The HIV epidemic in Malawi poses multiple challenges

The HIV epidemic in Malawi poses multiple challenges from an equity perspective. It is estimated that 12% of Malawians are living with HIV among the 15-49 age group. This paper synthesises available information to bring an equity lens on counselling and testing and antiretroviral therapy policy, practice and provision in Malawi. A synthesis of a wide range of published and unpublished reports and studies using a variety of methodological approaches was undertaken. The analysis and recommendations were developed, through consultation with key stakeholders in Malawi. At the policy level Malawi is unique in having an equity in access to antiretroviral therapy policy, and equity considerations are also included in key counselling and testing documents. The number of people accessing counselling and testing has increased considerably from 149,540 in 2002 to 482,364 in 2005. There is urban bias in provision of counselling and testing and more women than men access counselling and testing. Antiretroviral therapy has been provided free since June 2004 and scale up of antiretroviral therapy provision is gathering pace. By end December 2006, there were 85,168 patients who had ever started on antiretroviral therapy in both the public and private health sector, 39% of the patients were male while 61% were female. The majority of patients were adults, and 7% were children, aged 14 years or below. Despite free antiretroviral therapy services, patients, especially poor rural patients, face significant barriers in access and adherence to services. There are missed opportunities in strengthening integration between counselling and testing and antiretroviral therapy and tuberculosis, sexually transmitted infections, and maternal health services. To promote equitable access for counselling and testing and antiretroviral therapy in Malawi there is need to further invest in human resources for health, and seize opportunities to integrate counselling and testing and antiretroviral therapy services with tuberculosis, sexually transmitted infection and maternal health services. This should not only promote access to services but also ensure that resources available for counselling and testing and antiretroviral therapy strengthen rather than undermine the provision of the essential health package in Malawi. Ongoing equity analysis of services is important in analyzing which groups are unrepresented in services and developing initiatives to address these. Creative models of decentralization, whilst maintaining quality of services are needed to further enhance access of poor rural women, men, girls and boys.

only 43% of Malawians in need of antiretroviral treatment had accessed it by the end of 2006, Malawi is well on its way to meeting its universal access treatment target of 50%. A clear priority in Malawi has been to promote equity in access to its free treatment first-come first-served programme that has been running since 2004. Significant barriers to achieving equity in access are the cost of transport and food as well as the opportunity costs of missing work, particularly when tuberculosis and antiretroviral treatment programmes are parallel, vertical programmes requiring separate clinic visits. Monitoring the age, sex, and socioeconomic status of people undergoing HIV testing and accessing HIV treatment services in all countries can help identify inequities that are unnecessary, avoidable, and unfair so that they can be rectified.