According to the World Health Organisation (WHO), the impact of HIV has been enormous in Malawi(WHO 2011). The human immunodeficiency virus (HIV) is a retrovirus that infects cells of the immune system, destroying or impairing their function. As the infection progresses, the immune system becomes weaker, and the person becomes more susceptible to infections. HIV is transmitted through unprotected sexual intercourse (anal or vaginal), transfusion of contaminated blood, sharing of contaminated needles, and between a mother and her infant during pregnancy, childbirth and breastfeeding (WHO 2011). Despite recent developments in the preventative and treatment methods for HIV, the number of people living with the virus continues to grow. HIV-related illness is the leading cause of death in Malawi, where the average life expectancy in the country is just 43 years. According to Theatre for a Change, HIV affects all sectors of the Malawian population, but has a much more severe impact on some groups than on others:
· HIV prevalence is highest among sex workers, at nearly 71%.
· Female police officers have the second-highest HIV prevalence, at over 32%.
· The third-highest prevalence is amongst male primary school teachers, at just over 24%.
· Currently there is an HIV prevalence rate of 17% in urban areas of Malawi, and almost 11% in rural ones
· In 2009, there were 120,000 children living with HIV.
· 65% of people living with HIV in Malawi are aged between 13 and 24.
Malawi ranks 153rd out of 169 countries on the United Nations Human Development Index. It scores particularly poorly on nutrition and food security, education, health provision, and gender equality. Two thirds of the population of 14.2 million live below the national poverty line, and 51% of the government budget comes from donor aid (Human Development Reports 2011). There is also a severe shortage of medical staff in Malawi, with only two doctors to every 100,000 people – one of the worst doctor-patient ratios in the world (NationMaster.com 2011). This is largely due to the ‘brain drain’, whereby Malawians with the highest levels of education, and particularly medical qualifications, tend to leave to work in the United Kingdom and other Western countries where they receive better wages.
Another challenge is presented by gender inequality. 60% of adults living with HIV in Malawi are women, and prevalence amongst women aged 15–24 is around 9%, compared with 2% amongst men of the same age (AVERT 2009). According to the WHO, male-to-female HIV transmission during sex is about twice as likely to occur as female-to-male transmission because women are physically more susceptible to HIV infection due to fact that they have a greater anatomical exposure to the virus (WHO 2011). A women’s social and economic inferiority is a further contributing factor in this disparity due to the fact of their lower social status means that most are unable to negotiate for safer sex practices (Theatre for a Change 2011). In an article for The Guardian newspaper in the United Kingdom, Dr Tariq Meguid, an obstetrician who works in the hospitals of Lilongwe, argues that the shockingly low status of women is at the heart of the HIV epidemic. He says, ‘In the end there is little doubt that women die in Africa because they are poor – really, really poor – and voiceless. They say absolutely nothing. It is a huge, huge scandal’ (Boseley 2008). Most women are taught to believe that they do not have the right to say 'no' to sex with their husbands, and nearly one in five women 15–19 year old, report that force or coercion was used against them in their first experience of sexual contact. In a survey of trainer- teachers, it was found that over 30% of participants believed that men should be in complete control of all sexual activity, while nearly 90% of female participants claimed they were unable to reject men's sexual advances in workshop improvisations (Stevenson 2009:16). Also, some communities in Malawi practice ‘wife inheritance’, where a widow is married to a relative of her husband after his death. This increases the risk of HIV transmission, especially in cases where the death of the widow’s husband was caused by HIV. The practice in some rural communities, of non-sterile female genital mutilation also contributes to transmission. There is a lot of stigma against people infected with HIV in Malawi, and there are prevalent negative opinions about sex workers, and any people, particularly women, who have multiple sex partners or who have sex outside of marriage. For example, a survey of training teachers found that over 80% believe that sex outside of marriage is immoral, and 54% believe that immorality was a key factor in HIV infection, with nearly 85% demonstrating stigmatising behaviours towards people living with HIV in workshop improvisations (Stevenson 2009: 15). A 2003 qualitative research study into Malawian cultural factors that affect positive living amongst those living with HIV found that sarcasm and back-biting were prevalent, and that this often caused HIV-positive people to isolate themselves from their communities (Jana 2003).
Because homosexuality is illegal in Malawi, drawing a prison sentence of up to 14 years, statistics for HIV prevalence amongst men having sex with men are likely to be inaccurate; however, a 2009 estimate suggests a prevalence rate of 21.4% (USAID 2009: 1). As well as the risk of legal repercussions, widespread cultural homophobia in Malawi makes it yet more difficult for men having sex with men to access information, treatment, and resources. As a result of these stigmas, most people living with HIV in Malawi are reluctant to make their status known. Treatment and prevention resources are underused; many people are unwilling to find out their HIV status because of the risk of persecution and potential prosecution and, because HIV-positive people usually keep their status a secret, it is difficult for support groups and home care organisations to reach them. People are unlikely to discuss HIV with their families, and some support groups are unable to meet openly (AEGiS 2004).