Malawi's ability to control the spread of HIV will be undermined by the structural barriers that prevent access to services by key populations: this was the message delivered to stakeholders participating in country dialogue to develop the southern African nation's HIV concept note.
Malawi is one of the countries targeted by the Global Fund under the new funding model (NFM) seeking to drive a greater share of resources to those countries with the highest burdens of disease. With some $475 million allocated until 2017, the country should continue to provide anti-retroviral therapy to some 420,000 people annually, while also expanding prevention, treatment and care options for others.
Civil society is keen to ensure that those 'others' are drawn from all populations -- especially key populations of MSM, commercial sex workers and miners -- with services and activities specifically tailored to their particular needs.
For now, getting representatives of key populations to even be present for the policy- and decision-making discussions, is the first hurdle.
"We have seen increased involvement by key populations in developing our national strategic plan (NSP) for HIV," said Gift Trapence, executive director of the Centre for the Development of People (CEDEP) and a newly elected member of the country coordinating mechanism (CCM).
But the progress on the policy side has not been matched by similar strides on the legislation side.
Sodomy laws remain on the books in Malawi: one of 34 countries in sub-Saharan Africa to continue to enforce anti-gay legislation. By keeping these laws active and enforceable, the country imperils any progress being made to control HIV, according to Trapence. In driving men who have sex with men (MSM) underground, these laws will ultimately contribute to spreading the epidemic, not curbing it.
"The laws reinforce discrimination and stigma," Trapence told Aidspan. "Some health workers think that they cannot condone something which is illegal -- and this also affects service providers who offer friendly services, like the distribution of condoms and lubricants. We need the policies and the laws to be harmonized, since they do not speak to each other."
Another hurdle comes with the data challenges confronting Malawi, including the lack of population-level data disaggregated by sex. According to Trapence, data collected has failed to count MSM, transgendered people or sex workers, meaning that there is no clear estimate about the population size. This has fuelled some push-back against efforts to focus the NSP on key populations; those opposed say that the numbers are too insignificant to warrant special attention.
The Global Fund's own push to disaggregate data comes at a critical moment for Malawi, said Trapence, which is beginning to develop its own set of health indicators, supported by a nationally representative sample size. These data will be the foundation of the NSP and will drive the HIV concept note, which should be submitted in October.
"We have an opportunity to have indicators that will be reported annually for key populations; what we need now is programs to reach them," he said, including prevention activities that respond to both the human rights challenges facing key populations and the structural barriers preventing them from accessing services.
"We cannot talk about the 'three zeros' -- zero deaths, zero infection and zero discrimination -- if we leave some groups behind when they have high HIV prevalence rates," he said. "We must see comprehensive programs targeting key populations in the concept note being submitted in October".