Counting fragile gains over HIV

Travellers in Malawi are seeing dramatic declines in Aids-related deaths everywhere they go. Why is such the case? JAMES CHAVULA investigates:

“It is incredible that one can travel [over 700 kilometres] between Blantyre and Mzuzu without meeting a funeral procession or a vehicle carrying a dead body,” says Lawrence Khonyongwa, from Malawi Network of People Living with HIV (Manet+).

HIV testing

He says the number of people dying from infections caused by Aids has drastically dropped due to a number of interventions, especially improved treatment.

“It shows the medicine is working and it is good for human bodies, so people can live longer and healthy,” Khonyongwa explains.

Treating everyone diagnosed with HIV has become Malawi’s magical bullet in the war on the virus which was claiming a life every eight minutes two decades ago.

Taking a pill per day, one can enjoy a healthy life without suffering deformities that once fuelled stigma and discrimination.

Gone is the era the incurable virus, which demolishes immunity to infections, was christened mdula moyo (terminator) after speeding minibuses that once terminated hundreds of passengers’ lives on the country’s perilous roads.

Nowadays, some people brag that they fear a pregnancy more than HIV, which reduced hospital wards to deathbeds, streets to coffin markets, musicians to dirge-makers and frequent mourners to silence.

The Aid related deaths did not only push government to expand its fleet of minibuses for transporting civil servants’ bodies, but also accept that the public health crisis as emergency ripping all spheres of life.

National Aids Commission (NAC) spokesperson Karen Msiska credits antiretroviral drugs (ARVs) with reducing the deaths rates from 64 000 to 13 000 since Malawians started taking the drugs free of charge 15 years ago.

Dan Namarika, principal secretary for Ministry of Health says the drop is “tangible” and “felt by every family”.

He is excited that by October last year, 92 in every 100 people living with the virus knew their status, 84 percent of them were on treatment and 91 of these had undetectable viral load.

However, he is worried that new infections are peaking again as horrifying memories of HIV fade.

“We have surpassed all 90-90-90 targets, except one. Now, we need to look at 95-95-95 by 2030,” he says, adding: “Because the change is dramatic, some people, especially young people, are complacent. We need to regain the momentum so that we do not slide back to the tragic days.”

Malawi missed its target to reduce new infections by 75 percent by this year.

In 2016, the country pledged to the Global Coalition on HIV Prevention to reduce the number of people getting infected from 59 000 in 2010 to just 11 000 this year.

However, the Ministry of Health reported last year that 38 000 people acquired the virus in 2018, up from 36 000 a year earlier.

Startled by the surge, Namarika says: “As we build on the existing successes in treatment, we need to analyse what’s driving new infections.” 

He reckons preventive strategies have been eclipsed by growing emphasis on treatment in donor-driven interventions.

“Prevention does not give quick results. If you invest more in voluntary medical male circumcision, you may not see the results or tell the number of infections you are averting. However, donors need quick results. They need data and impacts,” he says.

Activists warn that the national response will remain fragile unless government increases domestic funding for prevention, treatment, care and support.

“If you look at the budget, there is no allocation for ARVs and vital supplies to sustain the celebrated success. The country has relied on donors, who have their own priorities. They help government, but they look at the figures and choose where they want to work. If they select a few districts and responses, does the government have money for those left out?” asks Khonyongwa.

Khonyongwa says reckons donor dependence has partly derailed the National HIV Prevention Strategy and NAC’s strategic plan.

He states: “We have good strategies that can improve both prevention and care, but they are not fully funded. Meanwhile, the focus of many organisations is shifting from HIV and Aids to other donor priorities, such as migration and climate change. If this doesn’t stop, we will continue singing the same songs of low funding and the number of Aids-related death will rise again.”

Budget tracking by Malawi Health Equity Network (Mhen) shows aid constitutes more than 85 percent of the country’s healthcare budget. This means that the State-funded healthcare spending comes short of the requirements of the 2001 Abuja Declaration.

The African Union pact requires governments to ensure at least 15 percent of the national budget goes to strengthening health services. Presently, it gets just six percent in the current K1.7 trillion budget.

During the International Conference on Population and Development in Kenya last November, Minister of Health Jappi Mhango announced Capital Hill’s commitment to meet the 15 percent minimum by 2030.

This further postpones the fulfillment of the African Union resolution, but Mhango retorts: “We are investing slowly but steadily. By 2030, we should be able to reach the required 15 percent. We are only aligning our targets with the Sustainable Development Goal number three which requires us to deliver quality healthcare services for our citizens where they live.”

But Maziko Matemba, from Malawi Network of Aids Service Organisations (Manaso), says the country is racing against the clock in “the decade to end Aids”.

He urges government agencies and every sector to channels one percent of its funding towards combating HIV and Aids as required by the national HIV Strategy.

“Our healthcare needs remain at the mercy of donor preferences. This is unsustainable. Aid can be withdrawn unexpectedly,” he says.

In 2014, some donors closed aid taps following the looting of billions at Capital Hill by civil servants, politicians and their business cronies. Other financiers have redirected their budgetary contributions to projects implemented in partnership with international non-governmental organisations.

Similarly, the donation of NAC cheques to First Lady Gertrude Mutharika’s Beautify Malawi and Mulhako wa Alhomwe, for which President Peter Mutharika is a patron, irked Global Fund to shift its funding from the commission to ActionAid.

Matemba says new infections could be rising because organisations that used NAC funding to deliver behavioral change interventions and vital supplies at community, district and national levels are getting fewer.

“Many community-based organisations and groups, which were active in promoting HIV prevention, testing, treatment and rights, have either died silently or changed focus. We need to revitalise the HIV response at all levels because we are thin on the ground,” he says.

Since 2015, the global response has tilted towards ending Aids by 2030 by increasing the number of people on treatment.

The 90-90-90 campaign backed by UNAids requires countries to ensure that by 2020, at least 90 percent of people living with the virus should know their status, 90 percent of them start treatment and ensure 90 percent of them take drugs until the amount of virus in their bloodstream becomes undetectable.

New science shows people whose viral load has been suppressed to undetectable levels cannot transmit it to their sexual partners.

Ulanda Mtamba says it is important to ramp up HIV prevention, the vital 90 change agents hardly dial up when they talk about 90-90-90. She asks government and its partners to increase the preventive tools, especially for adolescent girls, women and other at-risk groups.

“To protect the population from new infections and sustain reductions in Aids-related deaths, we need to understand where the resources are going and whether we are reaping the desired results. We cannot win the battle unless we protect those most vulnerable to HIV infection. Although women are disproportionately affected, the condom is our only weapon and most women have no power to demand safe sex.”

About nine in 100 people in the country are living with HIV, NAC reports.

Mtamba urges government and nongovernmental organisations to track funding for dialling back HIV and Aids so that they do not only go towards quick gains.

She states: “We need sustainable interventions to end Aids. Clearly, we have missed the targets on prevention.”

And Khonyongwa warns against efforts that protect highly prone populations without shielding the majority they constantly interact with.

“Let us use the whole basket of HIV prevention strategy and we need to look at all age groups. We need not relent or relax.

“If we concentrate on at-risk populations, who will protect the larger population? Some may have no access to condoms, others may be powerless and yet others cannot negotiate safe sex. If we focus on key populations, what will happen to adolescent, who are neither sex workers nor men having sex with fellow men, but are having sex with their peers or aged persons?”

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