themselves or their children. For many women, there is simply no other option then selling their bodies and putting themselves at risk of becoming HIV positive.

This vulnerability of young women is clearly apparent in the statistics; among the young adults aged 15-24 almost four times more women are HIV positive then men. In the older age groups, the gender gap evens out with almost an equal percentage of men and women infected. But overall, HIV disproportionately affects women in Sub-Saharan Africa, strangling their development, human rights, education, involvement in the work force, and even their lives.

It’s hard to understand the severity of the epidemic by observing the average Malawian; for the most part, HIV and AIDS are hidden diseases.
When someone is sick with an AIDS related illness, for the most part they go to the hospital or stay at home with someone (usually a female) to care for them. Out of sight, out of mind. The only direct indications of the devastating impacts of HIV are the occasional HIV related billboard, T-shirt, or newspaper advertisement. And then there are the coffin shops, numerous, profitable, and unavoidable. The diminutive coffins, on display outside, sitting in the dirt or atop supporting units, are perhaps the most chilling reminders of the epidemic’s severity. Varying in size, from caskets which could barely hold an infant to ones which can hold large adults, they painfully denote the fate of so many Malawians, young, old and all ages in between. If infected at birth or at a very young age (usually through breast milk or rape) and left untreated, about 90% of HIV positive children will die before their 10th birthday. Without ARVs, adults will live anywhere from 2-15 years after the initial infection before they succumb to an opportunistic infection.

The stigma associated with being HIV positive has also proven a large barrier in the fight against HIV. People lose jobs. Husbands, wives, friends, boyfriends, and girlfriends run away. Families disown daughters, brothers, sons and sisters. To some people, HIV is god’s punishment for indulging in Sinful behaviour. Some just don’t understand the virus, and think it will be passed on to them if they live with or associate with a sero-positive person. Others just don’t want to associate with people who are infected, fearing others will think that they are as well. It’s no wonder that so many people do not want to know their sero-status. There is also another myth preventing people from getting tested in the first place: there is no way to treat the disease, and as such, there is no point in knowing ones sero-status, as testing positive is akin to an early death sentence.
For many, hiding from reality appears to be the best option.

Only a handful of countries have been worse hit by the epidemic.
Fortunately, some, such as Botswana, have at least some of the necessary financial resources to invest in adequate prevention and mitigation strategies. Yet others, like Malawi, are forced to rely on international assistance while stretching their own national budgets just to prevent the epidemic from getting worse.

Don’t let anyone tell you that HIV and AIDS have been conquered; there is far too much work that needs to be done throughout sub-Saharan Africa. Not only is the sickness resulting in the death and illness of countless numbers of people, the epidemic is further manifesting itself in the form of slowed or even backwards social and economic development. How can these countries invest in infrastructure when they must spend so much caring for the sick, the dieing, the orphans and the poor? How can countries with very limited national budgets afford to pay multinational corporations a large sum of their revenues for the purchase of anti-retroviral (ARV) drugs and other medicines? How can countries invest in human capital (education) when many of those who they educate will die at a young age, and therefore result in no return for their investments? These are some of the serious constraints that have retarded the advancement of sub-Saharan Africa over the last two decades.

Fortunately, there is light, however fait, at the end of the tunnel.
Some estimate that the spread of HIV has actually levelled off to the point that the number of new infections is almost the same as the death rate. That still means 80,000 are becoming infected and another 80,000 die each year, but this is a step in the right direction. Awareness campaigns have successfully made HIV and AIDS household subjects, and people are becoming less afraid to talk about them. Furthermore, some of the stigma associated with being HIV positive has been reduced, although people who are openly HIV positive still face extreme social and economic hardship. VCT (Voluntary Counselling and Testing) centres are located across the country, which provide condoms and HIV testing free of charge. Expectant mothers are also being screened for HIV and those who test positive are given the medical assistance needed to avoid passing the virus to their children. Almost everyone being admitted to hospital is now being tested (although you can refuse to hear the results). A national campaign has been launched through women’s salons which is training hairdressers to talk to their clients about HIV/AIDS, other STIs, and family planning, all while introducing female condoms to their patrons (which they have available at the heavily subsidized rate of about 25 cents for 2).

For those who are HIV positive, there have been a few encouraging developments. Anti-Retroviral (ARV) treatment has been made available free of charge for those who are positive and their CD4 blood cell (immune cells that the HIV virus attacks) count is below 200. For those who still have a CD4 count above 200, they are encouraged to regularly visit the clinic for counselling on living healthily with the virus in addition to checking on their immune system’s health. The unfortunate part is that for many of the rural masses (I believe about 80% of the population still lives in rural areas) who live far from clinics, they must take an expensive bus ride into town, if they even have that option. For some of the poor or those who are farmers, especially during important planting and harvesting times, this puts the drugs out of reach. Some men are refusing to go to the clinics if they are HIV positive, fearing that others will find out, instead insisting that their wives go and share the drugs with them (which makes the drugs ineffective for both of them and in fact increases the risk that a strain of HIV will develop that is resistant to ARV treatment).

In a future post, I’ll go more in depth on the cultural practices that have contributed to the spread of HIV in Malawi. For now, thank you for reading. Zikomo Kwambili. Tionana.

From Blantyre, Malawi,

Lucas