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Cultural Practices, Perception Key Factors in Malawi’s AIDS Epidemic

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LILONGWE, MALAWI, November 29, 2007 —One cannot dispute that levels of HIV/AIDS awareness in Malawi are very high. Almost 100 percent of those sampled in the Ministry of Health’s 2000 Malawi Demographic and Health Survey (MDHS) reported that they had heard about AIDS.

But, whether this awareness translates to behavioral change that can lead to containing the epidemic is another question. The question has caused the National Aids Commission (NAC) to investigate what is fuelling the epidemic in Malawi despite the excellent levels of awareness.

Although Malawi saw a decline in prevalence rates from about 18 percent in 1997 to 14 percent in 2005, the numbers still are relatively high for sub-Saharan Africa. Other countries with rates above 14 percent include Swaziland, Botswana, Lesotho, South Africa, Zimbabwe, and Zambia.

According to the 2006 Poverty and Vulnerability Assessment (PVA) done jointly by the World Bank and Malawi’s National Statistics Office, AIDS is the leading cause of death among people aged 20-49 years. Malawi’s life expectancy has dropped to 37 years due to the virus. It is estimated that without the epidemic life expectancy would be 55.

Partners Infecting Partners

a 12-year old boy reading a book about AIDS

A 12-year old boy reading a book about AIDS

Research findings on HIV/AIDS in Malawi presented at the Annual Review Conference for the National Response to HIV/AIDS in October 2007 point at several factors that drive the epidemic in Malawi. Topping the list: multiple and concurrent partners, perceptions on infection, inconsistent condom use, and cultural practices.

“Multiple and concurrent partnerships is the key driver,” according toBlacksonMatatiyo, a research officer at NAC.

The proportion of men who have other sexual partners is higher than that of women, according to the PVA 2006 report. As a result, prevalence rates are higher among women (13 percent) compared to men (9 percent). The PVA further observes that the gender differential is starker for young adults: prevalence was more than four times as high in females as males aged 15-24 in 2004.

“There is therefore a need to target men on mutual faithfulness,” Matatiyo said.

Research by Pakachere Health and Development Communications -- a multimedia organization whose goal is to prevent the spread of HIV in Malawi -- finds several reasons for people’s indulgence in multiple partnerships. Among them are lack of sexual satisfaction by one partner, alcohol and drug abuse, availability of disposable income, and peer pressure.

Perceptions about Infection

Perceptions about the risk of infection also are fuelling the epidemic.

“Many people do not think they could possibly be infected by HIV or any sexually transmitted disease,” says Alfred Chirwa, the World Bank’s Health Specialist in Malawi. “This results in people engaging in risky sexual behaviour thereby unknowingly infecting others or getting infected. Instead of depending on perception, it is best to get tested. Testing is what Malawi is focusing on now.”

According to the PVA, “in the absence of actual testing, peoples’ subjective evaluations of their HIV status are different from reality, i.e. some overestimate and others underestimate their risk of infection.

“Of the men who were infected,” the report said, “71 percent stated that they had zero or low likelihood of being infected. Among the infected women, 45 percent stated that they had zero or low likelihood of being infected. On the other hand most of those who indicated that they had a high chance of being infected were actually not infected (91 percent of the men and 87 percent of the women.)”

Advocacy for HIV counseling and testing (CT) has intensified over the years. More testing centers have been established, but the biggest annual drive is through the National Voluntary HIV Testing and Counselling (HTC) weeks coordinated by NAC and the Ministry of Health. The number of people tested during HTC week 2007 hit 186,631, double the figure for 2006. Of those tested, 8.4 percent were positive.

Low and Inconsistent Condom Use

A major advocacy message in Malawi, just like in many other countries, is ABC – Abstain, Be faithful, Condomise! Malawians high levels of knowledge about HIV/AIDS contrasts starkly with their extremely low levels of condom use.

In a 2004 Demographic and Health Survey (DHS) five percent of men aged 15-49 years reported to have bought sex in the 12 months prior to the survey. Only 43 percent used condoms during their most recent purchase.

The PVA observes that low condom use can partly be explained by the fact that condoms are associated with promiscuous behavior, and anecdotal evidence suggests that Malawians are generally unwilling to be seen buying them. This low level of condom usage may also be further explained by the perceptions on infection and unwillingness to get tested.

Cultural Practices

Great efforts are being directed toward addressing cultural practices that also facilitate the spread of the virus. Common in Malawi are initiation ceremonies.

“Adolescents who have been initiated or circumcised are more likely to be sexually experienced and active compared to those who are not,” said Matatiyo. “ What does this say about information given during initiation ceremonies? Can these initiation ceremonies be transformed to provide an opportunity for imparting HIV/AIDS information?”

With more awareness some communities are abandoning elements of their cultural practices that are likely to perpetuate HIV infection. However, NAC reports that some practices that are being discouraged and have seemingly stopped have actually not been abandoned but have gone underground. Among these is the use of sexual intercourse for cleansing against perceived evil. NAC recommends that more anthropological research should be done on such practices, more common in the southern region of the country, which has the highest HIV prevalence rate compared to the other two regions.

Fighting the Spread

Statistics indicate that only about 115,000 people with advanced HIV infection have ever received Anti Retroviral Therapy (ART). According to NAC, there are 146 health facilities in Malawi that provide the therapy. While ART drugs are usually available, shortages are being experienced in drugs for opportunistic infections.

The World Bank has been providing support to Malawi for HIV/AIDS since 2003, and will continue through its 4th Country Assistance Strategy (CAS) for 2007-2010. In the 4 th CAS, the World Bank plans to assist in decreasing vulnerability to HIV/AIDS at the household level. The Bank strategy will focus on the translation of awareness of HIV/AIDS into changes in behaviour, access to prevention and treatment, and supporting the involvement of other stakeholders such as civil society and community based organisations.

By Zeria Banda, World Bank Office, Malawi

 




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