Malawi

After Evelyn Siula’s husband died, she knew she had to get tested for HIV. The result came back as positive.

"I had prepared myself mentally for either outcome, but it was still a shock."

She was jobless and with three children to care for.

The stigma and discrimination surrounding the virus meant that many people were scared to disclose their status. "I had three friends whose families rejected them because their HIV status became known,” Evelyn shares.

But Evelyn chose to break the silence early, starting by telling her young daughter. Family support played a crucial role in Evelyn’s journey. Her family stood by her, offering constant encouragement and strength, vital for getting through the many challenges.

Stigma followed Evelyn. She recalls a particularly painful moment: “At a community gathering, someone pointed at me and asked, ‘Can you believe she’s HIV-positive?’ It was one of the worst experiences being talked about like that.”

Evelyn became a strong advocate for people living with HIV, standing up to stigma everywhere, including in her church. At a gathering in a church, when a speaker criticized people living with HIV, she shared her own status as HIV-positive and as a church elder. Her openness has helped challenge stigma and gain support. Through her work she  learned that many fellow church members were struggling in silence, and so helped create the Livingstonia Synod Positive Christians group, known as LISAP+.

Despite her bold advocacy, Evelyn acknowledges how mental health challenges, particularly fear and anxiety, have affected her. “I have thoughts like: ‘What if something happens to me? What if I die?’ I worry about my children and how they would manage without me. These are the fears that raise my blood pressure.”

But over time, Evelyn’s diagnosis has become not just a challenge but also a source of strength.

Today, Evelyn works for UNAIDS and is the vice chair of the UN Plus Advisory Group. She is proud to show that people living with HIV are leading healthy and productive lives.

She has completed  Bachelor’s and Master’s degrees in business administration. “The day I graduated with my Master’s degree was extra special because I graduated alongside my eldest son. It’s rare for a mother and son to share such a moment.”

Evelyn encourages everyone to ensure they know their HIV status as the first step to taking control of their health: “Please get tested. It's just a status. If you're positive, follow the advice of your doctors. There is full life after testing HIV positive. Take your medication religiously, eat well, and live a healthy life.”

“Never stigmatize anyone,” says Eveyln, “because we are all one.”

Girls’ education as a tool to prevent HIV infection has been centered at the 1st African Union Pan-African Conference on Girls’ and Women’s Education in Africa. This followed African leaders designating education as the 2024 African Union theme of the year.

At a high-level side event hosted by the Education Plus Initiative on the first day of conference held at the African Union Commission in Addis Ababa, Ethiopia, leaders, girls’ and women’s networks and advocates called for greater investments in girls’ education.

“Some people claim that providing girls with secondary education is too expensive. Such claims fail to consider the exponentially higher cost of not educating them,” said UNAIDS Executive Director, Winnie Byanyima. “We can get all our girls and boys to complete secondary education; that should be our legacy."

UNICEF calculates that 34 million girls in sub-Saharan Africa are out of secondary school. According to the Global Education Monitoring (GEM) Report 2023, in all regions in Africa, there are more girls out of school at the secondary level than boys, with gender disparities worsening as children move up to higher levels of education in favour of boys over girls. In sub-Saharan Africa, less than half of adolescent girls complete secondary education, their percentage standing at 42% and there has been no progress at all in closing this gap in the past 20 years.  Sub-Saharan Africa is the region furthest from parity at the expense of girls, with no progress since 2011 at the lower secondary level and since 2014 in upper secondary.

Gender is a key factor linked to disparities in enrolment, retention, completion, and learning outcomes through social conditioning, gender-based differences in parental expectations and education-related investments, child marriages and early childbearing, female genital mutilation, child labour, gender-based violence, period poverty and discrimination.

More than forty years into the HIV response, Africa remains an epicenter of the AIDS epidemic with adolescent girls and young women being disproportionately affected. Every week 3100 adolescent girls and young women acquired HIV in sub-Saharan Africa. Every three minutes, an adolescent girl or young woman aged 15-24 years acquired HIV in 2022 in sub-Saharan Africa.  Adolescent girls and young women aged 15-24 years in the region were more than three times as likely to acquire HIV than their male peers in 2022.

UN agencies, African Union representatives, government ministers, and young women leaders called for accelerated actions to translate commitments to action through leveraging girls' education for gender equality and preventing HIV, child marriage, teenage pregnancies, violence, gender-related stigma and discrimination in Africa.

Speakers emphasized the connection between health and education. Ministers spoke about key policy reforms and best practices aimed at promoting girls' education, including creating safe and inclusive school environments, strategies to get girls into secondary school, and the readmission policy that addresses high dropout rates due to pregnancy.  UN co-leads emphasised the need for improved collection of data disaggregated by sex and other relevant population characteristics to better understand educational participation, progression, and learning, and using gender-sensitive data for policymaking and planning. 

Other issues highlighted included the integration of digital literacy programs into the secondary education and vocational training curriculum to facilitate smooth transitions from school to employment; integrate gender equality into all aspects of the education system, including curriculum-based comprehensive sexuality education  and life skills, address gender-based violence  within schools and discriminatory laws and practices, and access to information, non-discriminatory HIV and sexual and reproductive health services access.

Young women leaders spoke on the role of partnerships and young women's leadership. Participants highlighted the upcoming 30th anniversary of the Beijing Declaration as an opportunity moment to accelerate accountability and commitments, as well as the CSW Resolution 60/2, Women, the Girl Child and HIV and AIDS as significant mechanisms to address political and resource gaps so no woman or girl is behind in the HIV response.

Education Plus is a rights-based, gender-responsive action agenda to ensure adolescent girls and young women have equal access to quality secondary education, alongside key education and health services and support for their economic autonomy and empowerment.  Co-led by five UN agencies, the initiative builds on existing frameworks like the Transforming Education Summit, the Continental Education Strategy for Africa (CESA) and the Dakar Education for All (EFA) Declaration to push for access and completion of education for women and girls in Africa.

GENEVA, 10 July 2019—UNAIDS regrets unnecessarily involving the authorities in Malawi in its outstanding issue with the Mango Network. UNAIDS and the Mango Network have amicably reached a resolution over the issue. UNAIDS has not engaged in any legal action and believes there is no need for any legal action. UNAIDS respectfully requests the immediate release of the two members of the Mango Network, Mr Gift Trapence and Mr Macdonald Sembereka, from police custody.

UNAIDS is strongly supportive of the full empowerment and engagement of civil society organizations in the AIDS response. It looks forward to continuing its partnership with community and civil society organizations in ensuring that all people affected by HIV have access to HIV prevention, treatment and social support services and that their human rights are protected.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

Dan Namarika, the Principal Secretary for Health in Malawi, graduated from the College of Medicine in 1999 as one of the first students to follow their entire medical training in Malawi. His long career as a medical doctor, which included four years as personal physician to the late President Bingu wa Mutharika, was prompted by a desire to act against AIDS.

“The reason I chose medicine was because of AIDS. I couldn’t believe there was an illness like this with no cure. I remember the first case in my neighbourhood. It was a lady who succumbed to AIDS after a chronic illness. I have had family members that have died. My long history has been impacted on by AIDS,” he says.

Since the peak of the HIV epidemic to which Mr Namarike refers, when there were 110 000 new infections (in 1993 and 1994) and 65 000 deaths because of AIDS-related illnesses (in 2004 and 2005), Malawi has made good progress in its HIV response.

This progress can be attributed to the introduction of innovations such as the test and start strategy in 2016, which offers immediate HIV treatment for all people living with HIV and Option B+ in 2011, a prevention of mother-to-child transmission of HIV strategy that ensures that all pregnant women living with HIV have lifelong access to HIV treatment. 

As a result, new HIV infections in Malawi have dropped by 40%, from 64 000 in 2010 to 39 000 in 2017, and AIDS-related deaths by half, from 34 000 in 2010 to 17 000 in 2017. Life expectancy continues to rise, from a mere 46 years in 2004 to 64 in 2018, and projections are that it will rise to 74 by 2030.

In 2017, 92% of pregnant women living with HIV in Malawi accessed services to prevent mother-to-child transmission of HIV. This lowered the number of new HIV infections among children (0–14 years) to an all-time low of 4900 in 2017.

Mr Namarika attributes these successes in large part to the multisectoral HIV response and high-level political commitment and leadership. “Besides policies being made at the highest levels of government, we also have ministries other than health involved, such as the treasury, gender, education and local government; we have civil society, the faith-based sector, cultural leaders and technical assistance from development partners, such as UNAIDS,” he says.

He also praises programmatic innovations, such as task shifting from doctors to nurses and community health-care workers, which has helped to reach more people with HIV testing and treatment services.

The 2015–2020 National Strategic Plan for HIV and AIDS has the 90–90–90 targets at its heart, with ending AIDS by 2030 in Malawi as the end goal. Malawi has made good progress in the number of people living with HIV who know their status (90%) and the number of people living with HIV who are on HIV treatment (71%). More work is needed to increase the number of people living with HIV who have suppressed viral loads (61%), which puts Malawi at risk of not meeting the targets in the next 500 days.

The major obstacle to Malawi’s progress in meeting the targets, according to Mr Namarika, is people being left behind because of socioeconomic and structural disparities driven by power relationships, such as poverty, unemployment and gender inequality. He also believes that a location–population approach is needed to address vulnerabilities exacerbated by migration and natural disasters, such as the drought–flood cycle experienced by people located in the south-east of the country.

Another challenge in the national AIDS response is high new HIV infections among adolescent girls and young women between the ages of 15 and 24 years, who accounted for 9500 new infections in 2017—more than double that of their male counterparts (4000).

“Most young people cannot make ends meet. This puts girls most at risk—their rights can be easily trampled on by older men. Also, health-seeking behaviour among young men needs to be improved,” says Mr Namarika.

However, Mr Namarika believes that the biggest obstacle to progress in the AIDS response is complacency.

“When I was a young medical doctor on some days we would have 19 deaths just in the paediatric ward alone. Not in the whole hospital, just in that one ward. Now, the young doctors don’t see that anymore, so they don’t believe that HIV is real,” he says.

He believes that it is critical to continue to engage with communities on AIDS with the same urgency that there was in the early 2000s, so that the significant gains that the country has made are not lost.

“If the cost of AIDS is not regarded as one of the biggest historical disasters we have experienced in the 54 years of our independence, then we have lost our history,” he insists.

The way forward primarily is to continue financing the AIDS response and to put more emphasis on HIV prevention. This will require a growing domestic investment, as well as convincing development partners to put more external sources of funding into HIV prevention, he says.

Lesbian, Intersex, Transgender and other Extensions (LITE) started out in 2016 as a support group for lesbian, gay, bisexual, transgender and intersex (LGBTI) people in Lilongwe, Malawi. “There was so much commonality in the challenges facing lesbian, gay, bisexual, transgender and intersex people that this motivated me to form a nongovernmental organization addressing these issues,” says Lawrence Phiri Chipili, Executive Director of LITE, who is a transgender man.

Since its formation in 2016 and its formal registration in 2017, LITE has navigated its way into important national platforms, including the Malawi National AIDS Commission’s technical working group that guides the multisectoral AIDS response.

In May 2019, LITE, along with five other LGBTI organizations in Malawi, formed the Diversity Forum to collaborate on their common goal of ensuring that LGBTI rights are promoted, protected and respected in Malawi. LITE is also the Deputy Chair of the Southern Africa Trans Forum, which brings together 18 transgender organizations from the Southern African Development Community. In 2019, LITE and Mr Chipili were recognized by the Human Rights Campaign as one of their global innovators.

None of this recognition has come easy to the organization. Using his academic background in economics, Mr Chipili has pushed for evidence to support the organization’s advocacy.

“We decided as we were forming the organization that we needed a baseline understanding of what the needs of transgender people are in both the rural and urban areas of Malawi,” he says. “We didn’t want to base our assumptions on a small group of people living in Lilongwe. We conducted a needs assessment with communities and we realized the overarching challenges they have in accessing health-care services, education, employment, legal services and the enjoyment of safety and security.”

The research has helped the organization to design its advocacy strategy, which involves rendering transgender people’s issues visible in the public and policy space.

The organization also uses policy and the law to shape its advocacy. In 2015, the Malawian Government accepted that LGBTI people should have access to health and security. However, according to Mr Chipili, these recommendations are not implemented on the ground. Thus, using these recommendations as a basis, LITE designs its strategy to generate research so that it can strategically engage with the government.

No one knows more about these challenges better than Mr Chipili. He has been thrown out of home, school and university. His resilience and determination seem only to have grown stronger from his experiences.

“I risk my life; I risk the lives of people in my immediate circles, but these are problems that we experience in our everyday lives so we must speak about them. Hate speech towards my community pains my soul but it motivates me because people don’t understand the impact of their words. My mission is to work hand in hand with these people and help them to understand,” he says.

Mr Chipili acknowledges that while it has been a lone struggle by the LGBTI community to become more visible, the role of partners, including UNAIDS, has been critical. “UNAIDS has assisted us in understanding where our gaps are in our organizational policies and helping us to shape the direction in which we should go,” he says. “It has advocated for our inclusion in national platforms and helped us to strategically engage with the government, with the ethos of leaving no one behind firmly at the centre.”

The work has just started for Mr Chipili and his organization. “We need more technical support, human resources and financial resources. One of the major issues is transgender programming and funding globally is limited. A lot of resources are given to organizations that work with men who have sex with men and female sex workers,” he says. “Transgender people are usually invisible, yet we are the people who are experiencing so much hate and stigma, making us even more at risk of HIV infection,” he says.

Voluntary medical male circumcision (VMMC) remains the only one-time intervention for reducing the risk of HIV infection. The procedure provides lifelong partial protection against female-to-male HIV transmission and should be used as part of wider sexual and reproductive health service provision for boys and men.

Scaling up VMMC in combination with condom promotion, pre-exposure prophylaxis, HIV testing and prompt initiation of antiretroviral therapy can have a major impact on HIV epidemics in high-prevalence settings. In Malawi, more than 165 000 circumcisions were conducted in 2017, more than double the number conducted in 2014 and up from just 589 in 2008.

In 2016, the United Nations General Assembly set a target of voluntarily circumcising an additional 25 million men in high-incidence countries by 2020, or 5 million men per year.

“If I want to see the change, I need to be the change,” said Aniz Mitha, the Executive Director of Community Health Rights Advocacy (CHeRA), an organization that works with male sex workers in Malawi. When Mr Mitha speaks of change, he does so with the quiet and unwavering authority of someone who knows what he is talking about.

From a conservative Muslim family in Malawi, Mr Mitha was thrown out of the house at a young age when his parents found out that he was gay. With nowhere to go and no means to support himself, he fled to Johannesburg, South Africa, where he spent many years as a sex worker. “For me, I was looking to survive; I wasn’t thinking about my health,” he said.

When he became ill, he took an HIV test, and he learned that he was living with HIV. Being an illegal immigrant, he couldn’t access health-care services in South Africa. He returned to Malawi, where he began HIV treatment and started CHeRA. “I thought: how can I help others not go through the same experience that I did?” he said.

CHeRA raises awareness and builds the capacity of male sex workers on HIV prevention and treatment, sexual and reproductive health and rights, economic empowerment, psychosocial support and access to justice. Through a UNAIDS funding arrangement, it recently reached more than 250 male sex workers in three priority districts in Malawi, distributed more than 30 000 condoms and lubricant and linked six male sex workers living with HIV to care and treatment. In another programme funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria, the organization has trained 50 peer educators and distributed more than 6000 condoms and condom-compatible lubricant.

Mr Mitha is keenly aware of the many challenges that face male sex workers, having faced them himself. “In Malawi, sex work is not recognized as work, so there are no laws to protect sex workers. Also, most of our male sex workers are gay men or men who have sex with men, so they live in fear of arrest because homosexuality is illegal in Malawi,” he said.

Stigma and discrimination is institutional, he said. “Male sex workers are not recognized as a key population in the HIV response in Malawi, so we are not prioritized in government plans. And negative attitudes from health-care workers push us away from care.”

“Say I am being abused or beaten and I go to a police station,” continues Mr Mitha, “I will get questions like “Why you are dressed like this or why do you speak like this?” The abuse is institutionalized. It pushes us away, so even in terms of health care, we go to private hospitals where we pay money even if we don’t have money.”

CHeRA is now registered as a nongovernmental organization. Although started in 2016, it was only registered in 2017 after UNAIDS played a pivotal role in amending provisions in the Malawi HIV and AIDS Management Control Act of 2018 that criminalized or discriminated against certain groups, such as sex workers. This paved the way for organizations of lesbian, gay, bisexual, transgender and intersex people and sex workers to be registered.

Like many people who serve others, his work has spilled over into his private life. Knowing what it feels like to be disowned by one’s family, Mr Mitha gives shelter to people who have nowhere else to go, who stay as long as it takes until they can look after themselves.

He has built an unshakeable sense of self, family and community through his work and his life. “I am living openly with HIV and as a gay person; I am a role model to so many. They see that it is possible. I see a lot more people like me opening up and living openly as gay and with HIV,” he said.

Mr Mitha wants to grow CHeRA into an organization that is a strong advocate for equitable access to health care for male sex workers.

“We need more financial support to expand the work we do,” he said. “We provide access to HIV prevention information and services to a population that is being left behind. It is making a difference. When you are working as a community organization, it means what affects my community affects me too,” he said.

Isaac Ahemesah has been involved in the AIDS response for almost 25 years, the last 16 of which were spent working for UNAIDS in various positions across Africa. His most recent assignment has been as a Fast-Track Adviser in the UNAIDS Country Office in Malawi.

Mr Ahemesah’s interest in the AIDS response started in 1995, when he was studying social work at university in Ghana. As part of his studies, he was required to carry out field work at the local hospital, where there was a hospice for the many people dying from AIDS-related illnesses.

“At that time, there was no treatment for HIV. There was nothing for people living with HIV at all,” he says. “I didn’t know what I was getting myself into,” he continues. I just knew I needed to help.”

This was the beginning of his long involvement in the AIDS response. He started his professional career at the Catholic Relief Service as an HIV and AIDS Programme Officer and went on to join UNAIDS in 2003 in the UNAIDS Country Office in Ghana. Since then, he has held various positions, including Institutional Development Adviser, Human Rights, Gender and Community Mobilization Adviser in Liberia and currently Fast-Track Adviser in Malawi.

Having survived the terrorist attack on the United Nations complex in Abuja, Nigeria, in 2011 and the outbreak of Ebola in Liberia in 2013, Mr Ahemesah remains undeterred in his passion for a people-centred AIDS response.

“People living with HIV need their voices to be amplified in a way that affords them dignity and respect. Everyone needs access to HIV prevention, treatment, care and support services that are free from stigma and discrimination. We need to ensure that no one is left behind,” he continues. “UNAIDS provides me with an opportunity to turn these important principles into reality.”

Among the achievements he is most proud of during his time in Malawi is the advocacy work that he and his colleagues have been able to carry out with partners such as the United Nations Development Programme and civil society organizations. Together, they worked on the country’s HIV and AIDS Management and Control Act in 2018 to strike out or amend all provisions that criminalized people or discriminated against certain groups. This partnership ensured that the final legislation was consistent with international human rights standards and in line with model laws developed by the South African Development Community and Law Commission.

The new law has helped to create an enabling environment in which HIV services can be provided to everyone in Malawi, including lesbian, gay, bisexual, transgender and intersex people and female sex workers, who are at higher risk of acquiring HIV than the general population.

“The changes to the legal environment have allowed UNAIDS and its partners to work more openly and effectively with key populations such as sex workers and lesbian, gay, bisexual, transgender and intersex (LGBTI) people,” says Mr Ahemesah. “Six LGBTI community-led organizations are now officially registered, which means they can apply for funding, follow training opportunities and be run as fully functional organizations.”

Mr Ahemesah is happy that Malawi is making good progress towards reaching the AIDS targets, including the 90–90–90 targets. There are around 1 million people living with HIV in Malawi, of whom 90% know their HIV status. It is estimated that 71% of people living with HIV are now on treatment and that 61% of people living with HIV have suppressed viral loads.

Advances against HIV have contributed to an increase in the country’s life expectancy, from 46 years in 2000 to 64 years in 2018. Malawi was also the first country in Africa to adopt the Option B+ strategy, which ensures that pregnant women living with HIV have immediate and lifelong access to treatment to ensure that they stay healthy and that their children remain HIV-free.

During the 15 years he has spent working at UNAIDS, Mr Ahemesah has occupied many different roles. His experience will stand him in good stead as he prepares to leave Malawi later this year to take up his next assignment, as the UNAIDS Country Director in Sierra Leone, but it is his passion and commitment to improve the lives of people living with and affected by HIV that continue to be his most valuable attribute.