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Background. The HIV and AIDS epidemic in Malawi poses multiple challenges from an equity perspective. It is estimated that 12% of Malawians are living with HIV or AIDS among the 15-49 age group. This paper synthesises available information to bring an equity lens on Counselling and Testing (CT) and Antiretroviral Therapy (ART) policy, practice and provision in Malawi. Methods. A synthesis of a wide range of published and unpublished reports and studies using a variety of methodological approaches was undertaken. The analysis and recommendations were developed, through consultation with key stakeholders in Malawi. Findings. At the policy level Malawi is unique in having an equity in access to ART policy, and equity considerations are also included in key CT documents. The number of people accessing CT has increased considerably from 149,540 in 2002 to 482,364 in 2005. There is urban bias in provision of CT and more women than men access CT. ART has been provided free since June 2004 and scale up of ART provision is gathering pace. By end December 2006, there were 85,168 patients who had ever started on ART in both the public and private health sector, 39% of the patients were male while 61% were female. The majority of patients were adults, and 7% were children, aged 14 years or below. Despite free ART services, patients, especially poor rural patients face significant barriers in access and adherence to services. There are missed opportunities in strengthening integration between CT and ART and TB, Sexually Transmitted Infections (STI) and maternal health services. Conclusion. To promote equitable access for CT and ART in Malawi there is need to further invest in human resources for health, and seize opportunities to integrate CT and ART services with tuberculosis, sexually transmitted infections and maternal health services. This should not only promote access to services but also ensure that resources available for CT and ART strengthen rather than undermine the provision of the essential health package in Malawi. Ongoing equity analysis of services is important in analyzing which groups are unrepresented in services and developing initiatives to address these. Creative models of decentralization, whilst maintaining quality of services are needed to further enhance access of poor rural women, men, girls and boys.
A meeting was first held with the research team which agreed on the key priority areas to be considered in the data collation and analysis and identified the available sources of information. A search for published and unpublished literature and programme and monitoring reports was undertaken. Collation and analysis of pre-existing information and indicators from different Malawian stakeholders, such as the Ministry of Health (MoH), National AIDS Commission (NAC), and within Research for Equity and Community Health (REACH) Trust, and some key providers of CT and ART was undertaken. There is a growing number of published and unpublished reports on CT and ART in and from Malawi produced by different organizations such as MoH, Non-governmental Organisations (NGO) and research groups. We did not have a strict inclusion and exclusion criteria in selection and collation of reports, but included all those that contained information that could illuminate the debate on equity and CT and ART. We contacted authors for clarification in cases where data was unclear or hard to interpret. The following box highlights some of the key challenges we faced in equity analysis of HIV prevalence, CT and ART data. i. It was difficult to use the prevalence rates estimated by the National AIDS Commission as they do not include children or people over 49 years. ii. Most data on ART access does not include detailed information on access by socio-economic groups, poverty status, or age (with the exception of adult or child classification). iii. The CT data is not disaggregated by age and data disaggregated by sex is only available for some of the client groups. Informal key informant interviews were conducted with key stakeholders from the Ministry of Health and the National AIDS Commission to supplement and triangulate the literature and data collected. The analysis and recommendations were discussed with key stakeholders from the Ministry of Health and the Department for International Development (DFID), Malawi. The data was supplemented by insights and quotations from a qualitative research project conducted by REACH Trust in Thyolo district which was aimed at exploring factors that influence access and adherence to ART. These insights are used to help explain and contextualize some of the findings. The study employed in-depth interviews and focus group discussions with patients on ART and those who had dropped out from ART.
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