HIV/AIDS in Malawi Lisa Garbus, MPP AIDS Policy Research Center, University of California San Francisco Published March 2003 Updated April 2003 (c) 2003 Regents of the University of California Table of Contents (click on page number to go directly to that section) PREFACE 4 NOTE ON DATA SOURCES 5 ACKNOWLEDGMENTS 5 CONTACT INFORMATION 5 EXECUTIVE SUMMARY 5 EPIDEMIOLOGY 5 POLITICAL ECONOMY AND SOCIOBEHAVIORAL CONTEXT 6 IMPACT 7 RESPONSE 8 EPIDEMIOLOGY 9 AT A GLANCE 9 HIV SENTINEL SURVEILLANCE 11 HIV INCIDENCE 12 UNAIDS ESTIMATES 13 AIDS CASES 14 AIDS MORTALITY 14 TRANSMISSION PATTERNS 14 DATA QUALITY ISSUES 15 POLITICAL ECONOMY AND SOCIOBEHAVIORAL CONTEXT 18 AT A GLANCE 18 POSTCOLONIAL CONTEXT 24 ECONOMY 25 POVERTY 27 POPULATION MOBILITY 28 FOOD CRISIS 30 DEBT 34 HUMAN DEVELOPMENT 36 KNOWLEDGE OF HIV/AIDS 46 STIGMA 47 GENDER 48 SEXUAL BEHAVIOR 52 MALE CIRCUMCISION 54 ALCOHOL AND DRUG USE 54 IMPACT 55 AT A GLANCE 55 MORTALITY 59 MACROECONOMIC 60 DEPENDENCY RATIO 60 AGRICULTURE 61 HEALTH 61 HOUSEHOLDS 64 ORPHANS AND OTHER VULNERABLE CHILDREN 65 MILITARY 66 PRISONS 66 RESPONSE 67 AT A GLANCE 67 GOVERNMENT 73 CURRENT CONSTRAINTS TO THE NATIONAL RESPONSE 80 DONORS 82 GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS & MALARIA (GFATM) 82 MINISTRIES OUTSIDE HEALTH 85 HUMAN RIGHTS 85 NGOS AND CBOS 86 ORPHANS 86 VCT 87 FEMALE-CONTROLLED PREVENTION TECHNOLOGIES 88 PMTCT 88 TREATMENT OF OPPORTUNISTIC INFECTIONS AND PROVISION OF HAART 89 CARE AND SUPPORT 90 TRADITIONAL HEALERS 91 WORKPLACE 91 LINKS 92 Preface This research was undertaken as part of the Country AIDS Policy Analysis Project, which is managed by the AIDS Policy Research Center at the University of California San Francisco. The project is funded by the U.S. Agency for International Development, Cooperative Agreement PHN-A-00-01-00001-00. Stephen F. Morin, PhD, is the project's Principal Investigator. The views expressed in this paper do not necessarily reflect those of USAID. The overarching objective of the Country AIDS Policy Analysis Project is to inform planning and prioritizing of effective and equitable HIV/AIDS prevention and treatment interventions through multidisciplinary research on HIV/AIDS. The project evolved from the acute need for analysis of the epidemiology of HIV/AIDS in tandem with analysis of countries' political economy and sociobehavioral context ¾ at household, sectoral, and macro levels. This multidisciplinary analysis aims to: * help inform national HIV/AIDS policies * strengthen ability to plan, prioritize, and implement effective interventions * highlight the range of sectoral interventions that may affect or be affected by HIV/AIDS * facilitate multisectoral/interministerial coordination * facilitate intercountry information sharing * increase national and subregional capacity for effective partnerships The project develops and disseminates online, easy-to-download, continually updated analyses of HIV/AIDS in 12 USAID Rapid Scale-Up/Intensive Focus/Basic Program countries: Ethiopia, Kenya, Malawi, Senegal, South Africa, Uganda, Tanzania, Zambia, Zimbabwe, Brazil, Cambodia, and India. The primary audience for the country analyses is in-country HIV/AIDS planners, including those from government ministries and agencies, multi- and bilateral donors, international and local NGOs, health care institutions, prevention programs, academia, faith-based organizations, affected communities, and the private sector. International investigators and policymakers also report using the analyses in their work. All country analyses undergo peer review at the AIDS Research Institute of the University of California San Francisco. In addition, two in-country experts from each profiled country serve as peer reviewers. A scientific advisory board also reviews all analyses. Each analysis is linked with national strategic plans for HIV/AIDS prevention, care, and support. Analyses also include extensive links to related resources. An interactive, global database of key HIV/AIDS and socioeconomic indicators is under development; it will allow users to conduct a variety of comparative analyses. Project staff are in regular contact with national HIV/AIDS professionals who provide and verify data as needed. Staff continually assess and incorporate new data to maintain the timeliness of the analyses. Note on Data Sources All racial categorizations and nomenclature used in the data sources cited throughout this paper have been maintained; they do not constitute an endorsement of any particular terminology. Acknowledgments The following individuals served as peer reviewers and provided valuable inputs to this paper: Dr. E. Michael Reyes, Pacific AIDS Education and Training Center and the University of California San Francisco; Dr. Johnstone Kumwenda, Department of Medicine, and Dr. Newton Kumwenda, Department of Community Health, both of the Malawi College of Medicine, Blantyre. They are not responsible for any errors of fact or judgment. Contact Information Because this analysis is continually updated, comments and suggested sources of new data are welcome and may be sent to the coinvestigator/project director at UCSF's AIDS Policy Research Center: Lgarbus@psg.ucsf.edu Executive Summary Epidemiology During the early years of the HIV epidemic, prevalence among women attending ANCs rose rapidly in urban areas, with the highest prevalences in Blantyre, the country's commercial center. In 1998, Malawi's adult HIV prevalence was estimated at 14 percent. Among regions, adult prevalence was highest in Southern Region, followed by Central and Northern regions. In 2001, HIV prevalence ranged from 10 percent in rural ANC sites to nearly 30 percent in urban ones. Adult HIV prevalence was estimated at 15 percent (13 percent in rural areas and 25 percent in urban areas). Although prevalence declines have recently been observed among some age groups in ANC sites in Lilongwe and Blantyre, whether they indicate a real trend requires validation and further study. At the end of 2001, UNAIDS estimated that 850,000 Malawians were living with HIV/AIDS and that adult prevalence was 15.0 percent. Of adults infected with HIV, 56.4 percent were women. The first case of AIDS in Malawi was reported in 1985. AIDS cases among women peak between ages 15 and 29, and among men at ages 30 and above. Heterosexual transmission accounts for 90 percent of HIV infection in Malawi. Mother-to-child transmission of HIV represents 9 percent of infections, and transmission via unsafe blood products about 1 percent. Data on transmission via men who have sex with men are unavailable. Determining current HIV/AIDS dynamics and trends in Malawi is impeded by lack of complete and timely surveillance and behavioral data. Although ANC data currently serve as Malawi's primary HIV sentinel surveillance, they may not accurately reflect the population, in particular rural and younger age groups. Moreover, poverty and the current food crisis may affect ANC attendance. Political Economy and Sociobehavioral Context Many of the factors discussed below exist in countries that, unlike Malawi, have low HIV prevalence; these include poverty, gender inequality, and history of colonialism and political and economic disenfranchisement. Analysis of these factors seeks to highlight the range of sectoral policies and interventions that may affect or be affected by HIV/AIDS. Malawi is one of the world's poorest countries. HIV/AIDS has undermined the country's efforts to reduce poverty and is now itself an important part of structural poverty in Malawi. Structural adjustment programs failed to create sustainable, broad-based growth. Further, many of the high costs of these programs were borne by the poor. Malawi is deeply dependent on a single crop for export earnings. The economy has been adversely affected by a severe drought in the 2001-02 agricultural season, and the country continues to rely heavily on foreign aid. In December 2000, Malawi qualified for debt relief under the Enhanced Heavily Indebted Poor Countries Initiative (HIPC). However, the projections and assumptions underlying HIPC have been strongly criticized. Throughout southern Africa, high levels of movement among urban, rural, and mining areas facilitate HIV transmission. Poverty may lead to increased migration, both within Malawi and to other countries, as people move from rural to urban areas in search of work ¾ or return to families if they lose their jobs or fall ill and cannot afford care. Male migration separates men from their families, places them in close proximity to "high-risk" sexual networks, and often results in their having an increased number of sexual contacts. Concurrently, it may lead to women's reliance on sex to supplement their incomes while their male partners are away for long periods. Key mobile groups in Malawi include truck drivers, sex workers, fishermen/women and fish traders, migrant and seasonal workers, military personnel, prisoners, and refugees. Floods, cholera, and famine also involve significant movement of people and regroupings of family units, which entail exposure to new sexual networks and thus may heighten vulnerability to HIV. Moreover, AIDS directly spurs population dislocation as, for example, orphans are sent to live with relatives residing in other regions of the country. An estimated 29 percent of Malawians are in need of food aid. Although erratic weather has contributed to the current food crisis, one of the key underlying factors is the depletion of human resources as a result of HIV/AIDS. High levels of HIV/AIDS infection mean that the coping strategies of communities, already under major stress, are at breaking point. Despite some improvements in health outcomes since independence, Malawians' health status remains poor. The human and financial constraints to improving Malawians' health care system are enormous. Concurrently, almost all the strategies that form the government's national response to HIV/AIDS depend heavily on the country's ability to improve delivery of basic health services. Although general awareness of AIDS is nearly universal, behavior change messages may not be effectively highlighting key strategies for HIV prevention, nor adequately debunking false beliefs about HIV transmission. Strong stigma around HIV/AIDS persists. Overall condom use is low. Malawian women become infected with HIV at younger ages than men for both biological and behavioral reasons. Many women are unable to insist on condom use and negotiate the timing of sex and the conditions under which it occurs. Gender inequality remains a major barrier to improving the standard of living and reproductive health of women in Malawi. Some communities observe certain practices that promote ritual sex and may entail risk of HIV infection, including initiation ceremonies, widow inheritance, and sexual cleansing. A related phenomenon is "grabbing," wherein relatives forcefully take possession of the deceased's assets. This scenario exacerbates the already precarious economic (and social) situation of widows and their children. Male circumcision is uncommon in Malawi. One Malawian study found that lack of male circumcision was associated, though not significantly, with HIV acquisition. Impact In 2002, life expectancy in Malawi was 38.5 years, whereas it would have been 56.3 in a "no-AIDS" scenario. By 2010, life expectancy is projected to fall to 36.9. In the medium term, Malawi will experience a 4.8 percent reduction in GDP per capita because of HIV/AIDS. Much of this decrease is the result of lost knowledge and skills due to AIDS mortality within the workforce. HIV/AIDS-related conditions currently account for over 40 percent of all inpatient admissions. Increases in health worker morbidity and mortality have reduced the supply of personnel and increased stress and overwork. Lost time and labor have rendered health care more scarce and more expensive, leaving households to take on a significant burden. Malawi's National TB Control Program is internationally recognized for its success. However, since the early 1990s, it has been struggling to cope with increasing numbers of HIV-infected TB patients and worsening economic conditions. Malawi's poor have traditionally relied on informal safety nets, such as the extended family. However, HIV/AIDS, poverty, macroeconomic policies, and food shortages have rendered traditional coping mechanisms largely irrelevant. Because of AIDS mortality, many elderly Malawians ¾ themselves facing economic hardship ¾ are caring for numerous orphans. Response Shortly after the first AIDS case in Malawi was diagnosed in 1985, the government adopted a blood screening policy. Subsequently, a public education strategy on HIV/AIDS was developed. In 1989, the government established the National AIDS Control Program (NACP) within the Ministry of Health and Population. The Cabinet Committee on HIV/AIDS Prevention and Care was formed to provide policy and political direction to NACP. During the 1990s, Malawi developed medium-term plans for HIV/AIDS and, as part of the country's larger decentralization process, district AIDS coordinators and district AIDS coordination committees were established. In 1996, the government and its partners evaluated the response to date. They found that despite high awareness of HIV/AIDS, behavior change had been limited and HIV incidence continued to increase. They also cited NACP's inability to provide the required technical leadership. In response, the government developed a national strategic framework for HIV/AIDS, which was launched by the president in October 1999, at which time he also declared HIV/AIDS a national emergency. As of the end of 2000, the government's efforts to grant NACP the autonomy to implement the strategic framework were proceeding slowly. Additionally, NACP remained understaffed, thereby impeding its ability to function. Given the limitations of NACP, the National AIDS Commission (NAC) was established in July 2001 to coordinate multisectoral implementation of the strategic framework. In May 2000, Malawi began the process of developing a national HIV/AIDS policy. As of January 2003, it still did not have such a policy, though it had aimed to have one completed by the end of 2002. However, some major steps have been taken, including early development of National Orphan Care Guidelines and release of an integrated behavior change intervention strategy in 2002. Among ministries outside health, Agriculture has undertaken major efforts to mainstream HIV/AIDS prevention and mitigation. The Ministry of Education, however, has faced numerous constraints in implementing HIV/AIDS-related curricula. To fund treatment, care, and support activities, Malawi applied to the Global Fund to Fight AIDS, Tuberculosis & Malaria. In August 2002, it received final approval from GFATM for US$196 million over five years. As of January 2003, no GFATM funds had yet been disbursed. The GFATM funds will be used to improve the country's health care delivery system to support HIV/AIDS activities, emphasizing local capacity and drawing on Malawi's success with DOTS to apply a similar monitoring system to HAART. However, whether the timeframe for developing the necessary infrastructure for delivery of HAART is sufficient is questionable, especially given the entrenched weaknesses of the health sector. Moreover, local AIDS entities lack formal coordination mechanisms, trained staff, sufficient equipment and operating funds, and monitoring and financial management systems. The stretched economic resources available at the community level also play a role in constraining the local response Knowledge of human rights is low in Malawi, particularly the role of law in HIV/AIDS. Policies that explicitly integrate a human rights-based approach to HIV/AIDS are in development. Although the government has long recognized that increasing numbers of children are being affected by HIV/AIDS, it has no means of identifying these children and no adequate safety net to protect them. Extended families, as well as numerous NGOs and CBOs (including faith-based organizations), are providing the majority of care for orphans and OVC. Because public tertiary health facilities are overburdened and the care they provide is costly, the majority of PWHA receive care at home. Numerous NGOs, CBOs, faith-based groups, associations of PWHA, and household members have shouldered most of this responsibility, with little government assistance. However, home-based care skills, capacity, and financing are extremely inadequate to meet increasing need. Many Malawians visit traditional healers. Given the deteriorating health care system, visits to traditional healers may be increasing. Although the government recognizes traditional healers as stakeholders in the national response to HIV/AIDS, there has been a lack of coordination between herbalists and health officials. Malawi's strategic framework for HIV/AIDS is premised on informed consent and confidentiality. Malawi has developed draft VCT guidelines and is developing curriculum and other training materials. Currently, the majority of VCT facilities are in urban areas. PMTCT services are offered on a pilot basis by NGOs and within research projects in medical institutions in eight districts. Malawi has a PMTCT Task Force but no national PMTCT program. With funding from GFATM, Malawi plans to establish a PMTCT working group to finalize and disseminate policy guidelines. Treatment of OIs has been limited by lack of HIV/AIDS diagnostic facilities, unclear treatment guidelines, frequent drug stock-outs, inadequate training of health care personnel, and poor referral processes. In January 2000, Malawi launched a pilot HAART program in Lilongwe and Blantyre. Several universities and NGOs are also conducting pilot HAART projects. Currently, Malawi has no national policy or guidelines on HAART, though there are plans to develop them. Malawi developed its "Industrial Relations Code of Practice on HIV/AIDS" in 1996. In 2001, it issued a comprehensive policy on HIV/AIDS in the workplace. To what degree these instruments are being implemented, however, is unknown. Epidemiology At a Glance Surveys of Women Attending Antenatal Clinics * During the early years of the HIV epidemic, prevalence among women attending ANCs rose rapidly in urban areas, with the highest prevalences in Blantyre. The 1985 sentinel survey in Blantyre found that HIV prevalence was 2 percent; in 1998, it had risen to 30 percent. * The 1998 ANC data found that across all age groups, HIV prevalence was higher among urban women than among those living in rural areas. HIV prevalence was highest among women ages 25 to 29 in Lilongwe (32 percent) and in Blantyre (44 percent). In rural areas, HIV prevalence ranged from 6 to 21 percent. * In 1998, Malawi's adult HIV prevalence was estimated at 14 percent, with prevalence over twice as high in urban areas (26 percent) as in rural ones (12 percent). Among regions, adult prevalence was highest in Southern Region (18 percent) followed by Central (11 percent) and Northern (9 percent) regions. * In the 2001 ANC survey, HIV prevalence ranged from 10 percent in rural sites to nearly 30 percent in urban ones. Adult HIV prevalence was estimated at 15 percent (13 percent in rural areas and 25 percent in urban areas). * Although prevalence declines have recently been observed among some age groups in ANC sites in Lilongwe and Blantyre, whether they indicate a real trend requires validation and further study. UNAIDS Estimates * At the end of 2001, UNAIDS estimated that 850,000 Malawians were living with HIV/AIDS (estimate range: 720,000 to 1.1 million) Of them, 780,000 were adults (ages 15 to 49), with adult prevalence at 15.0 percent. * UNAIDS estimates that of adults infected with HIV, 440,000 (56.4 percent) are women. HIV prevalence among women ages 15 to 24 ranges from 11.91 to 17.87 percent; the comparable range for men in the same age cohort is 5.08 to 7.62 percent. * According to UNAIDS, there were 65,000 Malawian children (ages 0 to 14) living with HIV/AIDS at the end of 2001. AIDS Cases * The first case of AIDS in Malawi was reported in 1985. * AIDS cases among women peak between ages 15 and 29, and among men at ages 30 and above. AIDS Mortality * HIV/AIDS is the leading cause of death among those ages 20 to 49. * In 2001, UNAIDS estimated that there were 80,000 adult and child AIDS deaths in Malawi. * The U.S. Bureau of the Census estimates that the crude death rate in Malawi in 2002 was 22.3 deaths per 1,000 population. In the absence of AIDS, this figure would have been 12.0. For 2010, the Census Bureau projects that these figures will be 23.1 and 9.9, respectively. Transmission Patterns * Heterosexual transmission accounts for 90 percent of HIV infection in Malawi. Mother-to-child transmission of HIV represents 9 percent of infections, and transmission via unsafe blood products about 1 percent. Data on transmission via men who have sex with men are unavailable. Data Quality Issues * Determining current HIV/AIDS dynamics and trends in Malawi is impeded by lack of complete, timely surveillance and behavioral data. * ANC data currently serve as Malawi's primary sentinel surveillance of HIV. However, Malawi's National AIDS Commission and the U.S. CDC report that the HIV sentinel surveillance system in Malawi does not accurately reflect the population, in particular rural and younger age groups. * Moreover, the population attending ANCs is likely to vary during the different stages of the epidemic. Poverty, the current food crisis, and other factors may also affect ANC attendance. HIV Sentinel Surveillance In 1985, Malawi's first HIV surveillance project was launched, among women attending the antenatal clinic at Queen Elizabeth Central Hospital in Blantyre. 1 (Blantyre, located in the country's Southern Region, is the country's main commercial center and largest city. Lilongwe is the capital, where all government ministries and Parliament are located, and is in the Central Region. [See accompanying map].) In 1994, Malawi's National AIDS Control Program (NACP) began HIV (and syphilis) sentinel surveillance among women attending antenatal clinics (ANCs) in 19 sites across the country. The average sample size is 500 to 600 for urban and semiurban sites and 150 to 200 for rural sites.2 Findings During the early years of the HIV epidemic, prevalence among women attending ANCs rose rapidly in urban areas, with the highest prevalences in Blantyre. The 1985 sentinel survey in Blantyre found that HIV prevalence was 2 percent; in 1998, it had risen to 30 percent. The 1998 ANC data found that across all age groups, HIV prevalence was higher among urban women than among those living in rural areas. HIV prevalence was highest among women ages 25 to 29 in Lilongwe (32 percent) and in Blantyre (44 percent). In Mzuzu, a city in the Northern Region, prevalence was highest among those ages 20 to 24 (21 percent). Outside these three cities, the highest urban prevalences were in Mulanje and Nkhata Bay (25 percent). In rural areas, there was wider variation in HIV prevalences, ranging from 6 percent in Dowa to 21 percent in Thyolo. 3 In 1998, NACP used ANC data to estimate prevalence for the entire adult population: 14 percent, with prevalence over twice as high in urban areas (26 percent) as in rural ones (12 percent). 4 Among regions, NACP estimated that adult prevalence was highest in Southern Region (18 percent) followed by Central (11 percent) and Northern (9 percent) regions. It reported that although HIV prevalence had increased in all parts of the country, the increase had been most dramatic in urban areas and in Southern Region.5 In 1998, NACP estimated that 46 percent of new adult infections occurred in those ages 15 to 24; women accounted for 60 percent of these new infections. 6 In 2001, blood samples were drawn from 7,361 women attending ANCs from the 19 sentinel sites. HIV prevalence ranged from 10 percent in rural sites to nearly 30 percent in urban ones. 7 Using these data, the National AIDS Commission (which had replaced NACP as the lead HIV/AIDS coordinating body) estimated that adult HIV prevalence in Malawi was 15 percent, with adult prevalence at 13 percent in rural areas and 25 percent in urban areas. NAC estimated that in 2001, there were 845,000 Malawian infected with HIV.8 Prevalence Trends in Lilongwe and Blantyre In Lilongwe, the 2001 HSS found HIV prevalence of 20 percent, significantly below the average of 26.5 percent for 1996-98. Moreover, in Lilongwe, prevalence among women ages 15-24 has declined steadily, from 22 percent in 1998 to 13 percent in 2001. Examining trends in HIV prevalence in those ages 15-19 may provide some indication of trends in recently acquired HIV infection as this group is unlikely to have been infected for a long period of time.9 Given that an early indicator of behavior change is prevalence decline in the youngest age groups, 10 this apparent decrease could be an indication of safer sexual behavior among youth in Lilongwe (although a study of behavior change among youth in Malawi is needed to validate this hypothesis). However, the perceived decline could be due to random fluctuations in the sample tested, increasing AIDS mortality, or migration (though migration is unlikely to play a major role.11) The government and its partners agree that it is too early to state that HIV prevalence is declining in Lilongwe. 12 HIV prevalence in Blantyre was about 33 percent in 1996, and has averaged about 29 percent from 1998 to 2001. Prevalence among those 25 years and older has declined from 45 percent in 1996 to about 27 percent in 1998-2001, whereas prevalence among women ages 15 to 24 has not shown a declining trend. In 2001, 30 percent of 15- to 19-year-olds in Blantyre were HIV-positive.13 Again, apparent decline in Blantyre could be due to random fluctuations in the sample tested, AIDS mortality, or migration (though it is unlikely to be attributable to behavior change, for the reasons discussed above).14 Examination of similar trends for Malawi's other sentinel sites reveals no clear trend in declining prevalence in the younger age groups.15 It is not clear why the situation in Blantyre and Lilongwe differs. Additional research will be needed to understand whether these trends are real and, if so, why the patterns differ.16 HIV Incidence Although monitoring trends in HIV prevalence provides information on the magnitude of the HIV epidemic, trends in prevalence cannot be relied upon to indicate trends in HIV incidence.17 The major incidence data from Malawi are from a study of male workers from the Nchalo sugar plantation. Researchers from the University of Malawi, Johns Hopkins, and Rutgers examined the incidence of HIV infection among two cohorts recruited in 1994 and 1998. There was a slight decline in HIV prevalence among men screened in 1994 (n = 1692; prevalence 24.3 percent) and 1998 (n = 1349; prevalence 21.0 percent) (?2 = 4.65; p = .03). During 1994-95, incidence of HIV was extremely high (17.1 percent). Following this initial high peak, HIV incidence declined dramatically over a relatively short period of time. For example, incidence of HIV during the second year of follow-up for the 1994 cohort was only 3.1 percent, a decrease of 14 percent. During 1996-97, incidence was 4.2 percent; 1997-98: 2.5 percent; and 1998-99: 4.2 percent. For the 1998 cohort, incidence during 1998-99 was 3.8 percent. 18 In the 1994 cohort, there was a linear decreasing trend in HIV incidence with increasing age, with the youngest group (18-24 years) having an incidence nearly double that of their oldest (55 years) counterparts (p = .12). In the 1998 cohort, in which men were observed on average for one year, and in which fewer cases of seroconversions were observed, no clear trend of declining HIV incidence with age was apparent (p = .91).19 Several factors may have played a role in the incidence decline and its subsequent stability. For example, in a closed cohort study conducted over a short period of time, there may have been few susceptible individuals to sustain transmission at the same rapid rate of seroconversion. Prevention interventions may have been a factor, as the researchers also found significant reductions in reported STIs and number and type of sexual partners, as well as a significant increase in reported condom use between 1994 and 1998. However, they believe that condom use was inconsistent (or that there were reporting errors) because there was no concomitant reduction in rates of reactive syphilis. Mortality, migration, and changes in the composition of the sugar plantation's labor force may also have been factors.20 Thus, determining current HIV/AIDS dynamics and trends in Malawi is difficult. Part of this problem is lack of complete, timely surveillance and behavioral data. (Weaknesses in Malawi's health surveillance system are discussed in depth in the Political Economy & Sociobehavioral Context section below.) UNAIDS Estimates At the end of 2001, UNAIDS estimated that 850,000 Malawians were living with HIV/AIDS (estimate range: 720,000 to 1.1 million) Of them, 780,000 were adults (ages 15 to 49), with adult prevalence at 15.0 percent.21 (At the end of 1999, UNAIDS estimated adult prevalence at 15.96 percent.22) Malawi's adult HIV prevalence is the eighth-highest in the world, following that of Botswana (38.8 percent), Zimbabwe (33.7), Swaziland (33.4 percent), Lesotho (31.0 percent), Namibia (22.5 percent), Zambia (21.5 percent), and South Africa (20.1 percent).23 UNAIDS estimates that of adults infected with HIV, 440,000 (56.4 percent) are women. HIV prevalence among women ages 15 to 24 ranges from 11.91 to 17.87 percent; the comparable range for men in the same age cohort is 5.08 to 7.62 percent. 24 According to UNAIDS, there were 65,000 Malawian children (ages 0 to 14) living with HIV/AIDS at the end of 2001.25 AIDS Cases The first case of AIDS in Malawi was reported in 1985. As of June 1999, over 53,000 AIDS cases had been officially reported. However, as most cases are not reported, the National AIDS Control Program estimated that the actual cumulative number of AIDS cases through 1998 was over 265,000.26 Examining cumulative AIDS cases, NACP found that AIDS cases among women peak between ages 15 and 29, and among men at ages 30 and above. 27 This suggests significant transmission from older males to younger females. (See "Age Mixing" below.) AIDS Mortality According to Malawi's National AIDS Commission, HIV/AIDS is the leading cause of death among those ages 20 to 49. 28 In 2001, UNAIDS estimated that there were 80,000 adult and child AIDS deaths in Malawi.29 (The comparable figure for 1999 was 70,000. 30) The U.S. Bureau of the Census estimates that the crude death rate in Malawi in 2002 was 22.3 deaths per 1,000 population. In the absence of AIDS, this figure would have been 12.0. For 2010, the Census Bureau projects that these figures will be 23.1 and 9.9, respectively.31 Transmission Patterns Heterosexual transmission accounts for 90 percent of HIV infection in Malawi. Mother-to-child transmission of HIV represents 9 percent of infections. 32 Data on transmission via men who have sex with men are unavailable. Blood Safety According to UNAIDS, in 1997, unsafe blood products accounted for 1.7 percent of HIV transmission in Malawi.33 During the early 1990s, HIV prevalence among blood donors in Blantyre remained fairly stable. In the late 1990s, there was a decline in HIV prevalence among blood donors to 18 percent. 34 Several recently published studies reveal that HIV prevalence in blood donors remains high. (Moreover, because blood donors represent a younger and healthier group within the general population, screening of blood donors for HIV tends to provide a low estimate of viral marker prevalence.35) * A retrospective randomized study that audited laboratory reports from 1990 to 1994 in Nsanje Rural Hospital in the Shire Valley in southern Malawi found that the hospital uses a substantial amount of blood in the treatment of anemia, as well as to address surgical and obstetric emergencies such as caesarean sections. A total of 547 blood samples were audited; of them, 45.56 percent were positive for HIV.36 * Researchers from Malawi's Ministry of Health and Population, the University of Cambridge, and Liverpool School of Tropical Medicine examined the prevalence of HIV, hepatitis B and C, and human T lymphotropic virus I (HTLV-I) among blood donors in Ntcheu in central Malawi (n=159). Prevalence of HIV was 10.7 percent, 8.1 percent for HBV carriage, 6.8 percent for anti-HCV, and 2.5 percent for anti-HTLV-I. HIV-1/HTLV-I and HIV-1/HCV dual infections were observed in 1.2 percent of donations.37 * Analyzing data involving blood donors who underwent voluntary HIV counseling and testing between January 1998 and July 2000 in Thyolo, Médecins sans Frontières found that crude HIV prevalence was 22 percent, with the age-standardized prevalence (>15 years) at 17 percent. Prevalence was lowest among rural donors, students, and males ages 15 to 19. There was a highly significant positive association of HIV prevalence with increasing urbanization. Significant risk factors associated with prevalence for both male and female donors included having a business-related occupation, living in a semiurban or urban area, and being in the age cohort 25-29 for females and 30-34 for males.38 These studies underscore that HIV transmission via blood and blood products remains a serious concern. Limiting blood transfusions is a crucial strategy, though difficult in Malawi, where the burden of malaria and maternal morbidity and mortality is high (discussed in depth below). Malawi's 2000-04 strategic framework for HIV/AIDS stresses that inadequate quality control compromises efforts to ensure safe blood supply and that the government must strengthen policy and standards for safe blood supply and infection control in hospitals and health care centers, as well as home-based care and traditional health facilities.39 Data Quality Issues ANC data currently serve as Malawi's primary sentinel surveillance of HIV. Although widely used, ANC are imperfect (see box 1). Among other factors, the population attending ANCs is likely to vary during the different stages of the epidemic. Poverty and the current food crisis (see below) may also affect ANC attendance; for example, in November 2002, UNFPA reported that that fewer Malawian women were likely to seek prenatal care (or give birth in hospitals), given that finding food has become their top priority.40 Another factor is subfertility associated with HIV. Comparative studies have shown that HIV prevalence among pregnant women in sub-Saharan Africa underestimates prevalence in women of reproductive age because fertility among HIV-positive women is substantially lower than among uninfected women. 41 For example, Gregson et al. have found 25 to 40 percent lower fertility in women with HIV in high-prevalence African countries; they attribute about half of this "subfertility" directly to HIV infection.42 At a workshop in 2001, the National AIDS Control Program and its partners analyzed the methodology and assumptions underlying ANC data. They noted the effect of subfertility in underestimating HIV prevalence among the general population (except among the youngest age groups). For the total population, they posited that ANC data overestimate prevalence below age 25 and underestimate it over age 25. For the entire 15-49 age group, NACP asserted that these differences cancel out and that ANC prevalence is a reasonable estimate of total prevalence among men and women ages 15 to 49.43 However, at the International AIDS Conference held in Barcelona in July 2002, researchers from Malawi's National AIDS Commission and the U.S. Centers for Disease Control and Prevention reported that the HIV sentinel surveillance system in Malawi does not accurately reflect the population, in particular the rural and younger age groups. They used data from the 2000 Malawi Demographic and Health Survey to generate a nationally representative sample of women who Box 1. HIV Sentinel Surveillance: Evaluating Data from Antenatal Clinics In many developing countries, estimates on the magnitude of and trends in the HIV epidemic are obtained through HIV seroprevalence surveys. These surveys are primarily conducted using sentinel populations. The most frequently used sentinel populations are women attending antenatal clinics and persons attending clinics for diagnosis and treatment of sexually transmitted infections. The objectives of sentinel seroprevalence surveys include: 1. obtaining information on the prevalence of HIV infection in the sentinel population 2. monitoring trends in HIV prevalence in the sentinel population 3. providing information for estimating future number of AIDS cases 4. providing information for program planning and evaluation of interventions Seroprevalence surveys are usually conducted annually at preselected clinics or hospitals. Surveys of women attending antenatal clinics can provide a reasonable estimate of HIV prevalence within the general population. The surveys are conducted among women ages 15 to 49 years attending the antenatal clinic for the first time during a current pregnancy. Surveys are usually conducted in an unlinked manner, in which serum remaining from routine syphilis screening is tested for HIV infection after all personal identifying information is removed from the specimen. Sampling is usually conducted during an 8- to 12-week period, and all eligible women are sampled consecutively until the desired sample size is achieved. In general, samples of 250 and 400 women are usually sufficiently large as to provide reasonable estimates of HIV prevalence over time. Although these surveys are extremely useful, there are several limitations to consider when interpreting the survey results. The surveys are not based upon a probability sample and therefore may not be representative of the population as a whole. True population-based surveys have found antenatal clinic data may overestimate or underestimate HIV prevalence. Moreover, the ANC studies do not provide information on mortality or HIV-associated morbidity. In addition, although monitoring trends in HIV prevalence provide information on the magnitude of the HIV epidemic, trends in prevalence cannot be relied upon to indicate trends in HIV incidence. However, examining trends in HIV prevalence in younger populations, particularly 15- to 19-year-olds, may provide some indication of trends in recently acquired HIV infection, as this group is unlikely to have been infected for a long period of time. Prepared by Sandy Schwarcz, MD, MPH Director, HIV/AIDS Statistics and Epidemiology Section, San Francisco Department of Public Health Adjunct Assistant Professor, Department of Epidemiology and Biostatistics, University of California San Francisco gave birth in the last year as a potential "universe" for the surveillance sample (however, see below for a caveat on the 2000 MDHS). Data from Malawi's 2001 sentinel surveillance were compared to the national sample to assess the validity of the data for national-level HIV prevalence estimations. NAC and CDC found that the sentinel surveillance sample differed significantly from the national data on pregnant women. Of the women who accessed antenatal care in the national sample, only 42 percent had blood drawn and thus had the potential to be sampled for surveillance. The percentage who had blood drawn ranged from 65 percent of clients in Northern urban areas, to 32 percent in the semiurban areas of the South. The surveillance sample was significantly more urban (25 percent) than the national sample (9 percent) (p< 0.05). The surveillance sample was also younger, more educated, and had fewer children. Geographically, 27 percent of the surveillance sample came from the North, compared to 11 percent of the national sample. Among 15- to 24-year-olds, 86 percent of the national sample came from rural areas, compared to only 19 percent of the surveillance sample.44 (Malawi's 2000 Demographic and Health Survey was undertaken by the National Statistical Office in collaboration with ORC Macro. It was funded by USAID, DFID, and UNICEF. A total of 14,213 households were interviewed during the survey. Within these households, 13,220 women ages 15 to 49 and 3,092 men ages 15 to 54 were interviewed. 45 However, Malawi's Global Fund Coordinating Committee notes that: [T]here is little programmatic data on HIV/AIDS. Current data on health systems performance are not well synchronized both in terms of data collection and analysis. These issues were not adequately addressed by the DHS which was completed in 2000. 46 Thus, the findings quoted from the 2000 MDHS throughout this report should be viewed with this caveat in mind.) Political Economy and Sociobehavioral Context At a Glance * Many of the factors discussed in this section exist in countries that, unlike Malawi, have low HIV prevalence; these include poverty, gender inequality, and history of colonialism and political and economic disenfranchisement. This section does not seek to demonstrate causality; rather, it aims to analyze key political economy and sociobehavioral contextual elements to highlight the range of sectoral policies and interventions that may affect or be affected by HIV/AIDS. Governance * Fraud, corruption, and misappropriation of public funds remain major problems in Malawi. * Despite extensive improvements in human rights under President Muluzi, abuses remain. Poverty * Malawi is one of the world's poorest countries. In 1998, 65.3 percent of the population was living below the poverty line. (This figure does not take account of the current famine.) In 2000, gross national income per capita was US$170, well below the average for all low-income economies (US$410) as well as for the sub-Saharan Africa region (US$470). Financial wealth is generally concentrated in the hands of a small elite. * The Southern Region has the highest proportion of poor households, compared to the Central and Northern regions. The Southern Region's poverty situation can partly be explained by high migration into it, including those seeking employment in its urban areas, including Blantyre. * HIV/AIDS has undermined the country's efforts to reduce poverty and is now itself an important part of structural poverty in Malawi. Economy * Structural adjustment programs failed to create sustainable, broad-based growth. Further, many of the high costs of these programs were borne by the poor. * Malawi is heavily dependent on a single crop ¾ tobacco ¾ for export earnings. The economy has been adversely affected by a severe drought in the 2001/02 agricultural season, and the country remains heavily dependent on foreign aid. * In December 2000, Malawi qualified for debt relief under the Enhanced Heavily Indebted Poor Countries Initiative (HIPC). It is currently in its interim HIPC period, meaning that to qualify for the full amount of debt relief available via HIPC, it must successfully meet creditor conditions. * HIPC is projected to release about US$90 million for additional social expenditure. However, the projections and assumptions underlying HIPC have been strongly criticized Human Development * In 2000, Malawi's HDI value was 0.400, placing it among "low-human development" countries and ranking it 163 out of the 173. Malawi's HDI value is lower than that of the median for the world's least-developed countries (0.445) as well as for sub-Saharan Africa (0.471). * A critical human development indicator is the maternal mortality ratio, which appears to have increased by about 45 percent from the late 1980s to the late 1990s. One can infer that a variety of factors that include HIV/AIDS played a role in this increase. Population Mobility * Throughout southern Africa, high levels of movement among urban, rural, and mining areas facilitate HIV transmission. Poverty may lead to increased migration, both within Malawi and to other countries, as people move from rural to urban areas in search of work ¾ or return to families if they lose their jobs or fall ill and cannot afford care. This scenario can place an additional burden on receiving households, which concurrently lose any remittance income from the person who has fallen ill. * Male migration, a common phenomenon in Malawi, separates men from their families, places them in close proximity to "high-risk" sexual networks, and often results in their having an increased number of sexual contacts. Concurrently, it may lead to women's reliance on sex to supplement their incomes while their male partners are away for long periods. * Both Malawian men and women are increasingly mobile as they pursue trading activities. Some studies in southern African have found that female cross-border traders are particularly vulnerable to HIV infection. Other key mobile groups in Malawi include truck drivers, sex workers, fishermen/women and fish traders, migrant and seasonal workers, military personnel, prisoners, and refugees. * Floods, cholera, and famine in Malawi involve significant movement of people and regroupings of family units, which also entail exposure to new sexual networks and thus may heighten vulnerability to HIV. * Moreover, AIDS directly spurs population dislocation as, for example, orphans are sent to live with relatives residing in other regions of the country. Food Crisis * An estimated 3.3 million Malawians ¾ 29 percent of the population ¾ are in need of food aid. Although famine threatens all three regions of Malawi, Central and Southern regions have proportionately more people at risk than the North. * Reports from an array of multilateral and civil society agencies who have recently conducted missions in Malawi concur that although erratic weather has contributed to the current food crisis, one of the key underlying factors is the depletion of human resources as a result of HIV/AIDS. Unsustainable debt, chronic poverty and malnutrition, deteriorating public health services and poor health outcomes, and reliance on a single crop have also played a role. * After years of World Bank- and IMF-supported agricultural sector reforms, Malawi still faces chronic food insecurity. Many argue that these reforms were imposed too rigidly and too quickly, often leaving poor farmers without support from or access to either state or market institutions. * Malawi's response to HIV/AIDS is predicated on an effective, efficient health care system as well as strengthened capacity at local level. However, given the impacts of the humanitarian crisis, the ability of the country to mount a national response to HIV/AIDS is gravely imperiled. * High levels of HIV/AIDS infection mean that the coping strategies of communities, already under major stress, are at breaking point. * Recent missions to Malawi have reported increased malnutrition, which is likely to further weaken the immune systems of people living with HIV/AIDS, thereby contributing to higher rates of morbidity and mortality. * Famine has also raised the opportunity cost of sending children to school. Girls, in particular, are affected. Lack of food, coupled with a subsequent breakdown in family structure, has placed more children on the streets where they may be at higher risk of mistreatment, sexual exploitation, and physical and emotional abuse. Communities caring for increasing numbers of AIDS orphans are facing additional economic pressure. Health Sector * Despite some improvements in health outcomes since independence, Malawians' health status remains poor. HIV/AIDS is the leading cause of death among those ages 15 to 49, followed by malaria. Other major health problems include TB, cholera, schistosomiasis, acute respiratory infection, acute diarrheal disease, and meningitis. * As with other health data, those on STIs are difficult to access. Findings from several studies demonstrate that STIs (particularly herpes) are fueling the HIV/AIDS epidemic in Malawi. * The human and financial constraints to improving Malawians' health care system are enormous: ? Access to care is limited. Although 80 percent of Malawians live in rural areas, most of the country's health resources are located in the major urban centers. Only 3 percent of Malawians live in a village with a health center. ? Quality of care is highly variable. ? There is a critical shortage of medical personnel, particularly in rural areas. ? Training capacity falls far short of needs. ? Essential drug distribution is unreliable. ? Technical support services, such as laboratories and pharmacies, are highly inadequate. ? Basic health information is often of low quality and is consequently not adequately factored into policy formulation and program planning. ? Although districts now prepare budgets tailored to their local priorities, resources reaching district health offices vary significantly by month. * Concurrently, almost all the strategies that form the government's national response to HIV/AIDS, as outlined in its proposal to the Global Fund to Fight AIDS, TB & Malaria, are heavily dependent on the country's ability to improve delivery of basic health services. Knowledge * General awareness of AIDS is nearly universal (though knowledge of MTCT of HIV is weak). Education is strongly related with belief that AIDS can be avoided. * Men and women cite abstinence and use of condoms as ways of avoiding HIV far more frequently than limiting number of sexual partners and avoiding sex with partners who have multiple partners. * Despite high knowledge of HIV/AIDS, behavior change messages may not be effectively highlighting key strategies for HIV prevention, nor adequately debunking false beliefs about HIV transmission. Stigma * Strong stigma around HIV/AIDS persists. * Although an overwhelming majority of women and men report that they would be willing to care for a relative with AIDS in their home, health care workers consistently report reluctance by families and communities to care for members with chronic and terminal conditions. This has resulted in "dumping" of family members in hospitals, which are already overstretched. * There is also a belief among some Malawians that HIV/AIDS is related to witchcraft, though the prevalence of and sociodemographic characteristics related to holders of this belief have not been quantified. Gender HIV Prevalence among Women * Malawian women become infected with HIV at younger ages than men for both biological and behavioral reasons. HIV prevalence among Malawian women ages 15 to 24 ranges from 11.91 to 17.87 percent, whereas the comparable range for men in the same age cohort is 5.08 to 7.62 percent. * AIDS cases among women peak between ages 15 to 29, and among men at ages 30 and above. This suggests significant transmission from older males to younger females. * By 2020, there will be more men than women in each of the five-year-age cohorts between the ages of 15 and 44, which may push men to seek partners in increasingly younger age cohorts. This factor in turn may increase HIV infection rates among younger women. * Many women are unable to insist on condom use and negotiate the timing of sex and the conditions under which it occurs. Even when women know that their husbands are at high risk of HIV, many do not raise the issue of condoms as to do so might be perceived as accusing their husbands of infidelity or depriving them of sexual pleasure. Women who do suggest condom use may be at increased risk of physical violence and/or economic abandonment. * Other factors that may render women vulnerable to HIV infection include: ? sex work ? transactional sex, in which sex may be exchanged for gifts, money, or food ? resulting sense of fatalism that may reduce women's motivation to protect their sexual health Women's Status * Gender inequality remains a major barrier to improving the standard of living and reproductive health of women in Malawi. * There are major gender disparities in literacy and education. Women's lower educational levels are related to lower formal labor force participation and decreased earnings and thus lessened economic autonomy. This situation may increase women's economic dependence on men and inability to refuse sex or insist on condom use ¾ factors that can increase vulnerability to HIV. Moreover, compared with boys, girls are more often kept out of school when household income and/or labor supply falls (an increasing phenomenon given high AIDS mortality and the famine). Women and Poverty * In 1998, about 52 percent of the poor were female. Females head 25 percent of all Malawian households, and these households have always been disproportionately poor, especially in rural areas. Widows * Some communities in Malawi observe certain practices that promote ritual sex and may entail risk of HIV infection. The most common are initiation ceremonies, widow inheritance, and sexual cleansing. Widows may be particularly vulnerable to HIV because of sexual cleansing and wife inheritance. * A related phenomenon is "grabbing," wherein relatives forcefully take possession of the deceased's household goods, land, livestock, clothes, and other assets. This scenario exacerbates the already precarious economic (and social) situation of widows and their children. Sexual Violence * Reliable data on sexual violence in Malawi are scarce. The Malawian government reports that gender-based violence remains a persistent problem. Condoms * Overall condom use is low in Malawi. An enormous percentage of pre- and extramarital sex is unprotected. * Urban men and women are more likely to use a condom with a spouse or with a noncohabiting partner than are those living in rural areas. Educational attainment is strongly associated with condom use for men and ¾ especially ¾ for women. * Among those ages 15 to 24, being able to obtain a condom ¾ even when a source is known ¾ is a serious constraint. Male Circumcision * Male circumcision is uncommon in Malawi. In a study of male workers from the Nchalo sugar plantation, researchers found that lack of circumcision was associated, though not significantly, with HIV acquisition. * Some observational studies from sub-Saharan Africa have indicated that male circumcision may reduce the risk of HIV acquisition, though circumcision does not appear to affect transmission from HIV-positive men to their partners. The limitations of these studies have been highlighted, and further study is needed on both biomedical and sociobehavioral issues before promoting male circumcision as a public health intervention. Alcohol and Drug Use * Researchers have noted an increase in alcohol and drug use among young people, attributed, in part, to the lack of resources and alternative activities for youth in Malawi. Many of the factors discussed in this section exist in countries that, unlike Malawi, have low HIV prevalence; these include poverty, gender inequality, and history of colonialism and political and economic disenfranchisement. The relationship between HIV prevalence and socioeconomic factors is highly complex. Increasingly, risk of HIV infection is recognized as related to, inter alia, one's socioeconomic status as well as the socioeconomic profile of the community in which one is situated.47, 48 This section does not seek to demonstrate causality; rather, it aims to analyze key political economy and sociobehavioral contextual elements to highlight the range of sectoral policies and interventions that may affect or be affected by HIV/AIDS. Postcolonial Context Malawi achieved full independence in July1964.49 Dr. Hastings Kamuzu Banda, who returned to the country in 1958 to head the Malawi Congress Party (MCP), had been named prime minister in 1963. In 1966, he became Malawi's first president under a new constitution that made the country a one-party state.50 In 1970, Dr. Banda was declared President for Life of the MCP, and in 1971 he was named President for Life of Malawi. 51 The police as well as the paramilitary wing of the MCP, the Young Pioneers, helped President. Banda keep Malawi under authoritarian rule until 1994. Human rights abuses were common, as the government imprisoned opponents, who had almost no recourse to the justice system. Prisons were overcrowded and conditions brutal. 52 , 53 Increasing domestic unrest and internal and external pressure led to a 1993 referendum, in which Malawians voted overwhelmingly in favor of multiparty democracy. In May 1994, free national elections were held. 54 Bakili Muluzi, leader of the United Democratic Front (UDF), defeated President Banda. The UDF won 82 of the 177 seats in the National Assembly and formed a coalition government with the Alliance for Democracy (AFORD). Malawi's newly written constitution (1995) eliminated special powers previously reserved for the MCP. 55 It also created the Malawi Human Rights Commission under chapter XI.56 Accelerated economic liberalization and structural reform also accompanied the political transition (discussed below). 57 President Muluzi and the UDF were reelected in June 1999 with little concomitant violence. Local elections were held in the country for the first time in November 2000, and the UDF won 70 percent of the wards. 58 Governance remains a major problem in Malawi, e.g., fraud, corruption, and misappropriation of public funds.59 Additionally, President Muluzi is proposing a constitutional amendment that would permit him to run for a third term as president. (Currently, the president is limited to two terms.60) In July 2002, this constitutional amendment was rejected by Parliament, and President Muluzi indicated that he would accept the parliamentary ruling. However, the UDF has again scheduled the bill for parliamentary debate during 2002-03. 61 (Some UDF members have publicly declared their opposition to the amendment, along with numerous human rights NGOs.62) President Muluzi issued a decree banning demonstrations linked to the amendment, a decree that was reversed by Malawi's High Court in October 2002.63 Recent demonstrations by civil rights groups protesting the amendment have been accompanied by clashes with police and ruling party supporters.64 Donors, including the EU, Germany, Norway, U.K., and U.S., have expressed concern about the amendment and about the concomitant intimidation of and violence toward those opposing it.65 The Malawi Human Rights Commission is investigating alleged police abuses related to recent demonstrations, as well as alleged government harassment of journalists and interference with the judiciary. 66 In its own poverty reduction strategy, the government noted that despite extensive improvements in human rights under President Muluzi, abuses remain.67 (See also Human Rights Watch: http://www.hrw.org/africa/malawi.php and Amnesty International: http://web.amnesty.org/ai.nsf/countries/malawi?OpenView&Start=1&Count=30&Expandall) Economy Landlocked Malawi's economy is heavily dependent on agriculture, which accounts for over 90 percent of its export earnings, contributes 45 percent of gross domestic product (GDP), and supports 90 percent of the population. 68 Almost 70 percent of agricultural produce comes from smallholder farmers operating on less than one hectare of land. 69 Maize is the principal food crop and the preferred staple for the majority of households. It is supplemented by sorghum, rice, cassava, sweet potatoes, and pulses. Production of these food crops, based mainly on rainfed agriculture, fluctuates often as a result of climatic disasters, especially frequent droughts, which cause extensive crop failures. Irrigation use is limited .70 Cash crops in Malawi include tobacco, tea, sugar, cotton, groundnuts and coffee. 71 Tobacco accounts for about 60 percent of export earnings.72 Malawi's dependence on a single crop, coupled with a decline in terms of trade, underscores the need for rapid diversification. 73 High transport costs, which can represent over 30 percent of its total import bill, constitute a serious impediment to economic development and trade. Malawi must import all its fuel products. Paucity of skilled labor; "red tape"; corruption; and inadequate and deteriorating road, electricity, water, and telecommunications infrastructure further hinder the country's economic development. However, recent government initiatives targeting improvements in roads, together with private sector participation in railroad and telecommunications, had begun to render the investment environment more attractive.74 (Though the current humanitarian crisis could reverse this scenario; see below.) Traditionally, Malawi has been self-sufficient in maize, and during the 1980s exported substantial quantities of it to its drought-stricken neighbors. 75 From independence through 1979, the Malawi economy experienced impressive growth. Real output growth, mainly spurred by the agricultural sector, averaged 6.7 percent during this period. However, the benefits of this growth were poorly distributed, as growth was narrowly based on estate (versus smallholder) agriculture.76 From 1979, Malawi's economy experienced high import costs as a result of oil price shocks, disruptions in trade routes, the influx of refugees from Mozambique, and droughts.77 Structural Adjustment Since 1981, Malawi has implemented a series of policy interventions through World Bank- and IMF-backed Structural Adjustment Programs (SAPs). These seek to stimulate private sector activity and participation through the elimination of price controls and industrial licensing, liberalization of trade and foreign exchange, rationalization of taxes, privatization of state-owned enterprises, and civil service reform.78 Since 1994, SAPs have been complemented by the Poverty Alleviation Program (PAP), which emphasizes the need to raise national productivity through sustainable broad-based economic growth and sociocultural development. 79 Malawi began to experience relatively strong economic growth between 1988 and 1991. Real GDP growth rose from 3.3 percent in 1988 to 7.8 percent in 1991. However, the gains arising from this growth were short-lived as growth fluctuated through the 1990s, largely as a result of external shocks such as droughts and the reduction of donor financial support between 1992 and 1994. Growth has averaged 2.6 percent between 1997 and 2000 and stood at 1.8 percent in 2001.80 Malawi's economy has been adversely affected by a severe drought in the 2001-02 agricultural season, and the country remains heavily dependent on foreign aid. In March 2000, the country started the process for obtaining debt relief under the HIPC initiative (see below). 81 In 1999, the World Bank and IMF replaced SAPs with new conditions for loans and debt relief: the Poverty Reduction Strategy Paper (PRSP). PRSPs are created by governments but with substantial Bank involvement. Moreover, only when the Bank and IMF are satisfied with their creation and implementation are funds for HIPC released. (Malawi's first full PRSP was launched in April 2002 and discussed and endorsed by the Board of the World Bank in August 2002.82) Criticism of PRSPs, from in-country parliamentarians, trade unionists, and NGOs, include complaints of being marginalized and that national ownership is undermined by externally imposed parameters and use of foreign consultants. 83 Christian Aid highlights that in Malawi, "the relationship between civil society and the state is marked by mistrust, and there is little government experience with participatory policy-making." 84 The Malawian government screened civil society organizations permitted to participate in the PRSP process. In response, the Malawi Economic Justice Network was formed to advocate for greater civil society involvement.85 Another criticism of PRSPs is that they seem very similar and fail to reflect the different histories, characteristics, and economies of individual countries.86 This was the case with the Malawi and Zambia PRSPs, recently reviewed by the author of the present report. Malawi's 2002 Poverty Reduction Strategy Paper states that: Inconsistent implementation of the SAPs led to only short-lived economic recovery and failed to create sustainable broad based growth. Further, many of the high costs of adjustment were borne by the poor. Despite some successes, the PAP suffered from the absence of a well-articulated action plan to ensure a holistic approach to implementation. In particular, there have been inadequate linkages to the budget, little prioritization and a lack of target setting. The impact of the wide ranging policy reforms implemented during the adjustment period has been mixed and mostly unsatisfactory insofar as poverty reduction is concerned. Although there have been periods of macroeconomic stability, sustainable growth has proved elusive. The instability has to a large extent arisen from external shocks, inconsistent implementation of reforms, fiscal policy slippages and the narrow base of production capacity. The inability to sustain high rates of growth over a long period has undermined any poverty reducing impact of growth. Furthermore, macroeconomic instability has aggravated the poverty situation. 87 As is usually the case when the Bank evaluates projects and policies it has championed, it lays most of the blame on poor government implementation. The Bank believes that the Malawian government has not adequately implemented structural adjustment policies because of, inter alia, "fiscal slippages."88 Certainly, this is the case to some degree, but serious concerns have been raised about underlying elements of SAPs. Oxfam, among other social justice groups, stresses that SAPs exacerbate the exclusion of the poorest from the market while further undermining human development and food security. 89 Researchers from the School of Oriental and African Studies at the University of London have found that in Malawi (and other sub-Saharan African countries), development benefits have been slow to emerge from economic liberalization.90 After almost two decades of structural adjustment, Malawi's 2000 per capita income of US$170 is well below the average for all low-income economies (US$410) as well as for the sub-Saharan Africa region (US$470). 91 The government acknowledges that this poor economic growth performance implies that the majority of the population has experienced almost no improvement in its economic status.92 Inflation Inflation is another pressing macroeconomic problem in Malawi. Between 1980 and 1990, the inflation rate, as indicated by the Consumer Price Index, remained stable, averaging 16.6 percent. During 1990-2000, the annual inflation rate fluctuated. Average inflation declined from 83 percent in 1995 to 9 percent in 1997. However, a large depreciation of the kwacha in August 1998 resulted in annual inflation rates of 29.8 percent and 44.7 percent in 1998 and 1999, respectively. In recent years, inflation has averaged 30 percent. 93 Poverty Malawi is one of the world's poorest countries. In 1991, 54 percent of the population was living below the poverty line. 94 According to Malawi's 1998 Integrated Household Survey, 65.3 percent of the population is now poor (this figure does not take account of the current famine). (Poor is defined as those whose consumption of basic needs [both food and nonfood] is below the minimum level, estimated at MK10.47 per day in 1998 [about US$0.34, given average exchange rate in 1998 of MK31.1 = US$1].) Among the poor population, 28.2 percent are living in "dire poverty"95 (not defined in Malawi's PRSP). Poverty is more prevalent in rural areas (where there are limited economic activities) than in urban areas. It is estimated that 66.5 percent of the rural population live in poverty, compared to 54.9 percent of the urban population. Although about 80 percent of the population lives in rural areas,96 91.3 percent of the poor and 91.5 percent of the "ultra poor" also live in rural areas. 97 However, pockets of poverty are found throughout the country. The areas with the highest poverty headcount are Ntcheu (84.0 percent), Phalombe (83.9 percent), Zomba Municipality (78.0 percent), Thyolo (76.8 percent), and Ntchisi (76.3 percent). The Southern Region has the highest proportion of poor households (68.1 percent), compared to the Central (62.8 percent) and Northern (62.5 percent) regions. The Southern Region's poverty situation can partly be explained by high migration into it, 98 including those seeking employment in its urban areas, including Blantyre. (Although the relationship between poverty and HIV prevalence is highly complex, note these data cited in the Epidemiology section: in 1998, adult HIV prevalence was highest in Southern Region (18 percent), followed by Central (11 percent) and Northern (9 percent) regions. 99) Financial wealth in Malawi is generally concentrated in the hands of a small elite. 100 The richest 20 percent of the population consume 46.3 percent of total goods and services, whereas the poorest 20 percent consume only 6.3 percent. Consumption is also more unequally distributed within urban areas, where the Gini coefficient is 0.52, as opposed to 0.37 for rural areas. 101 (The Gini coefficient measures the extent to which the distribution of income or consumption among individuals or households within a country deviates from a perfectly equal distribution. A value of 0 represents perfect equality, a value of 100 perfect inequality.102) Some subpopulations are poorer than others, including: * land-constrained smallholder farmers * labor-constrained female-headed households * estate workers or tenants * ganyu and other casual laborers * destitute or disadvantaged children, such as orphans, street children, and child heads of households * persons with disabilities * low-income urban households * the elderly * the uneducated * the unemployed. 103 All these populations are also likely to be highly vulnerable to acquiring HIV/AIDS. Moreover, HIV/AIDS may also play a role in the further impoverishment of these populations. (See Impact section below.) Poverty in Malawi is caused by numerous factors, including limited access to land, low education, poor health status, limited off-farm employment, and a lack of access to credit. Environmental degradation, rapid population growth, and gender inequalities are also factors. (In 1998, about 52 percent of the poor were female.) All these factors are exacerbated by generally weak institutional capacity within the country. 104 According to the National AIDS Commission, HIV/AIDS has undermined the country's efforts to reduce poverty.105 The U.N. notes that "HIV/AIDS is now an important part of structural poverty in Malawi, and its prevention and control are a central development concern." 106 In its 2002 poverty reduction strategy paper, the government noted that "there are clear links between HIV/AIDS and poverty. Poverty is one of the major underlying factors driving the epidemic." However, it did not provide contextual analysis specific to Malawi, but rather standard text on HIV/AIDS and poverty also found in the Zambia PRSP.107 Population Mobility Throughout southern Africa, high levels of movement among urban, rural, and mining areas facilitate HIV transmission.108 Poverty may lead to increased migration, both within Malawi and to other countries, as people move from rural to urban areas in search of work ¾ or return to families if they lose their jobs or fall ill and cannot afford care. This scenario can place an additional burden on receiving households, which concurrently lose any remittance income from the person who has fallen ill.109 According to Malawi's National AIDS Control Program, male migration is a common phenomenon.110 Migrant labor separates men from their families, places them in close proximity to "high-risk" sexual networks, and often results in their having an increased number of sexual contacts. Concurrently, it may lead to women's reliance on sex to supplement their incomes while their male partners are away for long periods. NACP also noted that both men and women (adults and youth) are increasingly mobile as they pursue trading activities.111 Some studies in southern African have found that female cross-border traders are particularly vulnerable to HIV infection. Many female traders report exchanging sex for transport. They also report rape and sexual harassment.112, 113 Other key mobile groups in Malawi include: * truck drivers * sex workers * fishermen/women and fish traders * migrant and seasonal workers * military personnel * prisoners (in the sense that they often return to their families/communities upon release) * refugees The study on male workers from the Nchalo sugar plantation, discussed above, recruited men primarily from 11 residential communities located inside and around the estate. (On sugar estates, men usually leave their families to work as cane cutters from March to November.) The study found that men's rate of HIV acquisition followed a gradient based on distance from the Nchalo trading center (where most recreational activities and commercial sex occurs): Both HIV and syphilis prevalences were highest in communities closest to the trading center and lowest in communities furthest from it.114 Between 1985 and 1995, Malawi accommodated over 1 million refugees from Mozambique. The refugee crisis placed a substantial strain on Malawi's economy, but also drew significant inflows of international assistance. Malawi's accommodation and eventual repatriation of Mozambicans are considered a major success by international organizations.115 However, the movement of large numbers of refugees may have played a role in facilitating HIV transmission, in Malawi, Mozambique, and the subregion. (Conflict and instability in the region have led to Malawi's continuing to receive refugees, for example, from Rwanda and the Democratic Republic of the Congo.) AIDS directly spurs population dislocation as, for example, orphans are sent to live with relatives residing in other regions of the country. Researchers from Brunel University in the U.K. note that a legacy of labor migration in southern Africa is a high degree of family dispersal. In examining the movement of orphans in Malawi (and Lesotho), they found that strategies for dealing with AIDS commonly involve young people's movement between households of the extended family. They also found that: * Migration occurs locally and over longer distances, which may involve moving from urban to rural areas. * Children's migration is highly complex, with many children engaging in multiple migrations in response to changing situations. * Migrant children typically reside with maternal grandparents. 116 Children who migrate face numerous difficulties, which are often exacerbated by AIDS. These include fitting into: * new families where they may feel discriminated against and/or have a high workload * new communities, which may involve having to make new social contracts, attend a new school, and (especially in rural areas) learn to undertake unfamiliar forms of work Children generally find ways of coping with migration, but these may involve adopting behaviors (such as smoking or drinking to "fit in"). 117 (Further findings from this study are discussed in the Impact section.) As discussed in the Food Crisis section below, flooding and famine involve significant movement of people and regroupings of family units, which also entail exposure to new sexual networks and thus may heighten vulnerability to HIV.118 Food Crisis On February 27, 2002, the Malawian government declared a national disaster due to actual and anticipated food shortages. In November 2002, USAID estimated that 3.3 million Malawians ¾ 29 percent of the population ¾ will be in need of food aid from September 1, 2002, through March 31, 2003.119 Although famine threatens all three regions of Malawi, Central and Southern regions have proportionately more people at risk than the North. (Part of this is because maize prices are highest in Central Region and lowest in Northern Region.) The U.N. has identified the following priority districts for food aid: Lilongwe, Dedza, Salima, and Mangochi.120 (Again, the vulnerability of Southern Region is highlighted.) The U.N. notes that: The first three months of 2002 saw hunger in rural Malawi at a level which older villagers cannot remember since the drought of 1949-50. Yet the proportionate shortfall in the harvest of April-May 2001 was not as severe as in that year, nor comparable to the disaster of the major drought year of 1991-92, when farmers were greatly impoverished but no famine was reported.... During the first three months of 2002 in Malawi, a threshold was crossed which had divided poverty in general, and seasonal hunger in particular, from food crisis.... Why was there such extraordinary hunger by late 2001 and early 2002?121 And according to Oxfam U.K. and the World Development Movement, British social justice NGOs: Hunger and food shortage has always been a problem in Malawi. In the past, food shortages have been addressed through food aid from donors and government subsidies for basic food channeled through the grain board, the Agricultural Development and Marketing Corporation (ADMARC). In 1991-92, there was a severe food shortage in Malawi, with yields much lower than those preceding the current famine. However, the state marketing board, ADMARC, had depots in the most inaccessible rural communities and made food available at subsidized prices. This system has allowed the people of Malawi to survive the seasons of adverse weather, and the government corruption and mismanagement which has persisted through years of good harvest and bad. This year, however, no such safety net exists. 122 , 123 ActionAid Malawi cites "misplaced complacency by many external actors, a failure to react to signals of an impending food crisis, the selling of the Strategic Grain Reserve, and the government's denial of the existence of a famine until February 2002" as contributing factors to the current situation. It goes on to state that: These immediate causes of the 2002 famine must also be conceptualized by noting the following underlying vulnerability factors: Declining soil fertility and restricted access to agricultural inputs during the 1990s; deepening poverty which eradicated asset buffers that the poor could exchange for food to bridge food gaps; the erosion of social capital and informal social support systems in poor communities; the demographic and economic consequences of HIV/AIDS; and the relative neglect at the policy level of the smallholder agriculture sector.124 Reports from an array of multilateral and civil society agencies who have recently conducted missions in Malawi concur that although erratic weather (droughts, flooding, waterlogging) has contributed to the current food crisis, one of the key underlying factors is the depletion of human resources as a result of HIV/AIDS.125 Unsustainable debt, chronic poverty and malnutrition, deteriorating public health services and poor health outcomes, and reliance on a single crop have also played a role. Moreover, after years of World Bank- and IMF-supported agricultural sector reforms, Malawi still faces chronic food insecurity. Many argue that these reforms were imposed too rigidly and too quickly, often leaving poor farmers without support from or access to either state or market institutions. 126 , 127 Moreover, many households overstretched their coping mechanisms last year, reducing their resilience and increasing their vulnerability in the face of the continued food shortages. 128 Certainly, Malawi needs agricultural reforms to enhance productivity and food security. Parastatals such as ADMARC require improved management and oversight. However, the agricultural reform policies implemented in Malawi since 1981 have led to crisis, rather than improved efficiency and productivity.129 , 130 As in other countries, agricultural reforms were imposed on Malawi without proper analysis of their potential impact and consequences, particularly on the poor. 131 Early in 2002, the Malawi Government sold almost all its 167,000 metric ton grain reserve. Malawian civil society groups have raised questions less about the wisdom of the sale than about what happened to the money raised, who benefited, and whether the proceeds could have been reinvested in buying new supplies on the commercial market.132 In April 2002, Malawi was suspended from HIPC over allegations of corruption around the sale. Donors have called for a full audit of the sale, which has yet to be undertaken. 133 , 134 Between October 2001and March 2002, the price of maize in Malawi increased 400 percent.135 In October 2002, the Famine Early Warning Systems Network (FEWSNet) released a report on cereal price trends in southern Africa, which indicated that the price of maize in Malawi (as well as Zimbabwe and Zambia) is likely to remain high and expected to escalate until the next harvest.136 For most rural households, the availability and price of maize on the market are key to food security. In many places, this is the second or third consecutive year of food shortages, and many people's ability to cope has been exhausted as they have increasingly fewer ways to earn enough cash to buy food. 137 Malawi has removed all subsidies to agriculture and, under its last agreement with the World Bank, had committed to privatizing ADMARC by the end of 2002. The initial impact of the reforms implemented in the agricultural sector led to a substantial increase in the production of tobacco as well as private sector participation in marketing of agricultural produce.138 , 139 However, over time, these benefits have been offset by input prices increasing faster than producer prices. The lifting of price controls and elimination of fertilizer subsidies (the "Starter Pack" program) have contributed to increased input costs. The U.N. notes that the elimination of Starter Packs contributed to the shortfall in maize produced last year. 140 (NB: The Starter Pack program is being reintroduced.141) Oxfam argues that reform measures have led to a widening gap between rich and poor and that liberalization has contributed to a massive increase in food insecurity. 142 At the same time that international financial institutions have been instructing Malawi and other countries to reform their agriculture sectors, Western Europe and the U.S. continue to pay their own farmers massive subsidies and refuse to fully open their markets to Africa's exports.143 , 144 Impact Malawi's response to HIV/AIDS is predicated on an effective, efficient health care system as well as strengthened capacity at local level.145 However, given the impacts of the humanitarian crisis described below, the ability of the country to mount a national response to HIV/AIDS is gravely imperiled. Recent missions to Malawi have reported increased malnutrition, which is likely to further weaken the immune systems of people living with HIV/AIDS, thereby contributing to higher rates of morbidity and mortality. 146 The International Food Policy Research Institute reports that people living with HIV have higher nutritional requirements: up to 50 percent more protein and up to 15 percent more calories. Moreover, diets rich in protein, energy, and micronutrients can help prevent opportunistic infections. HIV infection compounded by inadequate diet leads more rapidly to malnutrition. The poor suffer the most, as they are more likely to be malnourished before they become infected.147 According to the World Food Program, female-headed households are poorer and more vulnerable to the effects of food shortages, because of fewer income opportunities, less mobility, and high demands on their time as caregivers (they are also twice as likely to take in orphans than male-headed households).148 High levels of HIV/AIDS infection mean that the coping strategies of communities, already under major stress, are at breaking point. Those who have undertaken recent missions to Malawi report the following survival strategies: * eating potentially poisonous wild grasses * eating much-reduced maize harvest prematurely, before it has ripened * eating seed stocks (and thus lacking seeds to plant for the next agricultural season) * reducing the number of meals consumed per day to two or, often, one * stealing crops * undertaking sex work * bartering * taking children out of school * traveling enormous distances and queuing for days to purchase limited supplies of maize149 , 150 Population dislocation was also observed in early 2002, as unusually heavy rains led to flood damage in parts of all three regions, displacing over 150,000 people. Floods, displacement, and the movement of people in search of food led to the country's worst-ever cholera epidemic, with nearly 1,000 deaths, during the early part of 2002. 151 As mentioned, these large movements of people also entail exposure to new sexual networks and thus may heighten vulnerability to HIV. Intercountry migration is also affected, as famine, HIV/AIDS, and socioeconomic deterioration (and, in some cases, conflict and political unrest) are affecting Malawi's neighbors as well. People will seek work in other countries so that they can send remittances home, although this possibility may be reduced as neighboring countries are hard-hit. The U.N. notes that the famine has raised the opportunity cost of sending children to school. Girls, in particular, are affected. Lack of food, coupled with a subsequent breakdown in family structure, has placed more children on the streets where they may be at higher risk of mistreatment, sexual exploitation, and physical and emotional abuse. Communities caring for increasing numbers of AIDS orphans are facing additional economic pressure, thereby exacerbating the vulnerability of orphans.152 Traditionally, funerals are important events in Malawi. Those attending provide large amounts of food to show respect. Given the famine, as well as the increasing number of funerals because of AIDS mortality, many people are not able to provide sufficient food at funerals and are thus ostracized.153 (Malawi has expressed concerns over the environmental effects of biotech food, but is accepting such food aid as long as it is milled before distribution. And the government has publicly stated its intention not to disrupt the distribution of donated maize if milling is not possible. 154) Box 2. HIV/AIDS and Distribution of Food Aid In some districts in Malawi, Village AIDS Coordinating Committees are responsible for targeting food supplies. This includes food supplements to village crèches that are caring for HIV-affected children or through home-based care programs. Much of the maize required in Malawi (as well as Zambia and Zimbabwe) is being purchased and transported from South Africa, mostly by truck. Some commercial trucking companies have begun HIV awareness raising activities on their long-distance trucking routes. The Southern African AIDS Information Dissemination Service recommends that these interventions be scaled up and that civil society and governmental agencies already working in border towns coordinate to ensure that safer sex messages and condoms and related services be made accessible. Source: Southern African AIDS Information Dissemination Service. SAfAIDS News. June 2002 Women and children may be particularly vulnerable to sexual exploitation during humanitarian crises. UNICEF, for example, has highlighted that some women and children may offer sex to workers involved in transporting and distributing food aid to try and obtain preferential treatment in the distribution of supplies and services. Source: IRIN/U.N. Office for the Coordination of Humanitarian Affairs. "Southern Africa: Agencies Move to Protect Vulnerable from Sex Abuse." September 4, 2002. Debt During the 1970s and 1980s, Malawi's servicing of its public and publicly guaranteed debt ranged from 13.67 to 39.69 percent of central government revenues,155 rendering it one of the world's most highly indebted countries. Most of the country's debt is owed to the World Bank. In December 2000, Malawi qualified for debt relief under the Enhanced Heavily Indebted Poor Countries Initiative (HIPC). HIPC is not debt cancellation; rather it is a restructuring of debt repayment through provision of grants. Malawi is required to continue servicing its debt (even during the current humanitarian crisis). Moreover, HIPC does not preclude that a country will have to continue to borrow indefinitely. Malawi, for example, is and will continue to be heavily dependent on donors and foreign creditors. Under HIPC, an estimated US$1 billion was committed to Malawi as total debt relief from all its creditors. 156 This is equal to US$643 in net present value (the present value of future cash), of which US$331 million is to be provided by the World Bank and $30 million by the IMF. The World Bank projects that under HIPC, Malawi will save an average US$50 million annually in debt service payments over the next 20 years.157 In its quest to qualify for HIPC, Malawi has had to undertake some activities that ¾ at least on paper ¾ have resulted in increased attention to the poor, social services, and HIV/AIDS, as well as consultation with civil society. For example, it was required to produce a poverty reduction strategy (which, again, some contend is simply another term for structural adjustment). However, creation of Malawi's first PRSP was not deemed to have sufficiently included civil society, and thus the government was compelled to consult more widely with nongovernmental groups. 158 Malawi, as with other countries, also had to demonstrate how funds from HIPC would be used to finance social sector services. The HIPC initiative is projected to release US$91.4 million for additional social expenditure from 2000-01 to 2002-03. Over these three years, about one-third will be spent on health, one-third on education, and the remainder on safe water, community services, rural roads, and agriculture. 159 Note, however, that these are projections and that the assumptions underlying them have been strongly criticized (see below). Another criterion is that Malawi must demonstrate progress in implementation of the National AIDS Strategic Framework (see Government Response section), in particular ensuring that: 1. the National AIDS Commission be fully staffed, functional, and autonomous 2. 75 percent of all condom outlet points be stocked at any given time 3. HIV blood test kits be continuously available at all blood transfusion sites by increasing the number of kits from 1,500 to 2,500 4. an effective behavior change communication strategy be implemented 5. syndromic management of STIs be undertaken in all central and district hospitals, as well as major Christian Health Association of Malawi hospitals 160 Malawi is currently in its interim HIPC period, 161 meaning that to qualify for the full amount of debt relief available via HIPC, it must successfully implement its PRSP for at least a year. Several social justice NGOs, including Jubilee Plus, point to serious problems with HIPC. For example, HIPC assesses whether a country can afford to pay its debts by looking primarily at its export earnings and often making very optimistic assumptions about them. For countries such as Malawi, dependent on one export commodity (tobacco), this is unrealistic.162, as it is vulnerable to external shocks such as changes in the price of and demand for tobacco as well as climatic fluctuations. HIPC also assumes that real GDP growth in Malawi will rise to 4.5 percent in 2003 and to 6 percent by 2020. It assumes that export volumes will grow at a rate of 4.6 percent from 2001-20, incorporating 3 percent growth in tobacco exports and 7 percent growth in nontraditional exports. 163 In September 2002, the World Bank and IMF themselves noted that although most commodity prices are forecast to rise over the medium term,: ...recovery would be slow and key export commodity prices of the HIPCs would remain below the levels projected two years ago for quite some time. This will have adverse effects on future export earnings of the HIPCs and hence on the debt and debt service-to-exports ratios.164 They also note that Malawi has had "extended program interruptions, due largely to problems in fiscal and public resource management," thereby impeding its ability to reach "completion point" (i.e., meeting all creditor requirements).165 Jubilee Plus projects that by 2019, the level of Malawi's debt will only be 4 percent less than it would have been without assistance under HIPC. It estimates that debt service will fall by 40 percent in the short term, 60 percent in the medium term, but only 30 percent in the long term, compared to pre-HIPC levels; this pattern is partly due to new debt that Malawi will have to incur. 166 Debt is considered sustainable if its net present value is less than 150 percent of export earnings. According to Jubilee Plus, Malawi's debt will not be sustainable on the basis of the debt-to-exports criterion decided by the World Bank until after 2010 (based on highly optimistic projections of growth in export earnings as well as the country's ability to meet Bank and IMF macroeconomic targets). Moreover, as soon as 2002-03, debt service will be roughly equal to the HIPC amount released for social expenditure.167 These assumptions and assessments do not factor in famine and HIV/AIDS. Human Development One method of tracking human development in Malawi is to analyze trends in its Human Development Index. The HDI was created by UNDP to measures average achievements in life expectancy at birth; adult literacy and combined primary, secondary, and tertiary gross enrollment ratios; and GDP per capita (most UN agencies are now calling this gross national income [GNI]; details on its calculation can be obtained from the World Bank). An HDI of 0.800 or above = high human development; 0.500 - 0.799 = medium human development; less than 0.500 = low human development. In 2000, Malawi's HDI value was 0.400, placing it among "low-human development" countries and ranking it 163 out of the 173 countries for which UNDP calculated an HDI. Malawi's HDI value is lower than that of the median for the world's least-developed countries (0.445) as well as for sub-Saharan Africa (0.471).168 What is particularly worrying is that although Malawi's HDI value is already very low, it declined during the latter half of the 1990s. Between 1975 and 1995, the HDI value rose from 0.316 to 0.403, a reflection of, inter alia, the government's efforts to increase educational attainment and health outcomes. However, the HDI value fell to 0.400 in 2000.169 The decline in the HDI value doubtlessly reflects the enormous impact of AIDS mortality (see Impact section), which has drastically reduced the life expectancy component of the HDI value. A critical indicator of the well-being of children is the under-five mortality rate. Since independence, Malawi has made great strides in improving child health. In 1960, its under-five mortality rate was 361 per 1,000 live births; in 2000, it had fallen to 188. However, the figure of 188 was the world's 15th-highest under-five mortality rate in 2000, exceeding that of all the least-developed countries (161) and of sub-Saharan Africa (175). 170 Infant mortality, another key human development indicator, fell from 205 in 1960 to 117 in 2000; however, as with under-five mortality, the 2000 figure exceeds that of all the least-developed countries (102) and of sub-Saharan Africa (108). 171 The Demographic Impact section below quantifies the impact of HIV/AIDS on infant and child mortality. Another critical human development indicator is the maternal mortality ratio (MMR), the number of deaths to women per 100,000 live births that result from conditions related to pregnancy, delivery, and related complications. The 2000 MDHS estimated that the maternal mortality ratio was 1,120 during the seven-year period prior to the survey. The 1992 MDHS found that the MMR was 620 (again, applicable to the seven-year period before the survey). Thus, the MMR appears to have increased by about 45 percent from the late 1980s to the late 1990s.172 Although the increase in the MMR that can be attributed to HIV/AIDS is not known, one can infer that a variety of factors that include HIV/AIDS played a role in this increase. (As the accompanying indicator table shows, UNFPA estimates that Malawi's 2001 MMR was 580, a continually revised consensus estimate of WHO, UNICEF, and UNFPA.) Education In 1994, the government of President Muluzi showed tremendous leadership by introducing universal free primary education. This resulted in a sharp increase in primary enrolments, from 1.9 million in 1993-94 to 2.9 million children in 1999-2000. Free primary education led to greater access to education for poorer groups in rural areas. The gross primary enrollment rate for the poorest quintile increased from 58 percent to 110 percent between 1990-91 and 1997-98, whereas for the richest quintile, it increased from 110 percent to only 119 percent. 173 The share of recurrent educational expenditures for primary has risen from approximately 50 percent in 1993-94 to around 60 percent in 1999-2000. The shares of secondary (around 10 percent) and tertiary education (around 18 percent) have changed little.174 However, expenditures per pupil are eight times higher in secondary education than in primary education, and 202 times higher in tertiary education. 175 Moreover, poverty, famine, and HIV/AIDS mean that the indirect costs of primary education remain formidable for many households, including uniforms and books, and the opportunity cost of child's labor.176 There are significant geographic differences in access to primary schooling: Net enrolment rates are higher in the Northern region than in both the Southern and the Central regions.177 Enrolment rates are consistently higher in urban than in rural areas, where households are poorer and where physical access to schools is more difficult. 178 Despite the abolition of fees for primary education, dropout and repetition rates remain high. The largest dropout occurs between standard one and two, where approximately 30 percent of students drop out. Dropout rates are higher among the poorer income groups. The dropout rate is even higher for girls; despite equal numbers of girls and boys starting primary, girls represent only 42 percent of students in standard 8. Part of this phenomenon may be related to pregnancy and early marriage, 179 as well as the need for household labor, particularly given persistent poverty and HIV/AIDS care burdens. Only 11.2 percent of adults ages 25 and above ¾ and only 6.2 percent of women ¾ have completed standard 8 (a common measure of educational attainment).180 Despite increasing steadily since 1993-94, secondary enrolment remains low at 7 percent. Secondary education remains the preserve of the rich: The gross enrolment rate of children from the richest income quintile was over four times that of those in the poorest quintile and twice that of the next richest quintile, indicating the strong relationship between wealth and enrolment. As with primary, secondary enrolment ratios are highest in the Northern region and highly skewed toward urban areas. 181 University enrollment is low by regional standards: There are only about 3,500 students enrolled. Women represent less than one-third of university students. 182 Malawi's school system is still struggling to meet the demands of the rapid expansion of primary enrolments. Teaching capacity remains highly inadequate; about half the current teaching force is not fully trained. Malawi's six teacher training colleges are not currently producing enough teachers to replace even the 5,000 lost annually because of AIDS and regular attrition. There has been a significant decline in the share of recurrent educational expenditures for teacher training and administration. 183 The Malawian government and its donor partners are concerned that overcrowding and teacher shortages are threatening the quality of education. A DFID study, for example, notes that the abolition of fees for primary enrollment has led to lower quality of education, suggesting that more years of schooling will be needed to attain the minimum skills required to achieve poverty alleviation goals; thus, the overall cost of achieving these skills will rise for both households and the government.184 Health Sector Malawi's health system is structured around eight service delivery levels: 1. community 2. health post 3. dispensary 4. maternity unit 5. health center 6. rural/community hospital 7. district level hospital (including those of the Christian Health Association of Malawi) 8. central/regional hospital185 At community and health post levels, health surveillance assistants and community members are the main service providers. Dispensaries, maternity units, health centers, and rural/community hospitals are often collectively referred to as health centers. 186 Only 3 percent of Malawians live in a village with a health center.187 The Ministry of Health and Population (MOHP) provides about 60 percent of health services; the remainder are mainly provided by Christian Health Association of Malawi (CHAM) mission facilities. Other NGOs and private facilities provide around 3 percent of services.188 Almost all public health expenditure is financed by taxation; public health insurance does not play a significant role. Private insurance accounts for only 8.3 percent of private expenditures on health.189 Within southern Africa, only Mozambique spends less on health per capita (US$8) than Malawi (US$11) (this figure includes public and private expenditures).190 Public health allocations have remained between 2 and 3 percent of GDP since the mid-1990s. However, actual health spending has consistently fallen far short of budgeted amount because of slow donor disbursements, shortages of counterpart funds, and weak MOHP administrative capacity.191 Donor spending is increasingly being directed at the district level.192 Despite some improvements in health outcomes since independence, Malawians' health status remains poor (see accompanying indicator table). HIV/AIDS is the leading cause of death among those ages 15 to 49, followed by malaria, which is the main cause of child mortality.193 (More detail on malaria is found in box 3.) Other major health problems include TB (discussed below), cholera (see box 4), schistosomiasis (also known as bilharzia), acute respiratory infection, acute diarrheal disease, and meningitis. Leprosy was seemingly eradicated in 1994, but resurfaced in 2001.194 An outbreak of bubonic plague was reported in April 2002. By May 2002, 71 cases of bubonic plague were reported in the district of Nsanje. The outbreak has affected 26 villages: 23 in the Ndamera area, two in Chimombo, and one in neighboring Mozambique.195 Box 3. The Impact of Malaria in Malawi Each year, about 8 million Malawians (mainly in rural areas) suffer from malaria, and up to 5,000 people die because of it. In 2000, there were 27,682 malaria cases per 100,000 population. (Data refer to malaria cases reported to WHO and may represent only a fraction of the true number, given incomplete reporting systems or incomplete coverage by health services, or both.) By comparison, this figure was 143 for South Africa, 1,466 for Namibia, 2,913 for Swaziland, 4,760 for Botswana, 5,422 for Zimbabwe, 18,108 for Mozambique, and 34,274 for Zambia. (Figures for other southern African countries are given to provide a sense of the magnitude of Malawi's malaria burden, although because of the diversity of case detection and reporting systems, country comparisons should be viewed with caution.) Malaria accounts for 40 percent of all hospital admissions, 18 percent of all hospital deaths, and is the leading cause of outpatient visits. If anemia ¾ most of which is attributed to malaria ¾ is included, malaria and its complications account for 53 percent of hospital admissions. The Malawi government spends about US$7million per year to treat malaria. Households spend an average US$35 each year on malaria-related medical expenses; moreover, there is the uncaptured cost of lost productivity associated with malaria. Those most at risk of malaria are children over three months old and pregnant women. Pregnant women are four times more likely to suffer from complications of malaria than nonpregnant women. Children and pregnant women suffering from malaria-related anemia may require blood transfusions, which pose the risk of HIV transmission (see the Blood Safety section above). HIV infection increases malaria parasitemia and the incidence of malarial fevers; some studies have also found that viral load of HIV is higher in adults with malaria than in those without malaria. A malaria-associated increase in viral load could speed progression to AIDS, as well as increase HIV infectiousness, thereby resulting in increased probability of HIV transmission. Malawi participates in the Roll Back Malaria Initiative (see Links section). Sources: Malawi Global Fund Coordinating Committee. The National Response to HIV/AIDS and Malaria. Proposal to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. January 31, 2002. ; UNDP. Human Development Report 2002. New York ; IRIN/U.N. Office for the Coordination of Humanitarian Affairs. "Malawi: Mosquito net prices slashed in anti-malaria campaign." November 13, 2002 ; Malawi National Statistical Office and ORC Macro. Malawi Demographic and Health Survey 2000. Zomba, Malawi, and Calverton, Md., USA: 2001; Kublin JG, Jere CS, Miller WC, et al. "Malaria infection elevates HIV-1 viral load." Abstract no. WeOrC1375. XIV International Conference on AIDS, Barcelona, July 7-12, 2002. Against the backdrop of these enormous health challenges, the human and financial resources to meet them are extremely inadequate. In its proposal to the GFATM, Malawi's Global Fund Coordinating Committee notes the following constraints: Access to care is limited; although 80 percent of Malawians live in rural areas,196 most of the country's health resources are located in the major urban centers. Quality of care is highly variable. Basic health information is often of low quality and is consequently not adequately factored into policy formulation and program planning. Training capacity falls far short of needs. Essential drug distribution is unreliable. Referral mechanisms are poorly defined. Technical support services, such as laboratories and pharmacies, are highly inadequate.197 Recent missions undertaken in conjunction with the food crisis have found an acute shortage of staff and basic equipment in most health facilities. (Among other findings, health facilities lack capacity to handle emergency obstetric care.) Moreover, the existing epidemiological surveillance system is incapable of providing timely information to national and international stakeholders. 198 Concurrently, almost all the strategies that form the government's national response to HIV/AIDS, as outlined in its proposal to the GFATM, are heavily dependent on the country's ability to improve delivery of basic health services (see Response section). 199 Inefficiencies and Inequities The effectiveness and equity of public health expenditures partly explain why health outcomes remain poor.200 Only 18 percent of the recurrent health care budget is allocated to primary health care, which most directly benefits the poor, whereas tertiary health services receive the highest share of the budget.201 People seeking medical services avoid clinics, because of the poor quality of infrastructure and the shortage of medical workers, drugs, and supplies. Up to 85 percent of central hospital admissions and an enormous number of outpatients could be treated at lower-level facilities. Poor patient management in hospitals and lack of supervision of remote facilities exacerbate the lack of human resources and medical supplies, leading to overall poor service delivery.202 Moreover, the concentration of cases at secondary and tertiary levels further draws resources away from primary facilities. 203 For about 75 percent of Malawians, reaching a health facility takes over 30 minutes.204 The 2000 MDHS asked all women whether they believed that specified issues were "a big problem" when they wanted to obtain treatment for an illness that they were experiencing. The cost of transport (60.0 percent), lack of money for treatment (56.2 percent), the time required to reach a health facility (56.2 percent), and availability of transport (52.3 percent) were the top four obstacles sited. These four reasons were more often cited by women in the Southern and Central regions, than by those in the North.205 Shortages of Medical Personnel There is a critical shortage of medical personnel, particularly in rural areas. Most districts lack a doctor, and nurses are in extremely short supply. 206 Vacancy rates range from 33 to 80 percent for some positions, resulting in extremely high ratios of population to medical personnel.207 A complex set of factors account for the staffing shortage, including low salaries, attrition to more lucrative jobs, insufficient capacity of in-country training institutions, and increased morbidity and mortality of health personnel (mainly because of HIV/AIDS).208 At the front lines, there are currently about 4,000 health surveillance assistants; MOPH plans to train another 4,000 over the next three years to raise the ratio to 1 HSA per 1,000-1,300 population. MOPH is dependent on donors for the requisite funding.209 Limited Access to Essential Drugs Another key problem is limited access to drugs and medical equipment. Results from a recent household survey found that lack of drugs was the number-one source of frustration reported by those seeking health care. Respondents stated that drug shortages were particularly acute in rural health centers and district hospitals, whereas they are generally available in central/regional hospitals.210 The government has steadily increased its contribution to drug expenditures, and, according to the World Bank, the budget allocation to drugs, particularly when donor contributions are included, is close to best practice standards. However, the effectiveness of drug expenditures is seriously constrained by weaknesses in drug procurement, storage, and distribution by the Central Medical Stores (CMS), as well as pilfering and inappropriate usage by public health providers. The World Bank and IMF have made reform of CMS a condition of release of HIPC funds. 211 Regardless of whether CMS reform should be tied to HIPC, reform is clearly needed. The Bank states that such reform involves making CMS an autonomous body, revising and adhering to an Essential Drug List, introducing need-based drug procurement, and creating a strong management information system that ensures equitable and timely distribution. To accomplish these will require a "cash-limited" system to ensure payment and tighter cost controls imposed on hospital drug budgets.212 Shortage of Clinical and Technical Support Services Because of low investment, there is also an acute shortage of clinical and technical support services in most district hospitals and health centers, including those related to laboratory and pharmacy services, radiology, ambulances, district and regional blood banks, orthopedics, and physiotherapy.213 Currently, most district-level and CHAM laboratories perform only basic functions, such as gram stains and HIV testing. A few, mainly in central hospitals, can undertake liver functions tests, bacterial cultures, and sensitivity analyses. The national response to HIV/AIDS depends on donor funding to implement the Essential Medical Laboratory Services Program, which will entail upgrades to existing laboratory standards and improvements in hematology and basic biochemistry capacity. 214 Poor Surveillance A situation analysis conducted by WHO in ten districts most affected by the recent food crisis in Malawi revealed that there are major weaknesses in health facilities' data collection, analysis, and utilization. For example, the assessment found that there was a much higher mortality rate within communities than recorded by health facilities.215 Six district hospitals out of ten could not provide adequate records on deaths that occurred during the period under study. Lack of communication facilities (e.g., reliable telephone lines, faxes, and e-mail) affected the timeliness of data and its transmission to national level or other project coordination centers. 216 Resource Gaps In its proposal to the GFATM, the MOHP mentions several health planning documents that have been adopted since the late 1990s, e.g.: * To the Year 2020: A Vision of the Health Sector in Malawi * Ministry of Health and Population District Planning Guidelines * The National Health Plan 1999 - 2004 * The National Human Resources Development * The National Health Facilities Development Plan 1999 - 2004 * The National HIV/AIDS Strategic Framework 2000 - 2004 However, a World Bank analysis of Malawi's National Health Plan 1999-2004 found that: * The plan's service coverage and program targets (e.g., halving the maternal mortality ratio, 50 percent reduction in HIV prevalence, and 50 percent reduction in childhood malnutrition) are not feasible. * The gap between the resources needed to implement the plan and those secured is severely underestimated; the Bank believes that the funding gap is between US$256 million and US$316 million over five years. * Although the plan's stated objective is to improve primary health care, its facility targets are biased toward hospitals. 217 The GFATM proposal states that the MOHP's approach to health sector reform is predicated on: * introducing the essential health package, which targets: ? vaccine-preventable diseases ? malaria ? maternal and neonatal outcomes (including family planning) ? TB ? acute respiratory infection ? acute diarrheal disease ? STIs, including HIV ? schistosomiasis ? nutritional deficiencies ? eye, ear, and skin infections ? common injuries * decentralizing health care management * broadening access to health services in remote areas * promoting cost sharing through extending health insurance schemes and implementing user fees where appropriate 218 The MOHP estimates that implementation of the essential health package will cost, at present estimates, US$17.53 per capita annually. 219 (Note that annual total health expenditure in Malawi ¾ public and private ¾ is US$11.220) Health sector reform is predicated on decentralization and the transfer of responsibility for staffing decisions, management of primary health facilities, and communicable disease programs from the MOHP to local authorities. The timing of the transition depends on building the required financial and technical capacity at district level. The government has taken various steps to facilitate this process. Regional Health Offices were abolished in 1999/2000, and cost centers at the district level were established. Districts now prepare budgets tailored to their local priorities. However, largely due to variations in central government cash flow, resources reaching district health offices vary significantly by month. This lack of resource predictability is a serious constraint to budget execution. 221 User Fees The World Bank has advised Malawi to implement cost-sharing measures in the health sector.222 Discussions about cost-sharing have been ongoing since the 1980s, but Malawi does not have a comprehensive, national cost-sharing policy with strong political support. Currently, tertiary hospitals and a few district hospitals are the only facilities charging fees; fee structures and health services that are charged are determined on an ad hoc basis. For example, at Queen Elizabeth Central Hospital, cost-sharing revenues account for 5 percent of total hospital expenditure. Few patients are covered by health insurance, and thus many who use hospital services cannot pay the entire cost of specialized services. However, there are services that can operate on a full cost recovery basis such as the use of private rooms, whereas the poor are likely to self-select into general wards. 223 The Bank points to CHAM facilities, which charge user fees set at the local level by independent committees. According to the Bank, CHAM generates as much as one-third of its revenues from user fees. Although CHAM facilities also suffer from shortages of medical personnel and drugs, user surveys suggest quality of care in CHAM facilities is higher than that provided by equivalent government hospitals. The Bank seems to be positing that health care seekers are willing to pay for higher-quality care and thus introduction of user fees in (improved) public health facilities is rational. To achieve improved public health service delivery, the Bank recommends that the government (which subsidizes the salaries of CHAM health workers) increase its subsidy to CHAM (which has been increasing, from 0.7 percent of recurrent health spending in 1997 to 5.2 percent in 2000); introduce explicit service contracts with CHAM; formally designate CHAM facilities as district hospitals in areas with no government hospitals; and closely coordinate policy decisions, including health facility construction, with CHAM. The Bank also highlights the success of community-based drug revolving funds as illustration of Malawians' willingness to pay for quality services. It states that: The poor can be protected through fee exemptions for specific services (such as maternal and child health), through demographic targeting, or through community waiver programs organized along community health or other social funds. 224 The Bank's recommendations on closer and more formal collaboration with CHAM may be quite reasonable, especially as the national response to HIV/AIDS relies heavily on CHAM. 225 However, experience with user fee exemptions, in, for example, Zambia, has shown that there have been serious inequities in implementing them. There have been very high errors of exclusion and inclusion; those who can afford to pay or are ineligible under the criteria have been granted exemption, whereas many who were eligible have been denied exemption. Moreover, exemption mechanisms, even if they worked as intended, would not necessarily address inequalities in the use of services related to income or distance to health facility.226 In addition, as discussed in previous sections, households are already at breaking point due to the humanitarian crisis and many if not most would not have any cash (or assets left that could be sold) to pay for health services. Sexually Transmitted Infections Malawi's strategic framework for HIV/AIDS includes: * expanding STI syndromic management to all health institutions and health facilities, including in rural areas * strengthening STI counseling services and mobilizing people for early treatment, especially among youth * providing adequate STI drugs and training adequate numbers of medical personnel for STI syndromic management * promoting routine screening and treatment of STIs in antenatal attendees and among "people associated with high risk behaviors"227 As with other health data, those on STIs are difficult to access. Findings from several studies are presented below, which demonstrate that STIs (particularly herpes) are likely fueling the HIV/AIDS epidemic in Malawi: * In the study involving male workers from the Nchalo sugar plantation, discussed above, the most important risk factor for HIV acquisition in both the 1994 and 1998 cohorts was a reactive syphilis test. Reactive syphilis increased the probability of HIV acquisition about twofold among men in both the 1994 and 1998 cohorts; however, it was only statistically significant in the 1994 analyses.228 * As part of the same study, the authors investigated associations between HIV prevalence and herpes simplex virus 2, hepatitis C, and hepatitis B, using a nested case-control study of 279 HIV-positive and 280 HIV-negative male sugar plantation workers. The prevalence of herpes was 88.1 percent among HIV-positive men and 64.3 percent among those who were HIV-negative (p <.01). This difference persisted after adjusting for sexual behavior and history of STI (OR = 4.12; 95% CI: 2.21-7.68), with herpes significantly associated with HIV. The prevalence of hepatitis C was 12.7 percent among HIV-positive persons and 10.0 percent among those who were not infected with HIV (p =.31); the comparable figures for hepatitis B were 16.9 and 14.4 percent, respectively.229 * Researchers from the University of Malawi, Johns Hopkins, and Rutgers used a cross-sectional study to examine the association between bacterial vaginosis (BV) and HIV infection among women attending ANCs (n=1,196). They found that BV was significantly associated with antenatal HIV seroconversion (adjusted OR = 3.7) and postnatal HIV seroconversion (adjusted OR = 2.3). There was a significant trend of increased risk of HIV seroconversion with increasing severity of vaginal disturbance among both ante- and postnatal women. The approximate attributable risk of BV alone was 23 percent for antenatal HIV seroconversions and 14 percent for postnatal seroconversions.230 * Researchers working in the Shire Valley in rural southern Malawi have found that hepatitis B and C are endemic. They did not, however, find a statistical association between HIV and hepatitis B or C. 231 Sexual and Reproductive Health The accompanying table provides selected indicators of sexual & reproductive health. As shown, there is a high burden of fertility on young women. The 2000 MDHS found that the desired total fertility rate among all women is 5.2, meaning that 30 percent of married women (including those in consensual unions) have an unmet need for family planning.232 Malawi's maternal mortality ratio is already higher than the global average (550 vs. 400). A recent U.N. situation analysis conducted in ten districts hard-hit by the food crisis found higher maternal mortality during 2001-02 compared to 2000-01. In eight district hospitals for which mortality data were available, maternal deaths had increased by 72 percent, although the number of deliveries had declined by 7.6 percent during the same period. These data indicated a diminishing number of women gaining access to hospitals, combined with increased mortality of those who do. The mission found that the increase in maternal mortality was directly attributed to the food shortage, which is exacerbating already high anemia rates found in pregnant women, as well as cultural practices that require mothers to eat last in the family. 233 Given these findings, UNFPA recently urged that reproductive health care be integral to the response to the humanitarian crisis. It noted that hunger and cholera also contribute to increasing maternal mortality. Concurrently, as finding food is the top priority, fewer women are likely to seek prenatal care or give birth in hospitals. Malnourished mothers are more likely to be anemic and therefore at risk of bleeding, particularly after delivery, thus rendering them more susceptible to infections. In these situations as well, blood transfusions may be necessary, thereby possibly increasing risk of acquiring HIV. 234 Knowledge of HIV/AIDS The 2000 MDHS found that general awareness of AIDS is nearly universal: 98.9 percent of women and 99.7 percent of men have heard of AIDS. Among women, 93.1 percent believe that "there is a way to avoid getting AIDS"; for men, this figure is 97.7 percent. Women and men in rural areas and in the Northern Region are more likely to report that AIDS cannot be avoided than those in urban areas and Central and Southern regions. 235 Education is strongly related with belief that AIDS can be avoided. Among women with secondary education, 99.5 percent believed that AIDS can be avoided; for women with no formal education, this figure was 88.8 percent. For women with primary education 1-4, 91.7 percent believe that AIDS can be avoided; for women with primary education 5-8, 96.0 percent. 236 Abstinence and use of condoms were by far the most frequently cited ways of avoiding HIV by men and women. Among women, 67.1 and 54.6, respectively, cited these methods. Among men, these figures were 77.3 and 71.4 percent, respectively. Limiting number of sexual partners was cited by 27.4 percent of women and 20.4 percent of men. Only 2.5 percent of women and 1.3 percent of men cited avoiding sex with partners who have multiple partners. 237 Among women, 85.3 percent knew of two or three "programmatically important ways to avoid HIV/AIDS" (i.e., abstaining from sex, using condoms, and limiting number of sexual partners); for men, this figure was 91.7 percent. The relationship between educational attainment and knowledge of the three methods just mentioned was strong: only 4.9 percent of women with secondary education knew fewer than two ways to avoid HIV/AIDS, whereas for women with no schooling, this figure was 21.3 percent. There was also a strong rural-urban differential: 93 percent of urban versus 83.8 percent of rural women knew two or three ways to avoid HIV/AIDS. Among these women, knowledge was highest among women in Southern Region (88.8 percent), followed by Northern (82.8 percent) and Central (81.6 percent) regions. 238 The percentage of men with secondary or higher education who knew two or three "programmatic" ways to avoid HIV/AIDS was very close to that of women with the same educational attainment: 95.4 percent (for women: 95.1 percent). As with women, this figure also rose in tandem with educational levels. The urban-rural differential was not as pronounced (95.0 vs. 90.9 percent) as it was with women. With regard to regions, more men in Southern Region (94.0 percent) than in Central (90.8 percent) or Northern (85.4 percent) regions knew two or three programmatic ways to avoid HIV/AIDS. 239 Despite high knowledge of HIV/AIDS, some findings from the 2000 MDHS suggest that behavior change messages may not be effectively highlighting key strategies for HIV prevention, nor adequately debunking false beliefs about HIV transmission. Although HIV may be transmitted via unsafe injections, this is a rare occurrence compared to sexual transmission. Yet 10.6 percent of women and 10.9 percent of men cited avoiding injections as a method to avoid HIV/AIDS. Similarly, HIV transmission through sharing of razor blades is rare; however, 33.7 percent of women and 26.9 percent of men cited avoidance of sharing razors/blades as a means to avoid HIV/AIDS. (Compare these figures with those above regarding limiting number of sexual partners and avoiding sex with partners who have multiple partners.) Avoidance of kissing and of mosquito bites was rarely cited. 240 When asked whether a "healthy looking person can have the AIDS virus," 84.3 percent of women and 91.7 percent of men correctly replied yes. A strong urban-rural differential was found: among women: 95.1 vs. 82.3 percent, and among men: 80.5 vs. 70.9 percent. 241 Knowledge of MTCT of HIV is weak. The percentages of women who responded that HIV can be transmitted from mother to child during pregnancy, delivery, or breastfeeding were 65.6, 62.3, and 64.8 percent, respectively. Among men, these figures were 70.4, 61.5, and 62.1 percent, respectively. 242 Twenty-four percent of women and 16.5 percent of men do not believe that condoms are safe. This belief was highest among those who have never had sex (women: 32.1 percent; men: 22.8 percent) and among those living in Northern Region (women: 52.8 percent; men: 29.2 percent). 243 Stigma Among Malawian women, 72.2 percent report that they personally know someone who has AIDS or has died because of AIDS (urban women: 78.0; rural women: 71.1 percent). Among men, this figure is 81.5 percent (urban: 82.0 percent vs. rural: 81.3 percent).244 Among currently married women who have heard of AIDS, 72.3 percent report that they have discussed HIV prevention with their spouse; for men, this figure is 85.8 percent. There was a high urban-rural differential among women (80.5 vs. 70.9 percent), though not among men (85.6 vs. 85.8 percent). For both men and women, educational level was strongly associated with having discussed HIV with one's spouse. 245 The 2000 MDHS found that 51.3 percent of women and 46.9 percent of men believe that a coworker with HIV should not be allowed to continue worki