47 Republic of Malawi NATIONAL HIV PREVENTION STRATEGY 2009-2013 June 2009 2 TABLE OF CONTENTS ACRONYMS 4 ACKNOWLEDGEMENTS 6 PREFACE 7 1.0 INTRODUCTION 8 1.1 N ATIONAL HIV P REVENTION S TRATEGY 8 1.2 R ATIONALE 8 1.3 D EVELOPMENT P ROCESS 9 2.0 BACKGROUND 11 2.1 HIV S ITUATION IN M ALAWI 11 2.2 E PIDEMIOLOGICAL P ATTERNS OF HIV IN M ALAWI 11 2.2.1 HIV Prevalence by age and sex 11 2.2.2 HIV Prevalence by some socio-economic characteristics 12 2.2.3 HIV prevalence and risk factors among the youth 13 2.2.4 HIV prevalence among couples in marital relationships including youth 14 2.2.5 HIV by occupation and place 15 2.2.6 Paediatric HIV 15 2.2.7 Subgroups with very high incidence of HIV 15 2.2.8 Sources of new HIV infections 16 2.3 F ACTORS FACILITATING HIV TRANSMISSION IN M ALAWI 17 2.3.1 Multiple and concurrent sexual partnerships 18 2.3.2 Discordancy in long-term couples (one partner HIV-negative and one positive) 18 2.3.3 Late initiation of ART 18 2.3.4 The TB/HIV Co-epidemic 18 2.3.6 Low and inconsistent condom use 19 2.3.7 Suboptimal implementation of HIV prevention within clinical settings including provision of HTC 19 2.3.8 Other determinants facilitating HIV transmission 20 3.0 HIV PREVENTION RESPONSE IN MALAWI 22 3.1 C OVERAGE AND EFFECTIVENESS OF HIV PREVENTION PROGRAMMESMES IN M ALAWI 22 3.1.1 Behaviour change communications 22 3.1.2 Teaching of life skills education and peer education 22 3.1.3 Advocacy sessions and community-based campaigns 23 3.1.4 Condom programmesming 23 3.1.5 HIV testing and counseling (HTC) 24 3.1.6 Promotion of prevention of mother to child transmission of HIV 24 3.1.7 Blood safety and infection prevention 24 3.1.8 STI management 25 3.1.9 Education campaigns against stigma and discrimination due to HIV 25 3.1.10 Workplace prevention interventions 25 4.0 GOAL, STRATEGIC OBJECTIVES AND GUIDING PRINCIPLES 26 4.1 G OAL 26 4.2 S TRATEGIC OBJECTIVES 26 4.3 S TRATEGIC O BJECTIVES FOR CROSS - CUTTING ISSUES 26 4.4 G UIDING PRINCIPLES 26 5.0 STRATEGIC OBJECTIVES, APPROACHES AND BROAD ACTIVITIES 27 5.0 COORDINATION MECHANISMS 41 5.1 I MPLEMENTATION 41 5.2 M ONITORING , EVALUATION AND RESEARCH 41 3 6.0 INDICATORS 42 ANNEXES 43 ANNEX 1: N ATIONAL HIV P REVENTION I NDICATORS AND T ARGETS 45 A NNEX II: ACTION PLAN FOR THE NATIONAL HIV PREVENTION STRATEGY, 2009-2012 49 ANNEX III: R EFERENCES 64 4 ACRONYMS AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Clinic ART Antiretroviral Therapy ARVs Antiretroviral BCI Behaviour Change Interventions BSS Behaviour Surveillance Survey CDC Centres for Disease Control and Prevention CHAM Christian Health Association of Malawi CRS Centre for Social Research SW Sex Work GBV Gender-based Violence KAPB Knowledge, Attitude, Practice and Behaviours HIV Human Immunodeficiency Virus HTC HIV Testing and Counselling IEC Information, Education and Communication MANASO Malawi Network of AIDS Service Organisations MANET+ Malawi Network of People Living with HIV MBTS Malawi Blood Transfusion Service MCH Maternal and Child Health MDHS Malawi Demographic and Health Survey MHRC Malawi Human Rights Commission MIAA Malawi Interfaith AIDS Association MICS Multiple Indicator Cluster Study MIS Management Information System MOEST Ministry of Education, Science and Technology MOEPD Ministry of Economic Planning and Development MOH Ministry of Health MOICE Ministry of Information and Civic Education MOLGRD Ministry of Local Government and Rural Development MOT Modes of Transmission model MSDY Ministry of Sports and Youth Development MSM Men who have Sex with Men MTCT Mother to Child Transmission of HIV NAC National AIDS Commission NAPHAM National Association for People Living with HIV in Malawi NGO Non-Governmental Organization OPC Office of the President and Cabinet PMTCT Prevention of Mother to Child Transmission of HIV SSS Sentinel Surveillance Survey STI Sexually Transmitted Infections UN United Nations UNAIDS Joint United Nations Programme on HIV and AIDS 5 UNICEF United Nations Children Fund UNFPA United Nations Population Fund WHO World Health Organisation 6 ACKNOWLEDGEMENTS The development of the National HIV Prevention Strategy was consultative and participatory. Experts from Government Ministries, the National AIDS Commission, development partners, NGOs, the academia and members of the public participated in the process. The National AIDS Commission would like to thank the following members of the national HIV prevention steering committee and task force for their technical input and guidance: Dr. Mary Shawa, Dr. Biziwick Mwale, Dr. Desmond Jones, Dr. Kelita Kamoto, Mrs. Bridget Chibwana, Dr. Mathew Barnhart, Mr. Humphreys Shumba, Mr. Patrick Chakholoma, Mrs. Amanda Manjolo, Dr. Frank Chimbwandira, Dr. Sarah Hersey, Ms. Glory Mkandawire, Dr. Ken Maleta, Mr. Lloyd Simwaka, Professor Cameroon Bowe, Dr. Richard Banda, Mr. George Kampango, Dr. Chisale Mhango, Mr. Simon Sikwese, Dr. Roberto Brant-Campos, Dr. Beth Barr, Dr. Miriam Chipimo, Ms Pamela Mkwamba, Mr. Robert Chizimba, Mrs. Florence Kayambo, Mr. Blackson Matatiyo, Mr. Christopher Teleka, Mr. Eliam Kamanga, Mrs. Maria Mukwala, Mrs. Mirriam Kaluwa, Mr. Felix Pensulo Phiri, Mr. Owen Banda and Dr. Andrina Mwansambo. The Commission is also grateful to members of the following key social groups that participated in a series of consultation workshops: traditional and religious leaders, health service providers, inmates, sex workers, children living with HIV aged between 8-14 years, men who have sex with men, people with disabilities, vendors, nursing college students, Local Assembly representatives and BCI, Health and HIV technical working groups. The Commission would like to acknowledge financial support it received from various funding partners of the national response to HIV and AIDS towards development of the strategy. 7 PREFACE Implementation of effective HIV prevention interventions to reduce new infections still poses a challenge in the national response to HIV and AIDS in Malawi. Although the national HIV prevalence is declining, on average there are nearly 90, 000 new HIV infections each year with at least half occurring among young people aged 15-24. The majority of people being infected are those who were previously considered to be at low risk, for example, couples and partners in stable sexual relationships. In response to this challenge, the Government of Malawi in collaboration with its stakeholders has developed and implemented several prevention strategies and plans aimed at reducing further transmission of HIV through unprotected sex, mother to child, invasive procedures, blood and blood products. These strategies and plans include: the National Behaviour Change Interventions Strategy, PMTCT Scale up Plan, Abstinence Strategy, Mutual Faithfulness Strategy, National Plan of Action for Scaling up Sexual Reproductive Health HIV Prevention Interventions for Young People, Condom Strategy and HIV Testing and Counselling (HTC) Scale-up plan. HIV prevention interventions have been implemented addressing behaviour change, HTC, Prevention of Mother to Child Transmission of HIV (PMTCT), Sexually Transmitted Infections (STI) management and blood safety. The National HIV Prevention Strategy (2009-2013) has been developed to respond to the current gaps in HIV prevention interventions. The strategy builds on the various strategic documents mentioned above which have guided prevention efforts in the country. This National HIV Prevention Strategy presents a goal, strategic objectives, approaches and broad activities addressing HIV prevention at individual, group and community levels. The strategy also presents contextual factors and determinants which have been termed in the strategy as Cross-cutting. These cross- cutting issues are factors that need to be addressed to create an enabling environment for sustained positive behaviours in Malawi. These issues include gender, human rights, culture, legal and capacity building. In order to achieve maximum impact, partners in the national response will implement interventions at the national, district and community levels. The strategy also presents monitoring and evaluation indicators for tracking progress in implementation of HIV prevention. To enhance coordination in HIV prevention efforts, the strategy presents key lead agencies on each strategic area. Lastly, I would like to call upon all partners in the national response to HIV and AIDS to intensify their efforts in HIV prevention in order to reduce new HIV infections in Malawi. Dr. Mary Shawa Secretary for Nutrition, HIV and AIDS OFFICE OF THE PRESIDENT AND CABINET 8 1.0 INTRODUCTION 1.1 National HIV Prevention Strategy The National HIV Prevention Strategy (2009-2013) is a guiding tool for planning, implementation, monitoring and evaluating and resource mobilization for HIV prevention interventions. The strategy will provide practical guidance for improving current HIV prevention programming for maximum impact. The goal of the strategy is to reduce new HIV infections in order to further mitigate the burden and impact of HIV and AIDS in Malawi. In 2001, Malawi signed the United Nations Declaration of Commitment on HIV and AIDS, which set a wide agenda to address the HIV and AIDS crisis by taking action in a number of areas including prevention. At a regional level in 2006, Malawi signed the Congo Brazzaville Declaration of Commitment to intensifying HIV prevention efforts at country level. In May 2006, Malawi developed its Universal Access Framework to prevention, treatment, care and support which among other things required scaling-up of prevention programmes. This strategy is, therefore, part of the implementation process of these commitments. The HIV Prevention Strategy demonstrates a renewed emphasis on evidence-based and data-driven prevention programming consistent with best practice and firmly supported by strong epidemiological analysis, formative research and baseline and follow-up evaluations to monitor the effectiveness of programming and continuously improve its quality. Importantly, epidemiological analysis has already estimated that over 90% of new HIV infections among adults in Malawi occur in multiple and concurrent sexual partnerships and discordant couples. The National HIV Prevention Strategy focuses on both biomedical and behavioural prevention interventions including HIV testing and counselling, prevention of mother-to-child transmission, STI management, blood and injection safety, safe medical male circumcision, timely initiation of ART, condom programming, advocacy, community mobilisation, life skills education and HIV communications among others. In addition, the strategy addresses structural and cultural factors that increase vulnerability to HIV infection to foster sustainable changes in both individual behaviours and social norms. 1.2 Rationale Malawi is among the ten countries with the highest HIV prevalence in the world, estimated at 12% of adults aged 15-49 years. Although trends in HIV prevalence from sentinel surveillance indicate a slight decline, overall the downward trend in prevalence appears relatively shallow. In addition, some behaviour indicators are stagnating or even worsening. For example, the proportion of male youth aged 15-24 years having sex with more than one non-regular partner is high and condom use with non regular partner is low. While the national ART programme has been successful in scaling-up antiretroviral therapy (ART) to about 200,000 Malawians by end December 2008, the number of new infections estimated at 90,000 per year continues to outpace the number of people starting ART each year. 9 Malawi developed its Universal Access to prevention, treatment, care and support which includes a commitment to scale-up prevention programmes in order to reach as many people as possible. The National HIV Prevention Strategy is therefore a culmination of the national effort to scale-up prevention in line with Universal Access. In this light, it is important to note that prevention and treatment goals of Universal Access are mutually complementary and dependant. To maximise the prevention of transmission, it is important to ensure that people living with HIV have timely access to treatment and positive prevention interventions. In addition, prevention of new infections will assist to reduce further the burden on the health care system in Malawi. As a continued effort in HIV prevention response, the Government in collaboration with stakeholders developed a number of strategies, guidelines and action plans such as: National Behaviour Change Interventions Strategy for HIV/AIDS and Sexual Reproductive Health (2003), National Plan of Action for Scaling up Sexual and Reproductive Health HIV Prevention for Young People (2008-2012), Plan for Scaling up HIV Testing and Counselling (2006-2010), Plan for Scaling up Prevention of Mother to Child Transmission of HIV Services in Malawi (2008-2012), ART Scale up Plan (2006-2010), Condom Strategy (2006), Abstinence Strategy (2008) and Mutual Faithfulness Strategy (2008-2012). While it is acknowledged that these strategies and plans have assisted in guiding prevention efforts, one major shortcoming was that the various approaches were not optimally integrated, linked and coordinated. The National HIV Prevention Strategy has, therefore, sought to bring the various evidence-based HIV prevention interventions in a cohesive and mutually reinforcing manner in order to have a comprehensive package for effective programming. Coordination, leadership and accountability mechanisms on HIV prevention are important to the success of the national response. Malawi has therefore developed this National HIV Prevention Strategy to address the gaps that have been identified and ensure that prevention activities are integrated. 1.3 Development Process The development process of the strategy was consultative involving various stakeholders. A concept paper was developed that defined the need to have the strategy and outlined the development process. A national Think Tank meeting was held to isolate drivers of the epidemic, underlying factors and identified key partners to be engaged in the process. This was followed by formation of a National Steering Committee and a Task Force. The Steering Committee was responsible for overseeing the development process by providing policy guidance and advice to the members of the National Task Force with reference to national and global strategies and conventions. The National Task Force facilitated the process by reviewing draft documents produced by the consultants at various stages of the assignment and providing technical guidance with regard to presentation, clarity and accuracy of issues, data and information. Two consultants were engaged to review HIV and AIDS reports and facilitate a series of consultative meetings with a range of stakeholders that included: the informal Sector (vendors), private sector, herbalists and traditional healers, health service providers and researchers, experts in human rights and gender issues, members of various HIV and AIDS technical working groups, People Living 10 with HIV (PLHIV), faith leaders, children living with HIV aged 8-14 years, academia, the youth, persons with disabilities, sex workers, prisoners and members of the general public. The aim of the consultations was to solicit views on factors that are driving the epidemic in Malawi and how they should be addressed. After the consultations, consensus building workshops involving a core team of experts to develop the strategy were held. The draft strategy was presented to members of the National Task Force for input and finalization and to the members of the National Steering Committee for endorsement. [...]... reduction of HIV risk and vulnerability c) Promote legal and human rights issues that reduce HIV risk and vulnerability d) Increase the capacity and strengthen systems and structures to support, manage, expand and sustain the national prevention response e) Monitor and evaluate the national prevention response 4.4 Guiding principles The success of the implementation of the National HIV Prevention Strategy. .. and visible leadership for the HIV prevention response at national, Local Assembly, institutional and community-levels b) Based on local, national and international best practices and flexible and responsive to incorporating new evidence c) Observance of human rights-based approaches to HIV programming d) Adherence to meaningful involvement of People Living with HIV (PLHIV) e) Gender responsive programming,... with HIV in Malawi (Sentinel Surveillance, MOH 2007) Over 90% of paediatric HIV infection is acquired through vertical transmission from an HIV infected mother to the child There is need, therefore, to intensify prevention interventions for women of child bearing age and their partners, HIV positive pregnant mothers and children born to HIV positive mothers 2.2.7 Subgroups with very high incidence of HIV. .. differentials in HIV prevalence suggest that HIV risk is fairly evenly distributed across socio-economic status variables Differences in HIV prevalence by type of residence and region provide important information for the strategic distribution of HIV prevention interventions and resources as demonstrated in Table 3 where comparisons are made in HIV prevalence when adjusted in population size 12 Table 3: HIV prevalence... calls for a comprehensive provision of prevention interventions to couples such as HIV testing and counselling, condoms, timely initiation of ART, and 14 other evidence-based positive prevention interventions that would successfully prevent transmission of HIV 2.2.5 HIV by occupation and place HIV prevalence among the occupational groups in Malawi greatly exceeds the national prevalence of 12% in all instances... PMTCT services involving PLHIV The major challenge in fighting stigma and discrimination has been lack of comprehensive knowledge about HIV and AIDS that continue to perpetuate myths and misconceptions about the epidemic 3.1.10 Workplace prevention interventions Development and implementation of HIV and AIDS workplace interventions has been another critical area of focus in HIV prevention Most public and... GOAL, STRATEGIC OBJECTIVES AND GUIDING PRINCIPLES 4.1 Goal The overarching goal is to reduce new HIV infections in order to further mitigate the burden and impact of HIV and AIDS in Malawi 4.2 Strategic objectives a) Reduce sexual transmission of HIV b) Prevent mother-to-child HIV transmission of HIV c) Prevent HIV transmission through blood, blood products and invasive instruments 4.3 Strategic Objectives... and information have assisted in developing interventions in the strategy which are audience specific and addressing risk behaviours 2.2 Epidemiological Patterns of HIV in Malawi 2.2.1 HIV Prevalence by age and sex The HIV prevalence distribution by age in Malawi is typical of HIV epidemics at similar stages in Eastern and Southern Africa HIV prevalence is high among young people, higher in females aged... unprotected sex Early initiation of ART is a very crucial secondary HIV prevention intervention because it lowers viral load in PLHIV HIV Testing and Counselling services should therefore be promoted and made available in order to increase access and those found positive are timely referred to ART services 2.3.4 The TB /HIV Co-epidemic The HIV and AIDS epidemic in Malawi has resulted in a rise in the number... Prioritization of prevention responses based on effectiveness and ensure equitable, epidemiologically-sound distribution of resources g) Adherence to the “Three One’s” Principle: One national coordinating authority, one national action framework and one monitoring and evaluation plan h) Alignment with national, regional and international declarations and commitments i) Integration of HIV preventive services . Nutrition, HIV and AIDS OFFICE OF THE PRESIDENT AND CABINET 8 1.0 INTRODUCTION 1.1 National HIV Prevention Strategy The National HIV Prevention Strategy. mechanisms on HIV prevention are important to the success of the national response. Malawi has therefore developed this National HIV Prevention Strategy to