a) Condom and lubricant programming
Mid-term review findings show challenges in meeting distribution targets, poor understanding of the Total Market Approach among stakeholders, unharmonized demand creation, minimal engagement of private distributors, and suboptimal distribution to rural and poor populations. Successes include good coordination at the national level and development of the Last Mile Condom Distribution Guidelines. Data on the targets for percentage of condomized sexual acts and knowledge about consistent and correct use of condoms were not available at the time of the midterm review.
b) Pre-Exposure Prophylaxis
The Ministry of Health in Malawi approved oral Pre-Exposure Prophylaxis (PrEP) as an additional prevention intervention for individuals at substantial risk of acquiring HIV such as female sex workers and men who have sex with men. The NSP 2020-25 devised strategic interventions to support PrEP scale-up, but progress towards achieving the targets by the end of 2022 had been slow due to challenges such as low uptake and adherence to PrEP, particularly among adolescent girls and young women and men. However, successes were achieved in the good integration of PrEP with other Sexual and Reproductive Health services and the development of national PrEP guidelines and communication strategy. Malawi is also planning to conduct implementation studies on long-acting injectable cabotegravir among key and vulnerable populations in 2023.
c) Voluntary Medical Male Circumcision
Malawi rolled out the Voluntary Medical Male Circumcision (VMMC) program in 2012, and the NSP 2020-25 devised strategic interventions to support VMMC scale up. However, based on available data, most of the targets may not be achieved by 2025. The major success has been the decentralization of VMMC procedures to districts and private clinics which has resulted in increased uptake, but limited infrastructure and human resource capacity remain major challenges affecting VMMC scale up nationally.
d) Adolescent Girls and Young Women
The 2020-25 NSP has set targets to reduce new infections among Adolescent Girls and Young Women (AGYW) by 22% through interventions such as strengthening multi-sectoral coordination, increasing access to quality SRHR/HIV services, and engaging with young networks to disseminate prevention messages. There has been a mid-term reduction of 17% in new infections among AGYW, but data on other program indicators is not yet available. Successes include the successful delivery of comprehensive AGYW packages in partner-supported districts and increased coverage of youth CBDAs providing some components of AGYW services. Challenges include poor coverage of interventions targeting Adolescent Boys and Young Men (ABYM) and their sexual partners, incomplete delivery of comprehensive knowledge/sexuality education among AGYW, and sub-optimal coverage of Community Youth Centers to keep girls in school.
e) Key Populations
The strategic interventions for the KVP programme include strengthening governance and coordination, pursuing SLAs with private providers, scaling up community-based testing, and delivering HIV, GBV, SRHR, and mental health services in emergency situations. Mid-term progress shows that targets for coverage of prevention services for FSWs and MSM have been achieved, and almost achieved for viral suppression, but data for other indicators are either not available or unreliable. Successes in implementing the KVP programme include the availability of DICs and training of HCWs in KP-friendly services, as well as improvements in the legal environment. However, challenges persist, including limited coverage of DICs and moonlight SRH/HIV services, persistent stigma and discrimination, and frequent stockouts of STI drugs.
The eMTCT program is a priority in Malawi’s efforts to eliminate pediatric HIV, with strategic interventions focused on increasing demand and uptake of SRH and HIV prevention services, offering integrated youth-friendly health services, engaging male partners, supporting family planning, improving screening, and strengthening treatment and retention. However, progress towards targets set for reducing MTCT rates and new pediatric infections has been slow, with challenges of poor retention of mothers and infants, stock-outs of test kits, and inadequate coverage of services. Despite these challenges, there have been successes such as high ANC and ART coverage, good integration of services, and the introduction of retesting guidelines and community-based services.
STIs are a known risk factor for HIV transmission and acquisition, and the WHO recommends STI services as part of a comprehensive HIV prevention package. However, the MTR suggests none of the STI program targets had been met, although screening of STI clients for HIV was close to the target. Some of the successes of the STI program included the increased availability of integrated STI/SRH services delivery platforms in health facilities and DICs, the introduction of cervical cancer screening and treatment services in some facilities, the availability of AMR monitoring guidelines, and the establishment of NG AMR sentinel surveillance. However, some of the key challenges included poor collaboration between public and private facilities in the provision of integrated STI/SRH services, frequent STI drug stockouts, increasing NG AMR, sub-optimal integration of cervical cancer screening and treatment services, and the misclassification of FGS as STIs in some areas.
h) Wellness and workplace
The Wellness and Workplace HIV program aims to develop policies and programs for HIV prevention and treatment, targeting formal and informal sectors, migrant laborers, and young women. It also focuses on empowering private sectors to effectively deliver HIV services, adherence to standards and regulations, and increasing financial contributions towards combating HIV/AIDS. Although data for the program indicators are not available, there has been good coordination between the National AIDS Commission (NAC), the Ministry of Labour, and the Malawi Business Coalition for Health (MBCH) in the implementation of the program. The revision of the National HIV and AIDS Workplace Policy is also a key success, which will guide the formulation and revision of workplace policies in outdated sectors. The mid-term review highlights poor planning and coordination, sub-optimal implementation, poor enforcement, and limited financial resources as key challenges to fully implementing the program.
i) Blood safety
The 2020-25 NSP did not set specific targets for blood safety, but the program aimed to improve the availability, quality, and management of blood transfusion services and set up sentinel sites in major hospitals. The program has been successful in the universal screening of blood units for transfusion-transmitted infections, but challenges include the MBTS’s inability to meet national blood demand due to limited blood donors and COVID-19 disruptions, the limited sensitivity of serological tests leading to false positive results, and limited infrastructure in districts for blood banks.
Differentiated HIV testing
The program has exceeded the UNAIDS testing and treatment targets, but awareness levels are lower in males than in females. The program has been successful in implementing secondary HIV testing and same-day testing and treatment initiation, but there are high costs associated with community-based testing. HIV testing and counselling are not offered to people on remand in prisons, so there is a need to review the HTS protocol for prisons. The program has successfully implemented a 3-test algorithm and quality assurance programs but there is a need to sustain good quality assurance performance. HIV Diagnostic Assistants (HDAs) and expert clients have been successful in linking HIV-positive clients to ART care, mostly in partner-supported districts, but the proportion of HIV self-test (ST) clients who return for confirmatory tests remained very low. The program has successfully integrated HTS into VMMC, STI services, and moonlight/hotspot testing. The private sector needs to be mobilized to take up more HTS roles, and there is a need to promote access to testing coverage among outpatient attendees with suggestive symptoms.
Treatment, care, and support
By the end of 2022, all targets were surpassed in all PLHIV overall, but not in children living with HIV aged 0-14 years, adolescents, and men. Although there was a reduction in AIDS-related mortality, there were challenges in implementing the strategic interventions in the Differentiated HIV Testing Pillar. The findings call for enhanced efforts to increase testing and treatment coverage, improve retention in care for PLHIV, and improve the quality of care for PLHIV. There is a need for increased investment in infrastructure, medicines, equipment, and human resources to manage co-morbidities in PLHIV on ART. The priority areas for improvement include increasing access to treatment for children, adolescents, and men, improving retention and adherence to ART, strengthening treatment monitoring, and improving the management of advanced HIV disease and other HIV-related diseases and co-morbidities.
The mid-term review found key achievements, such as the establishment of the Parliamentary Caucus for TB in Malawi and the availability of diagnostic services in all district hospitals. However, challenges include over-reliance on smear microscopy for diagnosis and insufficient integration of TB screening in facility service delivery points. Lessons learned include the need for robust pharmacovigilance for co-treated patients and the promotion of TB preventive therapy among all household contacts.
Malawi identifies vulnerable children through criteria such as living in low-income households, not living with biological parents, or in households with uneducated adults or single/double orphans. The NSP 2020-25 aimed to improve HIV-sensitive child protection case management, care, and support for children affected by HIV and gender-based violence. Key achievements include ongoing awareness campaigns and recruitment of additional Community Child Protection Workers, while challenges included weak coordination and lack of resources. Additional investment and training is needed for CCPWs and a clear selection criteria for beneficiaries should be established. The innovative use of Constituency Development Fund (CDF) to support vulnerable children is potentially sustainable.
Reducing human rights and gender barriers
The Malawi Government has shown commitment to protecting the rights of key populations, including establishing Key Population TWGs, Human Rights and Gender TWGs, and deploying Gender Officers. However, pervasive negative social norms and illiteracy limit the impact of legal literacy campaigns. Challenges also include lack of human, material, and financial resources to implement and scale up interventions. The key success of the program includes increasing awareness of GBV cases and improving legal and human rights knowledge. The need for continued advocacy work and community engagement is emphasized for addressing harmful gender norms and reducing gender-based violence.
Social and Behaviour Change Communication
The mid-term review found that while the country has established strong foundations for SBCC programs, there are challenges in engagement with community and religious leaders to champion socio-cultural changes and limited coverage of SBCC interventions due to limited capacity and resources. There is a need to intensify the use of social media for communication, operationalize the Male Engagement Strategy, and establish M&E systems for SBCC interventions.
Resilient and Sustainable Systems for Health
Malawi’s health system faces chronic resource constraints that limit the delivery of HIV-related health services, threatening the country’s goal of achieving universal health coverage. While the health sector has a strong leadership and governance structure, there are challenges in terms of limited stakeholder awareness, poor tracking of HIV-related expenditure, and sub-optimal coordination capacity at the district level. The health infrastructure also hinders the expansion of service integration. However, there are positive developments in financial management, coordination of the response in line with the 3 Ones Principles, health products management systems, health information systems, human resources for health, availability of infrastructure, transport, and equipment, integrated service delivery and quality improvement, and strengthened community systems. Recommendations include tracking expenditure and value for money, strengthening capacity for multi-sectoral coordination at the district level, strengthening the capacity of data-driven decision-making, accelerating in-service training, and expanding health infrastructure to support integrated service delivery.