Witness the Reality

 

 

 

 

 

Report on the HIV/AIDS situation in Malawi and other developing countries

 

 

 

 

 

 

 

 

“Come and witness the reality of AIDS; see the devastation in our community; see the fresh graves; see the courage of those who live with the infection and of the children who have lost their parents. "

Nelson Mandela

 

INDEX 

PREFACE. 2

INTRODUCTION.. 2

GLOBAL OVERVIEW ON THE EPIDEMIC.. 3

Sub-Saharan Africa.. 4

MALAWI INSIDE OUT.. 4

Economic well-being.. 5

Agriculture. 5

Foreign investments. 5

Gross national product 5

Human development.. 5

Child and infant mortality. 5

Economically active population. 5

Energy. 5

Households. 5

Life expectancy. 6

Literacy. 6

Orphans. 6

Population. 6

Population density. 6

Sanitation. 6

Schooling. 6

Water. 6

Women rights. 6

Qualitative elements of development.. 6

OVERVIEW OF THE EPIDEMIC IN MALAWI 7

Past.. 7

Initial response. 7

1989-1993. 7

1993-1998. 7

Present.. 8

HIV prevalence. 8

Division by age and sex. 8

Health care. 8

Area division. 9

Future. 10

National HIV/AIDS Strategic Framework. 10

2000-2010. 10

THE IMPACT OF THE EPIDEMIC.. 11

Children.. 11

Communities. 11

Economic.. 11

Families. 12

Health care. 12

RESPONSE TO THE EPIDEMIC.. 12

Risk and risk reduction.. 13

Vulnerability and vulnerability reduction.. 13

Pathways to expand the response to HIV/AIDS. 13

VULNERABLE SEGMENTS OF POPULATION.. 14

Children.. 14

Mother-to-child transmission (MTCT). 14

Women.. 15

Men who have sex with men.. 16

Men in prison. 16

Sex Workers. 17

Drug Users. 17

RESOURCES ON THE INTERNET.. 17

REFERENCES.. 27

 

 

 

 

 

 

 

 

Witness the Reality

Report on the HIV/AIDS situation in

Malawi and other developing countries

Preface

 

In his monologue, Gray’s Anatomy , Spalding Gray is facing a deteriorating eyesight and potential blindness. He describes his initial reaction to the problem: “It was so terrifying that I had no choice but to ignore it.”

Since it first came to attention in the early 1980’s, acquired immunodeficiency syndrome  (AIDS ) has inspired much the same response.

Even though this deadly disease has been part of our lives for two decades now, the level of ignorance, misinformation, and disinterest we still hold about the human immunodeficiency virus  (HIV ) and the disease it leads to, is astonishing.

We cannot close our eyes anymore; we cannot ignore it - not cannot stand as a bystander anymore. In order us to help our next generations to have a life without the horrible presence of this disease our duty is to finally start putting all our efforts into the fight against HIV/AIDS.

This fight is not just for you to fight, we should join our hands and efforts to become strong, vital and energetic unit to be able to achieve our goals that we have set together.

The purpose of this report is not to give answers for everything; it is not an encyclopaedia of HIV/AIDS or a handbook what we should do. The purpose is to give a broad look at the current HIV/AIDS situation in Malawi and other developing countries in general and raise questions and ideas through the dilemmas that exist when analysing the situation.

I hope that this report would work as a guide and inspiration when you are considering engaging yourself in development work in Africa or anywhere else in the world.

Who else than us can take the necessary steps? It is we, who can show our support for those infected and affected by HIV/AIDS, raise awareness among the public, demonstrate respect and compassion and encourage other people to take steps to prevent HIV. We are here – we are in the forefront and therefore we should act like it.

This report was written after 6 months of development work in Malawi, Africa for Hope Humana People to People project affiliated to DAPP (Development Aid from People to People) in Malawi.

“Witness the Reality” was written by Development Instructor Kimmo Karsikas. The information in this report comes from variety of sources.

January 2001, Malawi.

 

Introduction

 

Two decades since the beginning of the HIV/AIDS epidemic, a dual gap continues to grow relentlessly between the rapid spread of the HIV epidemic and the limited prevention efforts as well as between the rising needs for care, support, and impact-alleviation and the insufficient response to these needs.

We have taken our first steps into the 20^th century and still, there is no cure in sight for this one of the most frightening and devastating diseases the world has known. We should acknowledge the fact that HIV/AIDS will be part of our lives for some time to come; it will continue to affect the lives of millions around the world including ourselves.

By the end of 1999, 33.6 million people were living with HIV/AIDS, including 13.8 million women and 1.2 million children.

95 per cent of those 33.6 million people living with HIV/AIDS were in the developing world. In many developing countries, the epidemic has come to represent a threat to human security itself. It is sparing no one; children, parents, teachers, health workers, farmers and other active members of society are each taking their share.

Globally, young people – those who must build the bridges, create national wealth and conduct the research of the future – experience half of all new HIV infections. In many parts of the world, AIDS is the single greatest threat to economic, social and human development.

In order, us to achieve results we have to make sure that the very basic structures of living are in order. Even now, discrimination is one of the most significant human rights abuses in the area of HIV/AIDS.

Even in countries where one adult in ten – or as many as one adult in four – is infected, a conspiracy of shame and silence surrounds AIDS. People who are openly HIV positive often suffer rejection and discrimination.

HIV positive people are being invisible in society because disclosing one’s infection carries a risk of deprivation of full civil and human rights. Social practices reproduce situations where the HIV positive individual copes best by keeping silent about his/her infection. Disguising one’s infection is not a sign of fear but a survival strategy; the HIV positive person has a reason to be concerned at how the environment will react.

The stigma surrounding AIDS makes our challenge special. Even though sharing the knowledge of one’s status with the community is hard, it is an effective way of teaching. Therefore, people living with HIV have a special role to play in helping society to acknowledge and tackle the epidemic. Through their experiences and lives, we have a change to understand the true face of this epidemic.

We should try to encourage and give our full support to those brave people struggling with their every day life to show an example and come to the front and say; “I am HIV positive, I am not ashamed and I am here to teach you”.

The easiest way we can do that is to share our knowledge, which is perhaps our greatest and cheapest weapon in the fight against HIV/AIDS and it can be shared free.

 

 

Global Overview on the Epidemic

 

 

The rate at which new HIV infections are growing and the pace at which HIV infection progresses to AIDS, have begun to slow down in certain populations in some parts of the world. This is happening at the same time as people adopt safer behaviour and prevention and care services are expanding. Particularly richer countries owe the change to the availability of antiretroviral therapies.

There is abundant evidence globally, that well-designed prevention programs and other successful public health measures can reduce and stabilize the epidemic. In societies where services and programs were already well equipped before the epidemic of HIV/AIDS, the creation of new initiatives and the re-orientation of others, led to a gradual decline in the incidence of HIV. We can observe a similar trend in certain sections of the population even in resource-constrained settings, at least partly because of rigorous prevention efforts.

Nevertheless, the dynamics of the epidemic differ strongly between countries due to virological, epidemiological and socio-cultural factors, with continuing low prevalence in some of the northern and western countries, stabilising epidemics in others and staggering increases in many countries in the south.

Like many developing countries, which are experiencing exponential growth of HIV/AIDS cases. At the same time global spending on HIV/AIDS care, research and prevention reflects this disparity – developing countries only receive about 12% of such resources despite having 95% of the cases. In addition, the resources allocated to combat the epidemic are grossly inadequate - AIDS is spreading three times faster than the funding to control it.

In addition, the still visible public fear of HIV/AIDS interferes with the efforts to fight HIV/AIDS. It further reinforces stigmatisation towards people who, for social, racial, behavioural or any other reasons, are alleged to be at higher risk of acquiring HIV infection. This stigmatisation can limit the access to appropriate HIV prevention, care and support for people who may be most in need.

5.6 million people were infected with HIV in 1999, which equates to over 15,000 people being infected every day. Nearly half these new cases were in young people under the age of 24 years.

Since the start of the epidemic, the cumulative number of deaths due to HIV/AIDS is 16.3 million. It has left behind a cumulative total of 11.2 million AIDS orphans.

More than 70 percent of HIV infections worldwide occur through sex between men and women, and a further 10 percent through sex between men. Another 5 percent or so take place among people who inject drugs.

The overwhelming majority of people with HIV – 23.3 million people – are living in the developing world.

 

Sub-Saharan Africa

 

Like the industrialized world, Africa is struggling with an epidemic that is now entering its third decade. However, while a few African countries have succeeded in stabilizing or reversing HIV infection rates, the epidemic is out of control especially in the southern part of the continent.

Socio-economic factors like poverty, illiteracy, gender inequality, increased mobility of population and rapid industrialization involving the movement of workers from villages to cities, are still contributing to the spread of HIV/AIDS.

Today, when there are more than 20 million Africans infected, the situation is almost catastrophic. The facts that there were over two million deaths due to AIDS during 1998, including nearly half a million deaths occurring among children and four million new infections last year, prove that the epidemic is an unprecedented crisis for the continent.

In the most severely affected countries, a quarter of the adult population is infected. Hard-won gains in life expectancy and child survival are being wiped out. The AIDS-related suffering of individuals, families, and societies is enormous. Education and health systems are staggering under the burden as they lose trained professionals and incur higher costs because of the epidemic.

In Africa, sex between men and women is the primary mean of HIV transmission although in almost every country, there are also at least a few cases resulting from sex between men. Transmission through the injection of intravenous drugs is growing rapidly in Southern Africa and this method of transmission is probably going to be relevant in other African countries as well. Where screening of blood used for transfusions is not efficient enough, transmissions through blood transfusions are still occurring.

Approximately two thirds of people infected are living in sub-Saharan Africa and half of them are women. The trend is that in sub-Saharan countries, more women than men are infected and worldwide, women are infected at a faster rate than men are.

In some countries in southern Africa, between 20-45% of pregnant women are HIV positive and one million children are living with HIV, while another twelve million have lost their mother or both parents. Life expectancy is dropping to levels not seen since 1960; hard-won gains in child survival are being reversed.

The burden of the health system is affecting the quality of life of people living with HIV/AIDS. Health care is often very poor as quality care; support to patients and their families are inadequate.

The epidemic is the greatest threat to Africa’s social and economical development, it has spread beyond all predictions. It is wiping out development gains achieved over many decades and is a threat to the well-being and to the national development of countries.

Response to this should come from inside Africa as well as outside Africa. If such a response, which should be more substantial than before, is mounted quickly, tens of millions of deaths can be averted. Governments, NGOs, local communities, the private sector and international development organizations should all be part of this response.

Plans are not enough; national awareness, commitment and mobilization should be raised to adequate levels. Successes should come often and on a bigger scale to reverse the epidemic. External support should be on a level where it belongs on a current situation and it should be given as soon as possible without further hesitation.

 

Malawi inside out

 

Malawi is among the world’s poorest countries, its Gross National Product per capita in 1995 was US$170. The depth of poverty and disparity in wealth distribution, are increasing and poor Malawians feel that they are getting poorer.

Malawi is also one of the most unequal countries. It is densely populated, with a very high rate of forest loss and a fragile environment. Economic prospects are poor. Women suffer continued discrimination, and children’s rights are inadequately protected. Educational attainment is low and poverty has been increasing over the past decades.

 

Economic well-being

 

In a poor country such as Malawi, HIV is an additional burden, which is a cause as much because of poverty. On the one had, families, businesses and communities are impoverished by the costs of widespread illness and death from AIDS. On the other hand, lack of money makes it more difficult to care for the ill, more difficult to mount effective education campaigns and more likely that some women will exchange sex for money, food or shelter. In the beginning of the new millennium, six out of every ten Malawians earns less than 60 Kwacha a day.

Agriculture

Malawi’s economy is dominated by agriculture, which is acutely vulnerable to drought. Agriculture contributes 90% of rural employment. In addition, income and assets in Malawi are very unequally distributes and 72% of households cultivate less than one hectare.

This, and the increased cost of inputs following the removal of subsidies, means that the majority of households have not benefited from the removal on controls on prices and the freedom to grow and sell their own choice of crops. They consume more than they produce and have to hire out their labour. Working for others means neglecting work on their own fields at critical times.

Malawi attracts little foreign private investment. This partly reflects its limited resource base, but rising crime, poor physical and financial infrastructure, and procedural delays are other inhibiting factors. Malawi will continue to face tough competition from its neighbours, better endowed with natural resources and cannot expect foreign investment to be a major force for early economic growth.

Growth in GDP has averaged 3% over 1992-1997. To prevent the number of poor people rising will require growth above 5% per annum for decades. Agriculture contributes 35% of GDP.

 

 

Human development

 

High mortality rate in Malawi is related to nutritional status, which is related to access to land.

Poverty is an important determinant of the nutritional status of children, which is deteriorating: 48% of children are stunted (chronically malnourished) and half of those severely so.

Nutrition is however, a complex issue, involving lack of basic health care or safe water, poor nutritional education, malaria, low female literacy, and the heavy demands on poor mothers’ time as well as inequitable land and income distribution.

Child and infant mortality

Child and infant mortality (at 133 per thousand the fifth highest in the world) remain appalling, largely because of preventable and treatable infectious diseases.

Economically active population

There were about 6.8 million persons aged 10 years or older. Of this total, around 4.5 million (66%) were economically active. Of the economically active population, the majority (78%) were subsistence farmers while 13 percent were employees.

Energy

94% of Malawians used firewood as their main source of energy for cooking and 90% of them used paraffin for lighting. Only 2% used electricity as a source of energy for cooking and 5 percent for lighting.

Households

Majority of households in Malawi were male headed. Of the 2.3 million households enumerated in the country about 69 percent were headed by males. Households headed by divorced and widowed women are over-represented amongst the poorest.

Life expectancy

Life expectancy, at 43 the third worst in the world, is declining again after progress in the early 1990s.

Literacy

8.3 million persons are aged 5 years or older. 4.8 million (58%) were able to read and write a particular language.

Literacy rate increased from 42% in 1987 to 58% in 1998. Literacy rates among males and females stood at 64 and 51 percent respectively as compared to 52 and 32 percent for males and females respectively in 1987.

Orphans

There were about 5.7 million persons aged 20 or less. Of these, about 5.1 million (90%) reported that both their parents were alive. Furthermore, about 147,000 (3%) reported that their mothers were not alive; 333,000 (6%) reported that their fathers were not alive and around 88,000 (2%) reported that both their parents were dead.

Population

There is a total population of 9,933,868 or about 9.9 million. There were 4.9 million males and 5.0 million females. Population is divided into regions as follows, Northern Region 1.2 million, Central Region 4.1 million and Southern Region 4.6 million.

Population density

Population density in 1998 was 105 persons per square kilometre. The population density in the Northern Region was 46, in Central Region 113 and in Southern Region 146.

Sanitation

Around 7.2 million (73%) of the total population had access to traditional pit latrines while 2.2 million (22%) had no access to any toilet facility.

Schooling

Of the total population aged 5 years or older, 2.7 million or about a third had never attended any school. Fewer girls than boys are in schools and it is reflecting to the literacy disparity.

Water

About 2.6 million (27%) had access to boreholes as their main source of drinking water while 2.5 million (25%) drew their drinking water from unprotected wells. A further 21 % used either piped water or communal standpipes as their main sources of drinking water.

Women rights

While the Constitution protects women’s position, women still suffer from discrimination under customary law, particularly over inheritance and domestic violence, and face steep obstacles in asserting their formal rights.

Women produce 70-80% of food consumed in Malawi and make up 52% of the population, but are under-represented in Parliament (5.6%), in decision-making positions or in the Civil Service.

 

Qualitative elements of development

 

Multi-party elections were held in 1994 with international scrutiny after which President Muluzi’s United Democratic Front formed a minority government.

Democracy remains fragile: political parties are regionally aligned, and society as a whole is still learning about the democratic process. As a result, effective accountability is limited.

A new and sound Constitution was adopted in 1994. Freedom of speech has become entrenched and the written media functions largely without government interference, though the broadcast media are still Government controlled.

Better governance is a prerequisite for faster development. There are grave weaknesses in capacity to deliver on government policies. AIDS is further depleting very limited human resources; non-salary budgets are acutely constrained; and low salaries have led to an “allowance culture”.

Corruption remains a concern for the Government. It is still common for Ministers and officials to retain outside business interests.

 

Overview of the Epidemic in Malawi

 

The HIV/AIDS epidemic in Malawi is among the most severe in Africa and in the world. Since 1985, when the first AIDS cases were identified, the levels of HIV infection have progressively escalated from 17 people in 1985 to 53,575 until June 1999.

The causative agent for AIDS in Malawi is mostly HIV-1. There is no evidence so far that HIV-2 exists in Malawi. However, efforts are made to monitor HIV-2 in blood donors, particularly because Malawi had an influx of refugees in the past few years from Mozambique, where HIV-2 is known to occur.

The major mode of HIV transmission in Malawi is heterosexual. Data on AIDS cases collected so far indicates that approximately 90% of cases are due to heterosexual transmission. About 8% of cases are estimated to be due to mother-to-child transmission. The role of blood transfusions and unclean needles etc. is difficult to determine. It may contribute to the remaining 2% of the cases. Other modes of transmission, like intravenous drug use, play a minimal role if at all in the transmission.

The impact of the epidemic in terms of illness and death is now being increasingly felt. AIDS is a major determinant of life expectancy in Malawi and is a major cause of death among those aged 15 to 49. This has and will continue to adversely affect capacity building in the social and economic sectors both public and private.

Most of the infected individuals do not yet know their status. The already high infection rates seem to continue growing in spite of the apparent high awareness of HIV/AIDS amongst the general population.

 

Past

 

Even though the first cases of AIDS were confirmed in 1985, it is believed that HIV infections may have started in the 1970s. Estimations of HIV prevalence were first made in 1985 at the Queen Elizabeth Central Hospital. Back then the prevalence in women was estimated at 2%. By 1993, the HIV prevalence in women attending antenatal clinic had increased by 30.2%. Since then however, the prevalence seems to have levelled off, and was 31.8% in 1994, 32.7% in 1995, 34% in 1996, 30.8% in 1997 and 30.4% in 1998.

The reasons for the apparent levelling off the prevalence are not clear. This could be due to increased AIDS specific mortality rate as the epidemic matures and/or be related to reductions in new infections.

The response that the government of Malawi had to the epidemic since the first cases of AIDS were confirmed in the country in 1985 was:

Initial response

A blood screening policy was implemented in two major referral hospitals. In addition, government came up with a Strategy of public education on HIV/AIDS.

1989-1993

The first Medium Term Plan (MTP I) was developed. It continued implementing the blood screening and public education policies. The counselling component, home-based care initiative, the involvement of the private sector and religious organisations commenced.

1993-1998

MTP II underlined multi-sectored approaches and incorporated social, psychological and economic dimensions in dealing with the consequences of the epidemic.

The institutional framework for HIV/AIDS and STD prevention became more complex, including the public and private sectors, the NGOs, donors, religious organisations and community based organisations that also included people living with HIV/AIDS.

An evaluation of MTP I and II established, among others, the following facts – that:

q       In spite of high awareness levels – over 90%, little behaviour change was evident in the population.

q       HIV incidence continued to increase unabated.

q       The National AIDS Control Programme (NACP) was still poorly established.

q       There was over dependence on the health sector for the national response.

These facts led to the establishment of the Strategic Planning Unit (SPU) in the National AIDS Control Programme (NACP). SPU’s directive was to develop a comprehensive national 5-year strategic plan that would guide HIV/AIDS prevention, care and mitigation programs and activities in the next plan period.

 

Present

 

Since the first confirmed AIDS case in 1985 to June 1999, a total of 53,575 cases have been reported. However, this is believed to represent only between 10-15% of the projected number of AIDS cases that may have occurred so far. The NACP estimates that currently about 1 million people may be carrying the HI-virus and close to 260,000 may have died of AIDS.

In 1999

q       760,000 Malawians were living with HIV/AIDS, that is one in six of those between 15 and 49 years old.

q       40,000 children were infected.

q       390,000 children have lost their mother or both parents to the disease since the beginning of the epidemic.

q       70,000 people died from the disease.

q       80,000 people were newly infected.

 

The impact of HIV/AIDS is made worse by the stigma associated with the disease. Today, more people with the virus are open about their condition, but stigma still exists, preventing adequate care reaching those who need it and appropriate prevention messages reaching those who need them. At the heart of the stigma of AIDS lies shame – the perception that those with the virus have done something wrong for which they and their families should be ashamed.

The HIV prevalence from the data collected from antenatal clinic attendees gives an estimate of HIV prevalence in adults of the reproductive age group only.

In 1998, conservative estimates set the HIV infection rates in the age group of 15 to 49 years old at around 14% nationally.

Using the HIV prevalence in the reproductive age group, the distribution of AIDS cases according to age group and the population distribution in various parts of Malawi, we get the national estimate of 8.0% for 1998.

Division by age and sex

Almost all the adult cases are the result of sexual transmission and almost all the children with the virus contracted it in the womb or from breast milk.

More women (420,000) than men (340,000) are HIV-positive. Women also tend to contract HIV at a younger age than men. One in five women with AIDS develops the disease before they are 25, but only one in twelve men develop AIDS at the same age.

Vulnerability in puberty is higher in younger women who tend to have sex with older male partners. The older male partners are at a higher risk of being HIV positive and therefore are likely to pass it on to the younger sex mates.

The HIV infection in people aged 15-49 is concentrated in younger age group so that 46% of all new adult infections in 1998 occurred in youth aged 15 to 24. 60% of those cases occurred in younger females, which is 4 to 6 times higher than the infection rate in their male counterparts.

The 1998 sentinel surveillance data indicated HIV prevalence of about 20.4% in antenatal women aged 15-24 years, though the infection rate differs from 10% in rural areas to nearly 30% in urban areas.

These high HIV infection rates in women of childbearing age indicate equally high or higher rates in the general population aged 15-49. Given that there is about 30% risk of mother-to-child transmission, the high infection rates of HIV in women of childbearing age suggest that many children are born HIV infected.

The majority of the population of Malawi is children aged 0-14 years. These account for about 47% of total population. According to estimates, only 1.2% of them are HIV positive. However, as they reach puberty and start engaging in sex, they become very vulnerable to HIV infection.

Health care

With an adult prevalence rate of around 14%, Malawi is typical of many resource-constrained African countries that have been severely affected by the epidemic. WHO has estimated, that fewer than half of Malawi’s residents have access to essential drugs of any kind.

The health care services are over-stretched particularly from the increasing number of HIV related diseases like tuberculosis. Cases of tuberculosis have been quadrupling over the past 10 years. There is also a rise in drug-resistant tuberculosis, which is difficult and expensive to cure.

Most of the opportunistic infections could be treated or prevented with relatively cheap drugs. However, in Malawi, even cheap drugs for opportunistic infections are not always available.

Antiretroviral drugs have prolonged life for many people with AIDS in richer countries, but they are too expensive for the vast majority of people living with HIV.

Traditional medicine practiced by a reputable healer can be very effective in relieving some of the symptoms of opportunistic infections, but, despite the fact some healers claim they have a cure for AIDS, no drug or herbal or other treatment cure the disease.

Health care expenditures in Malawi are believed to have risen by 50% since the epidemic began and people with HIV may occupy over 70% of the hospital beds in the country.

It can cost up to 50,000 Kwacha to take care of someone with AIDS – four year’s income for the average Malawian. Due to the lack of money in the public health service, individuals and their families meet most of the costs. When people cannot afford hospital user fees, they stay and die at home. There the responsibility for care usually falls on women, with men either unwilling to help or prevented from helping by women unwilling to share the burden.

Area division

The highest rate of HIV prevalence in Malawi is found in the Southern Region and after that come the Central Region and last the Northern Region. In Southern Region urbanisation, transportation and migration are greatest. Studies suggest education status, particularly among males, is positively associated with HIV status. Professionals, skilled workers (including teachers) and the armed forces have higher rates of HIV than farmers, villagers and housewives.

Another striking difference in HIV rates is the urban /rural difference. The HIV rates are much higher in urban as opposed to rural sites. However, because the majority of Malawians live in rural areas, the absolute number of HIV positive people is higher in rural compared to urban areas.

The virus is most widespread in urban cities: Lilongwe (L), Blantyre (B) and Mzuzu (M) and in some semi-urban areas especially along the lakeshore area. There at least one in four pregnant women is HIV-positive and similar numbers of men have the virus. In rural areas, about one in nine people have the virus.

 

Future

 

In the new millennium, Malawi will combat HIV/AIDS with renewed hope and vigour. The national response calls upon all Malawians to take responsibility for action against HIV/AIDS through their families, communities, civic organisations, places of work and their own individual efforts. Collective action by all Malawians is required if the scourge of HIV/AIDS is to be reduced and eliminated.

One of the best ways of combating denial is to give AIDS “a human face” through what is called the Greater Involvement of People living with HIV/AIDS (GIPA).

 

Malawi together with Zambia was the first country in the world to take part in a GIPA project started by UNAIDS and the United Nations Volunteers (UNV) that recruits openly HIV-positive people and places them within a host institution, which could be an NGO, a government department, or a private company.

 

In addition to performing regular jobs, their mission is to make HIV/AIDS visible through personal testimony and positive example – using sensitivity training, prevention campaigns, and workplace counselling to bring AIDS into the open and encourage an effective and humane response by governments and civil society.

 

For the future Malawi has a National HIV/AIDS Strategic Framework to guide the government itself and other institutions in HIV/AIDS prevention.

 

National HIV/AIDS Strategic Framework

 

The current National HIV/AIDS Strategic Framework is intended to stimulate an expanded, multi-sectoral response to the epidemic in Malawi during this plan period. It sets out guidelines, strategies, objectives and broad activities that need to be followed.

It provides a common national vision for interventions in the HIV/AIDS area. It ends up, complete, with broadly stated behavioural and performance indicators, that should guide implementers.

The overall goal of the Framework is to “Reduce incidence of HIV and other sexually transmitted infections and improve the quality of life of those infected and affected by HIV/AIDS”. The success of the framework depends on the commitment of all stakeholders, interest groups and the response of individuals, families, communities and institutions.

The Strategic Framework for the National Response to HIV/AIDS sets a common vision for all Malawians for dealing with the HIV/AIDS epidemic. It creates an opportunity for partnership among the people in Malawi in responding to HIV/AIDS. Individuals, communities and institutions must work together and complement each other in HIV prevention and mitigation efforts.

 

2000-2010

 

The HIV crisis will not go away in the near future, even if we take drastic steps. However, what we can do is to change the current course of the epidemic.

Recent projections from the National AIDS Control Programme indicate that if the current trends of the epidemic continue, the number of Malawians living with HIV is likely to increase to more than a million over the next year, unless we take timely and concerted actions.

The same projections also estimate that:

By the year 2010, 100,000 people will fall ill every year, the number of AIDS orphans has tripled, 2 million Malawians have contracted the virus and GDP will be 10% less.

 

  The Impact of the Epidemic

 

In a few years of accelerated spread, AIDS has become the leading cause of adult death in some developing countries, and may be the most important macro-economic and social determinant of human welfare and poverty.

In 1996, the Malawi Government, in conjunction with the World Bank, conducted an assessment study on HIV/AIDS. The study clearly indicated the magnitude and impact HIV/AIDS epidemic is having in terms of increased illness, deaths and orphan-hood. Projection was that the clinical burden of AIDS would be increasing noticeably through the next decade.

The extent of the impact of HIV/AIDS will be a function of who and how many people are infected and how quickly this happens. It will also be a function of existing socio-economic structures. Wherever dysfunctionality exists, it will become worse as the epidemic deepens.

For example, if the education and health systems are weak, they will become weaker. If professional capacity is limited, it will become even more reduced. There will be more institutions malfunctioning, more mistakes made, more breakdowns occurring.

Because HIV/AIDS is concentrated in prime-age adults who are usually at the peak of their economic productivity and are often heads of families, it has an immense impact on life expectancy, it exacerbates inequality and increases the burden on health systems.

Discrimination against individuals with HIV – an egregious violation of human rights – takes many forms, from losing one’s job to being chased out of one’s home or even beaten and murdered. Discrimination and stigmatisation also affect communities, hampering HIV prevention by driving the problem underground and blocking access to much-needed services. People with HIV who fear disclosure are reluctant or unable to access help – including health care for themselves and the information and tools needed for preventing transmission to others.

 

Children

 

Problems children face because of HIV/AIDS begin long before the death of a parent or a guardian. Children have to live with a sick parent and watch the parent deteriorate and eventually die. These children often face loss of family and identity and increased malnutrition.

When the person with AIDS is the breadwinner, their children may suffer extreme poverty and malnutrition. They lose schooling if there is no money to pay for uniforms or books, or because teachers are dying and not replaced. Girls are expected to stay at home if there is no one to do domestic chores, boys if they have to work in the fields or make money in other ways. If their mother or both parents die, relatives who do not have the means or the interest to take proper care of them may bring up children, or they may be forced to live on the streets.

Thousands of children become orphans because of AIDS. Without adequate care and support, many of these children will be marginalized, exposed to child labour and abuse and face increased risk of HIV. In addition, about one in three infants born to mothers with HIV infection are infected as well, which causes AIDS due to transmission of the virus from mother to child.

 

Communities

 

Despite the fact that HIV infection rates are highest in urban areas, the absolute numbers of people infected and affected with HIV and AIDS are largest in rural areas where the majority of Malawians live, depending on subsistence farming for survival. HIV/AIDS will continue to divert labour from farming to care provision thereby increasing food insecurity and threatening the survival of communities.

For every person who is infected with HIV or ill with AIDS, dozens more are affected as the virus enters their household, leaves them orphaned, or strips them of their teachers, workers, managers, or political leaders. Within a few short years, HIV can ravage entire communities and undo dozens of years of human progress.

 

Economic

 

HIV/AIDS is affecting all sectors of society. Government departments, private institutions and nongovernmental organizations are all experiencing loss of productivity and increased costs due to absenteeism, medical bills, funeral costs and payment of premature death benefits. In addition to all these, it is difficult to replace highly qualified and experienced workers. In short, HIV/AIDS threatens to wipe out the social and economic gains Malawi has made in recent years.    

According to a study initiated by USAID in 1996, between 1995 and 2005 AIDS will have led to a staggering 14.5% decrease in Kenya’s economic output. In other countries in sub-Saharan Africa, the impact of AIDS has been measured using a Human Development Index (HDI) that includes life expectancy and rates of literacy.

Because of AIDS, the HDI in Namibia is expected to decrease by 10% by 2006, and in South Africa, it is expected to drop by 15% by 2010. Losses of this magnitude stunt the lives of individuals and are certain to have a lasting economic impact on the development of entire nations.

Agriculture is and will be, in the near future, the backbone of Malawi’s economy. Being a labour-intensive system of agriculture, the HIV/AIDS epidemic therefore directly affects agricultural productivity and the livelihood of the majority of the country’s population.

 

Families

 

The socio-economic impacts begin as soon as a member of the household starts to suffer from HIV-related illnesses. Loss of income of the patient (who in most cases is the main breadwinner), household expenditures on medicines, treatments and other care and nutrition expenses which consume a large share of the family income increase substantially and other members of the household, usually daughters and wives, may miss school or work less to care for the sick person.

As families experience economic pressure to generate cash, they often sell possessions and by the time death occurs, the family is reduced to poverty or destitution. Removal of children from school in order to save on educational expenses and increase household labour follows, resulting in a severe loss of future earning potential.

When ultimately death results in: a permanent loss of income, from less labour on the farm or from lower remittances and funereal costs.

 

Health care

 

Even countries with relatively low HIV prevalence are experiencing or will experience significantly increased health care costs because of HIV/AIDS. In the public sector, health and other welfare system expenditures are increasing dramatically.

The number of people ill with HIV-related conditions, strain the health care systems of many nations to breaking point ill with HIV-related conditions. In Zimbabwe, 50% of hospital inpatients have symptoms of HIV/AIDS related illnesses. By 2005, AIDS treatment costs are expected to account for more than a third of Ethiopia’s government health budget, more than half of Kenya’s government health spending, and nearly two-thirds of government health spending in Zimbabwe.

Productivity in the various sectors is also being compromised by the replacement of experienced staff with inexperienced, poorly qualified ones. There is also a shift of costs and care responsibilities from health institutions to households. This has implications on access to various medical services and the quality of care and support provided.

Obtaining sufficient food, clean water, and HIV drugs is often a problem. Health services are poor, and communication between health workers and patients is minimal. Prescribed drugs are frequently unavailable or too costly, and poor stock management and record keeping means that even essential tuberculosis and anti-fungal drugs are frequently unavailable, as are basic prevention tools such as condoms. Health care facilities lacked clinical guidelines and an essential drugs list. Health workers are over burned and have little time to give to their patients.

Diseases, which were less common and more easily cured before HIV/AIDS, are suddenly re-emerging. One such disease is TB. The number of TB cases has grown from 5,000 in 1985 to over 20,000 at present. Many Malawians have latent TB infection, but because they have healthy immune systems, they are able to keep it in check. HIV weakens the immune system and many people who have latent TB infection develop active TB, which is the leading cause of death in Malawians with AIDS. In addition, persons with TB can infect others, both those who are HIV positive and those who are negative.

The strain that TB and other HIV related illnesses exert on the national health budget will grow enormously and will require attention to be paid to alternative approaches of management such as focusing on home based care and support.

 

 

Response to the Epidemic

 

Prevention, care, support and impact-alleviation activities, guided by research findings, are inseparable elements of a meaningful response to HIV/AIDS. The success of prevention depends in part on strengthening the capacities of communities and of the health, economic, educational, social welfare, political and other systems to meet the needs of those who live with HIV and AIDS and those affected by HIV/AIDS.

 

Risk and risk reduction

 

In the context of HIV, risk is defined as the probability that a person may acquire HIV infection. Certain behaviours create, enhance and perpetuate such risk, for example unprotected sex with a partner whose HIV status is unknown.

Risk arises from individuals engaging in risk-taking behaviour for a variety of reasons. They may lack information on HIV, they may be unable to negotiate safer sex, and they may think that HIV/AIDS affects a different social stratum than their own, or they may not have access to condoms.

The initial response to HIV has aimed mainly at reduction in risk-taking behaviour through targeting individuals and groups. Examples of such targeted interventions include the provision of information and education, the promotion of condoms, the prevention and early treatment of sexually transmitted diseases. It also includes needle and syringe exchange among drug-injecting populations, and programs to enhance women’s and young people’s capacity to demand their own protection when the balance of power between them and their sexual partners is not in their favour. These strategies have also aimed at increasing the safety of medical procedures, including blood transfusion in the health-care setting.

Successes in HIV prevention using the risk-reduction approach have been documented over the past few years. These include programs that focus on condom promotion, voluntary counselling and testing services, provision of information, needle and syringe exchange programs, provision of STD diagnostic and treatment services, and prevention of mother-to-child transmission.

In order to have a significant impact on the epidemic, risk-reduction interventions must be rigorously designed according to the best practises and adapted to local needs; they need to gather and share evidence of what makes them work and how.

 

Vulnerability and vulnerability reduction

 

The approach to HIV/AIDS, however, has broadened over the recent years to focus not only on individual risk-taking behaviour, but also on the immediate environmental and societal factors that influence such behaviour, and the influence exercised  by families and communities on individual behaviour. Overarching the concept of risk and risk-taking behaviour is thus the broader concept of vulnerability and vulnerability of certain individuals and sections of society more than others are.

In the context of HIV/AIDS, vulnerability is influenced by the interaction of a range of factors including:

                                                   I.      Personal factors; sexual history, availability of knowledge and skills and access to them.

                                                 II.      Factors pertaining to the quality and coverage of services and programs aimed at prevention, care, social support and impact-alleviation. Including cultural inappropriateness of HIV/AIDS programs, the inaccessibility of such services due to distance, cost and other factors and the lack of capacity of health systems to response to a growing demand for care and support for people with HIV/AIDS and those affected.

                                               III.      Societal factors; cultural norms, laws or social practises and beliefs that act as barriers to essential prevention messages.

In combination, these factors may create or exacerbate individual vulnerability and as a result, collective vulnerability to HIV/AIDS.

The other dimension of expanding the response that complements risk-reduction efforts is the reduction of vulnerability. Such efforts need to be focused first within both HIV/AIDS-specific and other health-related programs.

Secondly, they need to be implemented within other sectors in order to bring about a multi-sectoral approach towards harnessing the comparative advantages of these sectors where efforts will influence the spread of HIV.

The latter approach of engaging sectors and partners not specific to HIV/AIDS is not entirely new to many countries. However, until now, with the exception of some countries like Zambia, Uganda and Thailand, to name a few prominent examples, such a broadened response has received neither adequate attention nor resources.

 

Pathways to expand the response to HIV/AIDS

 

Expanding the response to HIV/AIDS may follow several routes. Few communities or nations will need to expand their response to HIV/AIDS in all these ways at the same time. Yet moving along only one of the pathways to the neglect of others will not be adequate for real expansion of the response. The need to prioritise and focus action remains critical in this effort. Over-arching these pathways are the following principles:

q       Analysing the factors that enhance vulnerability in order to develop a focused national strategy

q       Expansion of the quality and scope of HIV/AIDS strategies through identifying, promoting and applying best practice in short-term and long-term risk-reduction strategies, actions, and taking them to scale

q       Enhancing the response to include those strategies that address vulnerability through short-term and long-term measures

q       Expanding coverage by geographically and by population

q       Focusing action by directing HIV resources in the first place to those who are most vulnerable to HIV infection

q       Expanding partnerships in the design, implementation and evaluation of HIV/AIDS related policies and programs

q       Involving all relevant sectors

q       Increasing resources mobilized in support of HIV/AIDS prevention and care by mobilizing and making optimal use of available and diverse human, institutional and financial resources.

q       Enhancement of sustainability of HIV/AIDS programs over time by strengthening local self-reliance in the design and implementation of short-term and medium- or long-term initiatives.

 

 

Vulnerable segments of population

 

Children

 

So far, the AIDS epidemic has claimed the lives of nearly 3 million children, and another 1 million are living with HIV today. Worldwide, one out of ten who became newly infected in 1998 were a child. Though Africa accounts for only 10% of the world’s population, to date around nine out of ten of all HIV-infected babies have been born in that region, largely because of high fertility rates combined with very high infection rates.

The child can be infected either before or during birth, but there is also a risk of transmission through breastfeeding – a natural practice that has long been promoted as a major way of enhancing child survival.

In some countries in southern Africa, between 20-45% of pregnant women is HIV positive with MTCT transmission of the virus during the pre- and post-natal periods reaching 30%.

The effects of the epidemic among young children are serious and far-reaching. AIDS threatens to reverse years of steady progress in child survival, and has already doubled infant mortality in the worst affected countries.

Mother-to-child transmission

 

Each year, more than 600 000 infants become infected by HIV/AIDS, mainly in developing countries. Since the beginning of the HIV epidemic, an estimated 5.1 million children worldwide have been infected with HIV. Mother to child transmission is responsible for more than 90% of these infections. Two-thirds are believed to occur during pregnancy and delivery, and about one-third through breastfeeding. As the number of women of childbearing age infected by HIV rises, so does the number of infected children.

Until recently, countries had only two main strategies for limiting the numbers of HIV-infected infants:

q       Primary prevention of MTCT – taking steps to protect women of childbearing age from becoming infected with HIV in the first place.

q       The provision of family planning services and pregnancy termination where it is legal should be enabled in order women to avoid unwanted births.

Today, however, there is a third option for HIV-positive women who want to give a birth which consists of a course of antiretroviral drugs for the mother and replacement feeding for the infant.

Introducing a strategy of antiretroviral drug use and replacement feeding is, however, a complex process. To take advantage of the intervention, mothers need to know that they are HIV-positive, and they must therefore have access to voluntary counselling and testing.

Measures to reduce MTCT of HIV, especially the administration of antiretroviral drugs and avoidance of breastfeeding, make it virtually impossible for HIV-positive women to keep their infection a secret from their families and people in the wider community. It is therefore essential to the safety and acceptability of MTCT interventions that effective steps be taken to combat rejection of people with HIV/AIDS.

The issue of replacement feeding is a complex one. Promotion of breastfeeding as the best possible nutrition for infants has been the cornerstone of child health and survival strategies for the past two decades, and has played a major part in lowering infant mortality in many parts of the world. It remains the best option for the great majority of infants, and in providing for replacement feeding as part of the strategy to reduce MTCT of HIV, policy-makers need to take into account the risks of undermining breastfeeding generally, and of relaxing vital controls on the promotion of infant formula by the industry.

The affordability of antiretroviral drugs and replacement feeding will depend a great deal on the condition of the health infrastructure within a country or district, and how much strengthening or expansion of services is needed before the strategy can be introduced.

Access to ARV therapy in general is minimal and costly for the average Malawian.  ARVs are available at QECH at the cost of K10,000 per month for dual therapy Zidovudine and Lamivudine. ARVs purchased at private hospitals and pharmacies are more expensive ranging from 40,000-60,000 per month.

In general, the following steps should be taken in order to reduce mother-to-child transmission:

q       Prevent HIV infection in women of childbearing age.

The best way to prevent HIV transmission through breastfeeding is to prevent women from becoming infected in the first place.

q       Develop and promote voluntary and confidential counselling and HIV testing services, which are committed to informed consent and protection of confidentiality.

A policy on infant feeding and HIV that is based on meeting the needs of individual mothers and infants requires that women know their HIV status. Improving access to counselling and testing for all women and their partners in antenatal care, family planning and all other appropriate points in the health service is necessary in order to implement interventions to reduce MTCT, such as infant feeding options and antiretroviral drug treatment.

q       Strengthen antenatal care services and encourage increased attendance

So that they can provide information about prevention of HIV infection, HIV counselling and testing, offer interventions to reduce MTCT, and refer HIV-positive women for infant feeding counselling, follow-up care and social support if needed. These should be provided in addition to the basic minimum package of antenatal care. There few women receive antenatal care; a priority will be to increase attendance.

 

Women

 

Gender inequality harms women’s health and prevents many women from participating fully in society. Unequal power relations between men and women often limit women’s control over sexual activity and their ability to protect themselves against unwanted pregnancy and sexually transmitted diseases, including HIV/AIDS.

 

Reproductive health programs can reduce levels of STDs, including HIV/AIDS.  Reduction can happen through providing information and counselling on critical issues such as sexuality, gender roles, power imbalances between women and men, gender-based violence and its link to HIV transmission, and mother-to-child transmission of HIV; distributing female and male condoms; diagnosing and treating STDs; developing strategies for contact tracing; and referring people infected with HIV for further services.

 

Primary prevention of HIV infection in women:

q       Educate the public about how to avoid HIV infection. It must not be forgotten that the source of the woman’s infection is usually her male partner and father of the child.

q       Develop policies and programs to reduce girls and women’s vulnerability to HIV infection, especially their social and economic vulnerability, through improving their status in society.

q       Target specifically the adolescent population for education about safe and responsible sexual behaviour.

q       Ensure that couples have access to condoms so that they can act on their knowledge of safer sex.

q       Provide information on MTCT, the importance of avoiding infection, and the advisability of practising safe sex during pregnancy and after giving birth as part of routine health education for men and women. Cultural and social factors which condone risky male sexual behaviours during the woman’s pregnancy and the early days following childbirth need to be addressed in Information, Education and Communication (IEC) programs.

q       Provide timely diagnosis and appropriate care for sexually transmitted diseases (STDs) including treatment for sexual partners, since STDs increase the risk of HIV transmission.

q       Ensure that medical and surgical procedures such as injections and operations are performed with properly sterilised instruments, and ensure safe blood transfusion services including screening of blood transfusion.

 

Men who have sex with men

 

Some countries deny the existence of taboo homosexual practices or claim that they are a Western construct or import, despite studies finding evidence of the extent of men having sex with men.

This type of transmission is frequently difficult to address also because, in many countries, men who have sex with men do not view themselves as non-heterosexual and, because of social stigmatisation, may not wish to be identified to others as such.

 

Men in prison

 

Inmates are a vulnerable group for HIV infection all over the world. Worldwide studies by UNAIDS indicate that there are high rates of HIV in prisons. There are several factors, which put inmates at risk of HIV infection. Sexual contact is one of the prominent factors in African prisons since intravenous drugs are not very common. Although sex between men is illegal in several African countries, it nevertheless takes places in prison.

Non-existence of female presence in cells, boredom due to lack of recreation, overcrowding in cells and sexual tension due to long sentences are seen as reasons why inmates indulge in sex between men.

Sex between men exists both consensual and coerced. Overcrowding in the prisons has led to a situation where juveniles live with adult inmates. These juveniles are victims of both forms of sex between men. In consensual homosexuality some older inmates who have adequate necessities like soap, sugar, salt etc lure juveniles lacking the same into sex between men by providing them with the necessities.

Coerced sex between men is not so common but it usually happens where juveniles live with adult inmates.  Some “chamba” (marijuana) smokers have strong sexual desires and threaten the juveniles to have sex with them.

As a solution to this problem, both the members of the staff and the inmates see that older prisoners should be separated from juveniles to reduce sexual contact between them. In addition, condoms should be promoted and distributed although there were mixed feelings about providing condoms.

Other said that sex between men is illegal and providing condoms would be like sanctioning the practise. Others said that even though sex between men is illegal it nevertheless takes place without singling out culprits hence condoms would assist in preventing HIV transmission for such people.

Also training of inmates as AIDS educators and isolation of HIV positive inmates were given as solutions. In addition, if inmates are provided with adequate food, groceries and there would be recreational facilities available it would lead to decreasing of sex between men in prisons.

 

“Prisoners are the community. They come from the community, they return to it. Protection of prisoners is protection of our communities.”

UNAIDS

 

Services for prisoners as a captive population should be equivalent to the education, treatment, care and support received by the general population. This means providing access to HIV-related prevention information, education, particularly ongoing peer programs, voluntary (including anonymous) testing and counselling, and the actual means to implement them (condoms, dental dams, water-based lubricants and bleach). 

Addressing homosexuality needs both policy formulation and administrative understanding. AIDS interventions could provide information on risks involved in indulging in such practices. Condom provision in Malawi Prisons is a sensitive issue, which needs immediate policy considerations considering the high rate of sex between men taking place in the prisons.

 

Sex Workers

 

Studies among sex workers and bar girls – women who live and work at the bar – show a rapid rise in HIV prevalence, reaching about 86% in 1994. Baseline behavioural data show sex workers as mainly single mothers. The majority of the women are between 20-29 years and are highly mobile.

Criminal law in the area of prostitution impedes the provision of HIV/AIDS prevention and care by driving people engaged in the industry underground. Such laws should be reviewed with the aim to decriminalize sex work where no victimization is involved, and regulate occupational health and safety conditions to protect sex workers and their clients.

Most prostitution laws are founded on nineteenth century notions of morality and were ineffective then, as now, in suppressing the industry while there continues to be a demand-driven market. By treating sex work as a personal service industry which is neither condemned nor condoned, public health objectives are much more likely to be achieved than under the criminal law.

There are many successful programs and projects for making sex work safe through improving conditions and/or diverting people away from the sex industry. Economic development programs can assist sex workers or potential workers by giving them additional sources of income, so that they are in better position to choose safes sex, improve opportunities, and/or have fewer clients. Alternative income-generation schemes can also enable women to leave or be diverted from the industry.

 

Drug Users

 

Transmission through injecting drug use so has mainly been a problem either in developed countries or in some developing countries mainly in Asia and Latin America. There is mainly two reasons for the strong existence of intravenous drugs: a strong market for drugs or a historical/cultural background for injecting drug using.

So far injecting drug using has not been a large problem nor has it existed on a larger scale in Africa. Nevertheless, recent statistics show that intravenous drug using is growing rapidly in South Africa. In addition, sub-Saharan Africa might be in danger in the future, when the economic situation gradually gets better.

Countries, which have a harm-reduction approach, tend to have avoided the high incidence of HIV among injecting drug users in some other countries. This approach aims to educate users about the need for safe injecting behaviour, and facilitate safe behaviour by providing easy access to clean injecting equipment.

Evaluations of such programs have shown that they have not encouraged greater use of drugs, but in fact have increased demand for drug treatment, decreased the number of unsafely disposed of used equipment, and helped contain the HIV/AIDS epidemic.

 

 

Resources on the Internet

 

ABIA-Brazil

http://www.alternex.com.br/~abia

Action for AIDS Singapore

http://www.afa.org.sg/afa.htm

AIDES Di Indonesia

http://www.rad.net.id/aids

AIDS Action League

http://www.aidsactionleague.org

AIDS Infoshare Russia

http://solar.rtd.utk.edu/ccsi/nisorgs/russwest/moscow/aidsinfo.htm

AIDS Net Austria

http://www.aidshilfe.or.at

AIDS Organisation of Iceland

http://www.centrum.is/aids

AIDS Survival Project

http://www.atl.mindspring.com/~asp

AIDS Treatment News

http://galen.library.ucsf.edu/sc/ahp/atn.html

AIDS Vaccine Advocacy Coalition

http://www.avac.org

AIDS Virtual Library

http://planetq.com/aidsvl/index.html

Albergues de México I.A.P. – Private Institutions for the Assistance of AIDS-HIV Patients

http://www.agora.stm.it/albergues/alber_en.htm

American Foundation for AIDS Research (AmFAR)

http://www.amfar.com

Body – AIDS and HIV Information Resource

http://www.thebody.com

Body Positive – Living Positively with HIV

http://www.bodypositive.org.uk

Brazilian AIDS and STD Programme

http://www.aids.gov.br

Center for AIDS Prevention Studies

http://www.caps.ucsf.edu

Centers for Disease Control and Prevention Division of HIV/AIDS Prevention

http://www.cdc.gov/nchstp/hiv_aids

Clinical Care Options for HIV

http://www.healthcg.com/hiv

Coalition des organismes communautaires québécois de lutte contre le Sida

http://pages.infinit.net/cocqsida

Denmark AIDS Information System

http://aids-info.dk

Deutsche AIDS-Hilfe

http://www.aidshilfe.de

Finnish AIDS Council

http://www.aidscouncil.fi

Finnish Body Positive Association

http://www.positiiviset.fi

Harvard AIDS Institute

http://www.hsph.harvard.edu/organizations/hai

HIV/AIDS in Zambia

www.zamnet.zm/zamnet/health/aids/aidszam.htm

HIV/AIDS Treatment Information Service

http://hivatis.org

HIV Coalition

http://www.hivco.org

HIV-Nieuws-Amsterdam

http://www.xs4all.nl/~tjerk

International Association of Physicians in AIDS Care

http://www.iapac.org

International Council of AIDS Service Organizations

http://web.net/~icaso/icaso.html

Johns Hopkins University AIDS Service

http://www.hopkins-aids.edu

Journal of the American Medical Association HIV Information Center

http://www.ama-assn.org/special/hiv/hivhome.htm

Managing Desire (information on safe sex, testing and counselling, etc.)

http://www.managingdesire.org

Mexican Government Page on AIDS

http://cenids.ssa.gob.mx

Mother’s Voices: United to End AIDS

http://www.mvoices.org

National Association of People with AIDS

http://www.napwa.org

National Institutes of Health Division on AIDS

http://www.niaid.nih.gov/research/daids.htm

National Minority AIDS Council

http://www.nmac.org

New Zealand AIDS Foundation

http://nz.com/NZ/Queer/NZAP

POZ Magazine (information on living with HIV)

http://www.thebody.com/poz/pozix.html

SEA-AIDS in Thailand

http://www.inet.co.th/org/unaids

SIDA en México

http://jeff.dca.udg.mx/sida/sida.html

SIDAnet

http://www.sidanet.asso.fr/home2.htm

Straight Talk in Uganda

http://www.swiftuganda.com/~strtalk

Swedish Association for HIV Positive People

http://home2.swipnet.se/~w-27414

The Terrence Higgins Trust

http://www.tht.org.uk

Treatment Action Group

http://www.aidsnyc.org/tag

UC San Francisco AIDS Research Institute

http://hivinsite.ucsf.edu/ari/ev.html

University of Zambia Medical Library

http://www.medguide.org.zm

UNAIDS in China

http://www.unchina.org/unaids

UNAIDS in Namibia

http://www.un.na/unaids

UNAIDS – Joint United Nations Programme on HIV/AIDS

http://www.unaids.org

UNAPRO

http://www.redkbs.com/unapro

United Nations Children’s Fund

http://www.unicef.org

United Nation Development Programme

http://www.undp.org

United Nations Population Fund

http://www.unfpa.org

United Nations International Drug Control Programme

http://www.undcp.org

United Nations Educational, Scientific and Cultural Organization

http://www.unesco.org

World Health Organization

http://www.who.org

World Bank

http://www.worldbank.org