Immediate Risks and Disruptions

A full resumption of HIV services is required for the effective delivery of HIV prevention services. HIV services are dependent, and different parts of the U.S. Government fund different components —for example, the Centers for Disease Control and Prevention funds HIV treatment - which received a partial waiver to continue - and USAID funds the supply chain. Partners funded by USAID received stop work orders, halting the flow of essential HIV treatment commodities and impacting the delivery of HIV treatment and prevention services. Partial waivers block the delivery of services.

The country has 37,000 vials of cabotegravir long acting injectables expiring in May 2026. A further 30,000 vials purchased under the Global Fund to Fight AIDS, Tuberculosis and Malaria will arrive in Malawi in June 2025 to support the scale-up of injectable PrEP.  To absorb the gap in the program created by U.S. funding cuts to the partner supporting this activity, the government has instructed the remaining implementer to continue with the scaling up of injectable PrEP focusing on people continuing PrEP and only recruit new pregnant and lactating women. However, the absence of implementing partners and the limit to recruit only continuing clients and pregnant and lactating women may not generate sufficient the client load risking the long acting injectables expiring. A resumption of the program to recruit on the full spectrum of eligible people into the program is required.

1. Human Resources:
   • Contract Terminations: More than 4,500 staff including 247 nurses, 1,642 Health Diagnostic Assistants, 1,871 treatment supporters, data clerks and others supported by U.S. funding have had their contracts terminated.  The exact numbers of staff impacted are difficult to quantify because of the stop-and -resume flow of human resources based on the stop-resume-stop implementation of the waivers.
   • Reduced Capacity: Although the government of Malawi has rationalized the continuation of services and deployed staff to fill the gaps created by the stop order and waiver, HIV services are yet to recover fully. Facilities providing prevention of vertical transmission of HIV, early infant diagnosis (EID), pediatric and adult HIV treatment services are operating at reduced capacity.  Community-led monitoring and other activities led by civil society have reduced. Only community-led activities supported by the GFATM are continuing, helping fill the gap in the availability of HIV services
   • Outreach Services: Outreach services, especially those targeting key populations, adolescent girls and young women, refugees and displaced people, have been affected, impacting prevention and treatment services and may lead to increased antiretroviral therapy default rates and new HIV infection.
2. Service Provision:
   • Facility Closures: Some facilities providing Antiretroviral Therapy (ART), especially the 18 drop-in centers serving more than 7,000 key populations living with HIV have reduced their operations and referred the people to to other facilities. Crowds of patients waiting for services typical of non-HIV services are now common in the HIV treatment section.
   • Testing Services: DNA-PCR testing for HIV Exposed Infants (HEI) will continue only at sites with point-of-care testing capacity. Other infants will be tested at 12 and 24 months using Rapid Diagnostic Tests (RDT).
   • Targeted viral load sample testing will take place in sites with point-of-care capacity. new HIV infections, with poor EID service, new HIV infections among children are likely to increase.
   • Supply chain and sample Transportation: The sample transportation system has been suspended. Although the government redeployed ambulances to transport samples, hundreds of thousands of samples remain stuck and unusable, A million HIV test kits risk expiring, without a revitalized HIV testing drive using local staff. Although implementing partners leading work on voluntary medical male circumcision (VMMC) received partial waivers to continue VMMC. Without a full resumption of the program, the VMMC faces an imminent stop in a month because the supplies are limited.
3. Commodity Stock Levels:
   • ARV Supplies: Stocks of antiretroviral (ARV) supplies, HIV, viral load (VL) and other lab test kits, and condoms are available with minimum disruption. However, dispensing of ARV emergency supplies has been suspended to avoid panic refills and depleting stocks.
   • Condom Stock Levels: Sufficient for the next 12 months, but non-facility condom programming has stopped.
4. Impact on Specific Populations:
   • Adolescent Girls and Young Women (AGYW): Reduced capacity for HIV prevention services, including PrEP, testing, and outreach programs. Malawi has 2,341,000 AGYW of which 2.4% are living with HIV. 25% of new HIV infections are among AGYW. Programs for orphans and vulnerable children have completely stopped and are not included the prioritization of HIV services.  
   • Key Populations (KPs): HIV prevention services for KPs have also been impacted. This includes continuation of provision of oral PrEP where human resources are available, and continuation of only old clients on injectable PrEP. Discontinuation of hepatitis B testing except in antenatal care and inpatient care. The Government with implementing partners support 18 Drop-in Centers spread across in Blantyre, Mangochi, Muzuzu and Lilongwe are devising a plan to keep the dropping centres. The centres cater to key populations with a total cohort of 7,600 people living with HIV accessing HIV treatment and 7,000 continuing PrEP. 

Politically Relevant Updates

1. Government Actions:
   • Task Team: A country-level task team has been convened to discuss the impact on service delivery and identify mitigation measures. This includes representatives from people living with HIV and key population networks.
   • Mitigation actions by government and country partners include expanded community health worker or peer-led health services and integration of HIV services into other health services.
   • Transitional Plan: The government is developing a plan for HIV commodities warehousing and distribution to transition from the current service provider to the Central Medical Stores Trust.
2. Civil Society Impact:
   • Community-Led Organizations (CLOs): CLOs are at risk of closure or severe reduction in services due to funding cuts. This affects their ability to deliver services, advocate for key issues, and participate in policy discussions.