Draft /8rh
August, 2003
DRAFT
Draft 18°i August, 2003
Abbreviations and Acronyms ................................................................................................. iii
Chapter 1: Introduction .......................................................................................................... 1
1.1 Background
......................................................................................................... 1
1.2 The
Context ....................................................................................................... 2
1.3 Goal
and Objectives ............................................................................................ 3
1.4 Preamble
............................................................................................................ 3
1.5 Guiding
Principles ............................................................................................... 4
Chapter 2: Strengthening and
Sustaining a Comprehensive Multi-Sectoral Response to
HIV/AIDS
......................................................................................................................... 6
Chapter 3: Promotion of HIV/AIDS Prevention, Treatment, Care, Support,
and Impact Mitigation 7
3.1 Prevention
.......................................................................................................... 7
3.1.1 Information, Education and Communication (IEC)
for Behaviour Change.................. 7
3.1.2 HIV
Testing ................................................................................................. 8
3.1.3 Condoms for HIV Prevention .............................................................................. 11
3.1.4 Prevention of Mother to Child (Vertical)
Transmission .......................................... 11
3.1.5 Treatment
of STIs ....................................................................................... 12
3.1.6 Blood
and Tissue Safety .............................................................................. 12
3.1.7 Universal
Precautions .................................................................................. 13
3.1.8 Clean
Injecting Materials and Skin-Piercing Instruments ................................ 13
3.1.9 Post-Exposure
Prophylaxis (PEP) ................................................................ 13
3.2 Treatment,
Care and Support ............................................................................. 14
Chapter 4: Protection, Participation and Empowerment
of People Living With HIV/AIDS. 16
Chapter
5: Protection, Participation and Empowerment of Vulnerable Populations 17
5.1 Women
and Girls ............................................................................................... 17
5.2 Orphans
........................................................................................................... 18
5.3 Widows
and Widowers ...................................................................................... 18
5.4 Children
and Young People ................................................................................ 18
5.5 The
Poor .......................................................................................................... 19
5.6 People
Engaged in Transactional Sex ................................................................. 19
5.7 Prisoners
.......................................................................................................... 20
5.8 Mobile
Populations ............................................................................................ 20
5.9 Persons
Engaged in Same-Sex Sexual Relations ................................................. 20
5.10 People with Disabilities .......................................................................................... 20
Chapter 6: Traditional and Religious Practice s/Services....................................................... 21
6.1 Customary
Practices ......................................................................................... 21
6.2 Traditional
Healers and Traditional Birth Attendants ............................................ 22
6.3 Religious
Practices/Services ............................................................................... 22
Chapter 7: Responding to HIV/AIDS in the Workplace ....................................................... 23
Chapter 8: Establishing and Sustaining a National
HIV/AIDS Research Agenda ................... 25
Chapter 9: Monitoring and
Evaluation ................................................................................. 26
Abbreviations
and Acronyms
AIDS Acquired Immune Deficiency Syndrome
ART antiretroviral therapy
ARV antiretroviral
CBO community-based organisation
CHBC community home-based care
FBO faith-based organisation
HAART Highly
Active Antiretroviral therapy
HBC Home-Based
Care
HIPC Highly Indebted Poor Countries
HIV Human Immunodeficiency Virus
IEC information, education, and
communication
M&E monitoring and evaluation
MCH maternal and child health
MOHP Ministry of Health and Population
NAC National AIDS Commission
NGO nongovernmental organisation
OI opportunistic infection
PEP post-exposure
prophylaxis
PLWAs people
living with HIV/AIDS
PMAPB Pharmacy,
Medicines, and Poisons Board
PMTCT prevention
of mother-to-child transmission
PRSP Poverty
Reduction Strategy Paper
STI sexually transmitted infection
TBA traditional birth attendant
UNDP United
Nations Development Programme
UNAIDS Joint
United Nations Programme on HIV/AIDS
UNHCR United
Nations High Commission on Refugees
VCT voluntary
counselling and testing
Chapter 1: Introduction
1.1 Background
HIV/AIDS has become a major
worldwide pandemic.
According
to the Joint United Nations Programme on HIV/AIDS (UNAIDS), the pandemic has
particularly affected sub-Saharan Africa, where, by the year 2001, more than
28.5 million people were infected, representing close to 70% of the total
number of HIV-positive people. More than 80% of HIV-infected women and 90% of
orphaned children live in sub-Saharan
The
impact of this HIV/AIDS epidemic has been felt by all sectors of Malawian
society, especially the social services sectors. For example, in the health
sector the maternal mortality rate has at least doubled, partly due to the
HIV/AIDS epidemic. HIV/AIDS patients occupy more than 50% of medical ward beds
and more than 70% of pulmonary tuberculosis patients also have HIV infection.
In the education and agricultural sectors, teachers and extension workers,
respectively, are dying at a faster rate than they can be trained. The large
numbers of orphaned children being cared for by elderly people and young
siblings has worsened the poverty status of many homes.
2001 sentinel surveillance report.
2 2001 sentinel surveillance report. 3 2001
sentinel surveillance report.
HIV/AIDS
that are resourced to the extent possible from national budgets, without
excluding other sources such as international cooperation; (2) confront stigma,
silence and denial; (3) address gender and age-based dimensions of the
epidemic; (4) eliminate discrimination and marginalisation; (5) strengthen
partnerships with civil society and the business sector; (6) encourage the full
participation of people living with HIV/AIDS, those in vulnerable groups, and
people most at risk, particularly women and young people; (7) fully promote and
protect all human rights and fundamental freedoms, including the right to the
highest attainable standard of physical and mental health; (8) integrate a
gender perspective; (9) address risk, vulnerability, prevention, care,
treatment and support, and reduction of the impact of the epidemic; and (10)
strengthen health, education, and legal system capacity.
1.2 The Context
The
key development challenges of
Government
has made poverty reduction its major goal. It has established a Poverty
Alleviation Programme and developed a Poverty Reduction Strategy Paper (PRSP).
Government is being supported in this respect by its donor partners and through
the use of funds from programmes such as the Highly Indebted Poor Countries
(HIPC).
The
population of
HIV/AIDS presents a major challenge to the individual
and collective well-being and human security of people in
4 1998 National Census
1.3 Goal and Objectives
The
goal of this policy is to prevent HIV infections; to reduce vulnerability to
HIV; to improve the provision of treatment, care, and support for people living
with HIV/AIDS; and to mitigate the socio-economic impact of HIV/AIDS on
individuals, families, communities and the nation.
The objectives are to:
·
Prevent HIV
infections;
·
Improve delivery
of prevention, treatment, care and support services;
·
Mitigate the
impact of HIV/AIDS on individuals, the family and communities;
·
Reduce individual
and societal vulnerability to HIV/AIDS through the creation of an
·
Strengthen the
multi-sectoral and multi-disciplinary institutional framework for coordination
and implementation of HIV/AIDS programmes in the country.
1.4
Preamble
The Government and people of
the
·
HIV/AIDS has
reached epidemic proportions;
·
HIV/AIDS is a
public health issue as it directly affects the health of large numbers of
people in society and reduces the overall health status and well-being of the
nation;
·
HIV/AIDS has an
adverse impact on families and communities;
·
An effective
response to HIV/AIDS requires respect for, protection of, and fulfilment of all
human rights-civil, political, economic, social and cultural-and the upholding
of the fundamental freedoms of all people, in accordance with the Constitution
of Malawi and existing international human rights principles, norms and
standards;
·
All people are
guaranteed freedom from discrimination on grounds of race, colour, sex,
language, religion, political or other opinion, nationality, ethnic or social
origin, disability, property, birth or other status including HIV/AIDS status,
in accordance with the provisions of the Constitution of Malawi and existing
international human rights principles, norms and standards; and
·
Prevention,
treatment, care, support and impact mitigation are mutually reinforcing
elements and a continuum of an effective response to HIV/AIDS.
Moreover, we recognize that
social, political and economic conditions create and sustain vulnerability to
the risk of HIV infection, including:
·
The unequal
position of girls and women in society and the fact that, due to biological,
social, cultural and economic factors women are more likely to become infected
and can be more adversely affected by HIV/AIDS than men; and
·
The reality that
people living with HIV/AIDS are discriminated against and marginalised, leading
to a lack of individual and collective well-being, development, and human
security.
Further,
we recognize that culture and religion have a strong influence on lifestyle and
choices.
Thus we hereby commit to:
·
Advancing a
public-health-based response that integrates principles of prevention,
treatment, care and support;
·
Promoting and
protecting human rights in accordance with the Constitution and international
human rights instruments to which Malawi has committed to effectively address
the social, political and economic factors that both increase vulnerability to
HIV infection and negatively affect the lives of people living with HIV/AIDS;
·
Applying
resources maximally and responsibly, including financial, technical, and human
resources, as well as infrastructure and community contributions-in kind, cash,
and time;
·
Ensuring that
decision making and delivery of this policy is transparent and accountable;
·
Ensuring timely
and sustained action;
·
Implementing a
multi-sectoral response where resources are harmonised for maximum impact; and
·
Ensuring that the
resources and programmes of Government and partners are equitably distributed
to all parts of Malawi.
1.5 Guiding Principles
This policy shall be guided,
governed by, and based on the following principles.
·
Political
Leadership and Commitment
Strong political leadership
and commitment at all levels is essential for a sustained and effective
response to HIV/AIDS.
·
Multi-sectoral
Approach and Partnerships
An
effective response to HIV/AIDS requires the active involvement of all sectors
of society. Thus, a multi-sectoral approach is required that includes
partnerships, consultations, and coordination with all stakeholders,
particularly people living with HIV/AIDS (PLWAs), in the design,
implementation, review, monitoring and evaluation of the national response to
HIV/AIDS.
·
Public Health
Approach
A
public health approach reduces the risk of transmission through intense mass
education regarding modes of transmission and risk-reduction methods,
widespread and vigorous use of barrier methods, antibody testing, beneficial
disclosure or partner notification, prevention of mother-to-child transmission
(PMTCT) services, and medical treatment and management of infected individuals.
·
Promotion and
Protection of Human Rights
International
human rights law and the Constitution of Malawi guarantee the right to equal
protection before the law and freedom from discrimination on grounds, singly or
in combination, of race, colour, sex, language, religion, political or other
opinion, nationality, ethnic or social origin, disability, property, birth or
other status. Discrimination on any of these grounds not only is wrong in
itself but also creates and sustains conditions leading to vulnerability to HIV
infection and to receiving inadequate treatment, care and support once
infected.
Groups
suffering from discrimination which makes them vulnerable in the context of
HIV/AIDS include women and young girls, orphans, widows and widowers, children
and young people, the poor, sex workers, prisoners, mobile populations, persons
engaged in same-sex relationships and people with disabilities.
An
effective response to the epidemic requires that the rights to equality before
the law and freedom from discrimination are respected, protected and
fulfilled-in particular, in gender relations between women and men and between
girls and boys.
The Greater Involvement of
People Living with HIV/AIDS
The greater involvement of
people living with HIV/AIDS at all levels is crucial for an effective response
to HIV/AIDS.
Good Governance,
Transparency and Accountability
An
effective national response to the epidemic requires Government to provide
leadership in effectively mobilising resources, including but not limited to
financial resources, as well as prudent management of resources at all levels
and in all sectors; and good governance, transparency and accountability.
Scientific and
Evidence-Based Research
It is essential that the national response to HIV/AIDS
be based on sound, current, and evidence-based research. As aspects of the
epidemic change from time to time and as scientific, medical and programmatic
knowledge of the epidemic progresses, our understanding of the HIV/AIDS
epidemic and how best to respond to it continually evolves. This may
necessitate changes in Malawi's response to the epidemic.
Chapter 2: Strengthening and Sustaining a
Comprehensive Multi-Sectoral Response to HIV/AIDS
Rationale
Due
to the multi-faceted nature of the HIV/AIDS epidemic, an effective
institutional framework for the national HIV/AIDS response requires a
multi-sectoral approach, which includes partnerships between Government and all
relevant stakeholders, including the private sector, community-based and
nongovernmental organisations (CBOs and NGOs), trade unions, faith-based
organisations (FBOs) and people living with HIV/AIDS. To be effective, there is
a need for proper coordination, management, monitoring and evaluation of all
HIV/AIDS interventions.
The
National AIDS Commission (NAC) shall play key roles of coordination, monitoring
and evaluation. Government, through the Office of the President and Cabinet,
shall take leadership in the mobilisation of adequate local and international
resources for an effective response to the epidemic.
Policy Statements
·
Government shall
ensure effective participation of all sectors of society in the design,
implementation,
monitoring and evaluation of the national response to HIV/AIDS.
·
Government shall,
in particular, ensure the effective participation of people living with
HIV/AIDS,
women, and vulnerable groups in the national response.
·
Government and
partners shall mobilise, allocate and manage both local and international
resources
to ensure an effective and efficient national response.
·
Government shall
allocate resources amounting to at least 2% of the national budget for
HIV/AIDS
activities.
·
Government
ministries, departments, and district and city assemblies shall provide
resources
amounting to at least 2% of their budgets for HIV/AIDS activities.
·
Government shall
finance the operations of the Board and Secretariat of NAC.
·
Government shall
ensure that each sector formulates and implements sector-specific
HIV/AIDS
policies and that there is effective co-ordination between the sectors in a
multi-sectoral
national response to HIV/AIDS.
·
Government and
partners shall ensure the mainstreaming of HIV/AIDS into all relevant policies,
plans and programmes.
·
Government and
partners shall establish and maintain accountability and transparency to each
other in the fulfilment of mandates.
·
NAC shall be
responsible for advising Government on HIV/AIDS issues based on best practices,
taking into account local circumstances.
·
NAC shall
coordinate, monitor and evaluate ongoing and planned interventions in a timely
manner to ensure the attainment of the goals and objectives of the National
Strategic Framework.
·
NAC shall
facilitate the provision of technical expertise to all partners involved in the
multi-sectoral response.
·
Government shall
ensure that private sector organisations and NGOs are encouraged and where
necessary provided with financial, material and technical support to
effectively participate in HIV/AIDS activities.
·
Government shall
promote the roles of HIV/AIDS support organisations in providing voluntary
services.
Chapter 3: Promotion of HIVIAIDS Prevention,
Treatment, Care, Support, and Impact Mitigation
Rationale
Prevention, treatment, care, support and impact
mitigation are all mutually reinforcing elements of a continuum of an effective
response to HIV/AIDS. HIV prevention strategies include the provision of
information and education, condoms, lubricants, sterile injection equipment,
voluntary counselling and testing (VCT), antiretroviral medicines (e.g., to
prevent mother-to-child transmission or as post-exposure prophylaxis) and, once
developed, safe and effective microbicides and vaccines. Comprehensive
treatment, care and support include the provision of antiretroviral and other
medicines; diagnostics and related technologies for the care of HIV/AIDS,
related opportunistic infections, and other conditions; good nutrition; social,
spiritual and psychological support; and family, community, and home-based
care. Impact mitigation strategies include the evaluation of the economic and
social impact of the HIV/AIDS epidemic and the development of multi-sectoral
strategies to address the impact at the individual, family, community and
national levels.
3.1 Prevention
3.1.1 Information, Education and Communication
(IEC) for Behaviour Change Rationale
To
tackle the HIV/AIDS epidemic, people must have the ability to adopt
risk-reducing behaviour and also be able to utilise existing opportunities to
cope with HIV infection and AIDS. Targeted information delivered within a
culturally sensitive context can help to increase awareness and knowledge and
to overcome the stigma, discrimination, myths, beliefs and prejudices
associated with HIV/AIDS and sexuality. Mass media, supported by interpersonal
communication, are vital channels to reach out to the largest number of people
with accurate, targeted and relevant messages.
However,
adopting and sustaining new behaviour requires not only access to information
and knowledge but also motivation and support to change attitudes, a forum to
practice the new behaviour, and an enabling environment in which this new
behaviour can take place.
Policy Statements
·
Government and
partners shall support the development of adequate, accessible, sound and
effective HIV/AIDS information and education programmes by and for vulnerable
populations and shall actively involve such populations in the design and
implementation of these programmes.
·
Government and
partners shall ensure that behavioural change interventions are guided by
evidence-based needs of the target populations and existing evidence on
potential opportunities and barriers to behavioural change.
• Government and partners shall ensure that behaviour change interventions emphasise and aim at a progressive transition from general awareness to knowlege of one's serostatus and, ultimately, to knowing how to protect oneself and others.
·
Government shall
integrate and promote HIV/AIDS information and education and lifeskills
education at all levels of formal and non-formal education.
·
Government and
partners shall support programmes that strengthen the role of parents and
guardians in shaping positive attitudes and behaviour of children and young
people with regard to sexuality and gender roles in the context of
HIV/AIDS/STIs.
·
Government and
partners shall ensure the greater involvement of PLWAs in the design and
implementation of HIV/AIDS information and education programmes, as well as
activities aimed at influencing behaviour change.
·
Government and
partners shall promote abstinence and/or mutual faithfulness among sexual
partners.
3.1.2 HIV Testing
3.1.2.1 Voluntary HIV Counselling and Testing Rationale
VCT
is an essential component in the continuum of prevention, treatment, care and
support for persons living with HIV/AIDS. Through pre- and post-test
counselling carried out in a supportive environment, a person undergoing
voluntary HIV counseling and testing is motivated for positive behaviour
change. It provides an opportunity for a person to ascertain HIV status, and if
infected with HIV, to prevent transmission to others as well as reinfection. It
also offers an opportunity to access care and support programmes, including
prophylaxis and treatment of opportunistic infections, access to antiretroviral
therapy (ART) and access to PMTCT programmes.
To
be effective, VCT services must be of good quality, accessible, affordable, and
confidential. Utilisation can be improved when VCT services are organised to
take into consideration the special needs of men, women, girls and boys as well
as the social status of clients. Since young people between the ages of 13 and
24 are particularly vulnerable to HIV infection, it is crucial that VCT
services be designed to accommodate the special needs of young people (girls
and boys) and other vulnerable groups, and be widely available. Observations in
Malawi and elsewhere have shown that same-day-results VCT services attract high
utilisation.
Policy Statements
·
Government shall
promote and provide high-quality, cost-effective, confidential and
accessible
VCT services to reach the largest number of people.
·
Government shall
ensure that:
·
VCT shall only be
carried out with the informed consent of the person seeking testing, who is
provided with adequate information about the nature of an HIV test, including
the
potential consequences of a positive or negative result, in order to take an
informed decision as to whether or not to undertake the test.
·
Children of the age of 13 or over shall be entitled to access VCT
without the consent of a guardian or other adult.
·
VCT shall be
anonymous except where referral to other HIV/AIDS-related services is mutually
agreed upon between the VCT provider and the person seeking testing.
·
The results of
any HIV test shall not be disclosed to a third party without the consent of the
person seeking testing, except as may be provided in this Policy.
·
VCT service
providers shall not provide written test results to persons seeking testing
except with the consent of such person for referral to other HIV/AIDS-related
services.
·
Government and
its partners shall promote and encourage couple counselling and partner
disclosure of HIV test results.
·
Government shall
ensure that VCT services are available countrywide, including in rural
areas,
and that they are staffed by an adequate number of trained counsellors.
·
Government,
through NAC, shall coordinate and ensure that linkages exist between VCT
services
and other HIV/AIDS-related services to provide a continuum of prevention,
treatment,
care, support, and impact mitigation.
3.1.2.2 Diagnostic Testing Rationale
Experience
has shown that persons fearing infection with HIV have difficulty making an
informed decision to have an HIV test. The fact that a patient presents
voluntarily with a health problem allows the assumption that he or she would be
grateful to be guided by a qualified health care worker in diagnosis and
management. In such instances and where HIV infection is suspected, HIV testing
should be part of the diagnostic process. As with all tests, the patient has
the right to "opt out" and refuse the test.
Policy Statement
·
Government shall
ensure that HIV testing for diagnostic purposes is available in all health
facilities, with the right for the client to opt out.
·
Government shall
ensure that adequate facilities and staff for HIV diagnostic testing are
available in all hospitals and clinics.
·
Government shall
permit testing, without consent, for diagnosis of an unconscious patient in the
absence of a parent or guardian, where the same is necessary for purposes of
optimal treatment.
3.1.2.3 Routine Testing Rationale
Routine testing is necessary for tracking HIV/AIDS,
informing the nation on the progression of the the epidemic, and ensuring the
safety of blood and blood products. Routine testing is vital for prevention of
HIV transmission from mother to child.
Policy Statement
·
Government shall
permit HIV testing without consent in the following circumstances:
·
Sample screening
of pregnant women through anonymous unlinked testing for surveillance; and
·
Testing of blood,
body fluids and other body tissues for transfusion and transplants.
·
Government shall ensure that all pregnant
women attending antenatal clinics are offered HIV testing with appropriate
information and the right to opt out of the test.
3.1.2.4 National Security Forces Rationale
For
national security reasons, the Army, Police, Prisons and Immigration shall be
permitted to carry out HIV testing as part of their pre-recruitment and
periodic general medical assessment for fitness.
Policy Statement
·
HIV testing shall
be permitted in the Army, Police, Prisons and Immigration as part of a broader
assessment of fitness for work.
3.1.2.5 Beneficial Disclosure Rationale
Given
that refusal to notify sexual partners of one's positive serostatus can result
in the onward transmission of HIV, HIV post-test counselling programmes should
involve strong and professional efforts to encourage, persuade and support
HIV-positive persons to notify their partners. In exceptional cases whereby a
properly counselled HIV-positive person refuses to disclose his or her status
to sexual partners, the health care provider will be able to notify those
partners without the consent of the source client. This beneficial disclosure
shall be subject to appropriate and explicit guidelines to be developed by
Government in accordance with UNAIDS' and the United Nations High Commission on
Refugees' (UNHCR's) HIV and Human Rights: International Guidelines.
Policy Statements
·
Government and
partners shall:
·
Promote voluntary
disclosure by a person living with HIV/AIDS of his or her HIV status to his or
her sexual partner;
·
Ensure that
voluntary disclosure of HIV status by the infected person to his or her
sexual
partner is explained and encouraged during counselling; and
·
Ensure that
professional and lay counsellors are trained on how to recommend and
assist
people living with HIV in how best to disclose their HIV status to their
partner.
Government
shall develop guidelines outlining how, when and to whom beneficial disclosure
by a health care worker may be made.
3.1.3 Condoms for HIV Prevention Rationale
Proper and consistent use of male and female condoms
can prevent both unwanted conception and sexually transmitted infections,
including HIV. To be effective, condoms must be of good quality. Providing
women with support to participate fully in the decision to use a condom during
every sexual encounter and involving men to promote condom use will enhance
more consistent condom use.
Policy Statements
·
Government and
its partners shall promote the proper use and disposal of both the male and the
female condom and other barrier methods to prevent HIV and STI transmission.
·
Government shall
ensure that male and female condoms and other barrier methods are of good
quality, affordable and widely accessible. In particular, Government shall
ensure that male and female condoms and other barrier methods are available to
prisoners.
·
Government and
partners shall promote the implementation of programmes aimed at providing
women with support to participate fully in decision making regarding the
utilisation of condoms.
·
Government shall
periodically review and revise fiscal and other measures to ensure equitable
access to and affordability of socially marketed condoms.
3.1.4 Prevention of Mother to Child (Vertical)
Transmission Rationale
HIV
can be transmitted from a mother to her child during pregnancy, during
delivery, and through breast milk. The desire of couples with HIV infection to
have a child must thus be balanced with the possibility of having an
HIV-infected baby who has a high risk of dying in early childhood.
In
addition, the death of the parent, especially the mother, drastically reduces
the baby's chances of survival. Interventions should therefore also address
treatment for parents so as to minimise orphanhood to improve the chances of
child survival.
Policy Statements
·
Government shall
promote both VCT for couples planning to have a child and early couple
attendance for antenatal care.
·
Government and
its partners shall promote and strengthen programmes that prevent HIV
infections and unwanted pregnancies, especially in young women of childbearing
age.
·
Government and
its partners shall provide access to accurate and accessible information on
prevention of mother-to-child transmission and infant feeding options to all
pregnant women and their partners.
·
Government shall
provide access to affordable antiretroviral treatment to prevent HIV
transmission from mother to child. PMTCT programmes shall also provide for
treatment, care and support for both parents.
·
Government and
partners shall provide an enabling environment for women to participate in
PMTCT or other preventive care or support programmes without the consent of
their husband, sexual partner or family.
·
Government shall
ensure that the management of drugs and medical supplies, including the
procurement, storage and distribution of essential and antiretroviral drugs, is
constantly monitored and improved as necessary.
·
Government shall
ensure that treatment of HIV/AIDS-related infections shall be provided
according to the Essential Health Package.
Chapter 4: Protection, Participation and Empowerment
of People Living With HIV/AIDS
Rationale
In
its Declaration of Commitment on HIV/AIDS, the United Nations General Assembly
noted that the realisation of human rights and fundamental freedoms for all is
essential to reduce vulnerability to HIV/AIDS. Respect for the rights of people
living with HIV/AIDS is an essential and central component of an effective
response. Discrimination against people living with HIV/AIDS violates their
rights and is counterproductive to an effective response to HIV/AIDS in that it
threatens voluntary disclosure of HIV status and increases vulnerability to HIV
infection, thereby undermining efforts in response to the epidemic. People
living with HIV/AIDS also have a responsibility to respect the rights and
health of others. The effective participation of people living with HIV/AIDS in
the design and implementation of HIV/AIDS programmes is essential to an
effective national response to the epidemic.
Policy
Statements
·
Government shall
ensure that the rights and dignity of people living with HIV/AIDS are
respected, protected and fulfilled.
·
Government and
partners shall ensure a conducive legal, political, economic, social and
cultural environment in which the rights of people living with and affected by
HIV/AIDS are respected, protected and fulfilled.
·
Government and
partners shall ensure the effective participation of people living with
HIV/AIDS in all decision making in relation to the design, implementation,
monitoring and evaluation of HIV/AIDS-related policies and programmes.
·
Government shall
ensure that people living with HIV/AIDS are not discriminated against in access
to health care and related services and that respect for privacy and
confidentiality are upheld.
·
Government and
partners shall ensure that HIV/AIDS, whether suspected or real, is not used as
a reason for denying an individual access to social services, including health
care, education, religious services, or employment.
·
Government shall
ensure that sector policymakers-including labour, corporate and social service
sectors-shall put in place sectoral policies that effectively address
discrimination on the basis of HIV/AIDS and take steps to effectively eliminate
stigma and discrimination in their institutions and in the implementation of
their sectoral mandates.
·
Government shall
ensure that people living with HIV/AIDS whose rights have been infringed have
access to independent, speedy and effective legal and/or administrative
procedures for seeking redress.
·
Government and
other institutions shall establish mechanisms and services at family, community
or national levels to protect those who choose to disclose their HIV status, as
well as their families and communities.
·
Government shall
ensure that people living with HIV/AIDS are aware of and take responsibility
for protecting themselves from reinfection and others from infection.
Chapter 5: Protection, Participation and Empowerment
of Vulnerable Populations
Rationale
Vulnerable
populations include women, children, orphans, widows, widowers, young people,
the poor, persons engaged in transactional sex (sex in exchange for cash or
in-kind benefit), prisoners, mobile populations, persons engaged in same-sex
relations, and people with disabilities. Those who are underprivileged
socially, culturally, economically or legally may be less able to fully access
education, health care and social services and means of HIV prevention; to
enforce HIV prevention options; and to access needed treatment, care and
support. They are thus more vulnerable to the risks of HIV infection and suffer
disproportionately from the economic and social consequences of HIV/AIDS.
5.1
Women and Girls
Policy Statements
·
Government shall
ensure that women and girls, regardless of marital status, have equal access to
appropriate, sound HIV-related information and education programmes, means of
prevention, and health services-including woman-specific and youth-friendly
sexual and reproductive health services for all women of reproductive age,
including women living with HIV/AIDS.
·
Government shall
protect the rights of women to have control over and to decide freely and
responsibly, free of coercion, discrimination and violence, on matters related
to their sexuality, including sexual and reproductive health.
·
Government shall
ensure that women and girls are protected against violence, including sexual
violence, rape and other forms of coerced sex, as well as against traditional
practices that negatively affect the health of women.
·
Government shall
ensure women's legal rights and equality within the family, in matters such as
divorce, inheritance, child custody, property and employment rights. In
particular, Government recognises the right to equal remuneration of men and
women for work of equal value, equal access to responsible positions, measures
to reduce conflicts between professional and family responsibilities, and
protection against sexual harassment in the workplace.
·
Government and
partners should ensure that women enjoy equal access to benefits of scientific
and technological progress so as to minimise risk of HIV infection.
·
Government shall
ensure that young girls and boys, both in and out of school, have access to
life skills education, which addresses unequal gender relations, to enable them
to protect themselves from HIV infection or live positively with HIV/AIDS if
they are already infected.
·
Government and
partners shall develop and implement gender-sensitive HIV/AIDS care programmes
that ensure continuity of care among hospital, clinic, community care, family
or household, and hospice.
5.2 Orphans Policy Statements
·
Government shall
ensure that orphans are not denied access to primary education, including by
virtue of their inability to pay.
·
Government shall
put in place mechanisms for the registration of births and deaths at a local
level, including by chiefs, to facilitate and inform the monitoring of and
planning for the orphan situation.
·
Government and
partners shall ensure that child-headed households are supported, in order to
safeguard the best interests of children.
·
Government shall
put in place mechanisms to ensure the protection of the inherited property of
orphans until they attain the age of majority.
5.3 Widows and Widowers Policy
Statements
·
Government and
partners shall ensure that communities, especially women and the elderly, have
access to accurate and comprehensive information about both laws protecting the
legal rights of a surviving spouse to inherit property, and ways to enforce
these rights.
·
Government and
partners shall ensure that victims of property grabbing and custody disputes
have access to affordable legal support services to enforce their rights.
5.4 Children and Young People Policy Statements
·
Government shall
strengthen and enforce existing legislation to protect children and young
people against any type of abuse or exploitation.
·
Government and
partners shall ensure that children and young people have access to youth-friendly
sexual and reproductive health information and education, including
HIV/AIDS/STI information, appropriate to their age and needs, to equip them
with knowledge and skills to protect themselves from HIV and other STIs.
·
Government shall
incorporate reproductive and sexual health education, including life skills and
peer education, into the school curriculum as a subject that undergoes regular
assessment, and shall ensure that similar reproductive and sexual education is
made accessible to youth out of school to protect them from HIV and other STIs.
·
Government and
partners shall ensure that traditional initiation counsellors incorporate sound
and appropriate sexual and reproductive health education into traditional and
cultural rites of passage/initiation processes.
5.7 Prisoners Policy Statements
·
Government shall
ensure that prisoners are not subjected to mandatory testing, nor quarantined,
segregated or isolated on the basis of HIV/AIDS status.
·
Government shall
ensure that all prisoners (and prison staff as appropriate) have access to
HIV-related prevention information, education, VCT, means of prevention
(including condoms), treatment (including ART), care and support.
·
Government shall
ensure that prison authorities take all necessary measures, including adequate
staffing, effective surveillance, and appropriate disciplinary measures, to
protect prisoners from rape, sexual violence and coercion by fellow prisoners
and by warders. Juveniles shall be segregated from adult
prisoners to protect them from abuse.
·
Government shall
ensure that prisoners who have been victims of rape, sexual violence or
coercion have timely access to effective complaint mechanisms and procedures
and the option to request separation from other prisoners for their own
protection.
5.8 Mobile Populations Policy
Statements
·
Government and
private sector shall identify, address and reduce the vulnerability of all
mobile groups to HIV/AIDS, including modification of their living and working
conditions.
·
Government shall
collaborate with regional institutions, such as the Southern African
Development Community and International Organisation on Migration, in
developing regional responses to HIV/AIDS that are rights based and meet public
health imperatives.
·
Government shall
ensure that the rights of refugees in Malawi are respected, protected and
fulfilled, including their rights with respect to HIV prevention, treatment,
care and support.
5.9 Persons Engaged in Same-Sex Sexual Relations
Policy Statements
·
Government and
partners shall put in place mechanisms to ensure that HIV/AIDS/STI prevention,
treatment, care and support, and impact mitigation services can be accessed by
all without discrimination, including members of this vulnerable population.
5.10 People with Disabilities Policy Statements
·
Government and
partners shall ensure that HIV-related prevention information, education,
treatment, and care and support strategies are tailored to the special needs of
people with disabilities and are accessible to people with disabilities.
·
Government and
partners shall ensure that all decision-making forums and structures make
provision for the full and active participation of people with disabilities.
·
Government and
partners shall ensure that all responses to HIV/AIDS consider the implications
for people with disabilities and plan for more effective responses based on
models of international best practice.
Chapter 6: Traditional and Religious
Practices/Services
6.1
Customary Practices
Rationale
Many practices, including polygamy, extramarital
sexual relations, marital rape, first aid to snakebite victims, ear piercing
and tattooing, and customary practices such as widow and widower inheritance
(chokolo), death cleansing (kupita kufa), forced sex for young girls coming of age
(fisi), newborn baby cleansing (kutenga mwana), circumcision (jando/mdulidwe),
ablution of dead bodies, consensual adultery for childless couples (fisi), wife
and husband exchange (chimwanamaye), temporary husband replacement (mbulo), and
tattoos (mphini) increase the risk of HIV infection.
Policy
Statements
·
Government shall,
in partnership with civil society-including traditional leaders and religious
leaders-promote and encourage monogamous marriages and fidelity within any type
of marriage, to prevent HIV and other STIs.
·
Government and
partners shall promote correct, consistent use of condoms in marital sex where
there is real or perceived risk of HIV infection.
·
Government shall
ensure that support services are available for spouses who assert their rights
to safer sex with their partners and are abused or thrown out of the home.
·
Government shall
ensure that traditional leaders and religious leaders sensitise their
communities to the dangers of, and discourage, widow/widower inheritance
practices.
·
Government shall
ensure that men and women are empowered to make independent decisions and
choices regarding widow/widower inheritance to reduce the risk of HIV
transmission.
·
Government-in
partnership with civil society, religious leaders and traditional leadersshall
promote VCT for men and women who willingly choose to practice widow/widower
inheritance.
·
Government shall
ensure the provision of support services and access to speedy remedies for
persons who reject the practice of widow/widower inheritance and are victimized
as a result.
·
Government shall
ensure that traditional leaders stop or modify unsafe customary practices to
make them safer in order to prevent HIV transmission, or shall promote
alternative customary practices which do not place people at risk of HIV
infection.
·
Government
shall-in partnership with civil society, traditional leaders and religious
leaders-sensitise childless couples and HIV-positive partners as to available
options, such as fostering, adoption and medical treatment.
·
Government shall
ensure that risky practices like tattooing and ear piercing are done safely to
prevent HIV infection.
6.2 Traditional Healers and Traditional Birth
Attendants Rationale
The
majority of Malawians rely on traditional healers and traditional birth
attendants for many of their health care needs. It is thus imperative to include
them in the fight against HIV/AIDS.
Policy Statements
·
Government shall
ensure that traditional healers and traditional birth attendants have access to
and training in HIV-related prevention information and education as well as
care and support for people living with HIV/AIDS.
·
Government
shall-in partnership with civil society, traditional and religious leaders and
traditional healers-sensitise communities as to the role of traditional healers
and traditional birth attendants in the context of HIV/AIDS.
·
Government
shall-in partnership with civil society, traditional leaders and religious
leaders-sensitise and discourage traditional healers from making false claims
of HIV/AIDS cures and prescribing practices that increase the risk of HIV
infection.
6.3 Religious Practices/Services Rationale
Religious
groups have an important role to play in promoting individual behaviour that
reduces the risk of HIV infection, such as the use of VCT prior to marriage and
during marriage reconciliations (after divorces or separations). These groups
also can provide care and support for people living with HIV/AIDS. Certain
religious practices-such as refusal to seek medical care and treatment, and
belief in miracle cures-do, however, increase vulnerability to HIV infection.
Policy Statements
·
Government and
partners shall work closely with religious leaders to facilitate the provision
of accurate HIV-related prevention information and education as well as care
and support for people living with HIV/AIDS.
·
Government and
partners shall sensitise religious practitioners to, and discourage them from,
making false claims of miracle HIV/AIDS cures.
Chapter 7: Responding to HIV/AIDS in the Workplace
Rationale
In
the workplace, unfair discrimination against people living with HIV and AIDS
has been perpetuated through practices such as pre-employment HIV testing,
dismissal for being HIV positive and the denial of employee benefits if known
to be infected.
HIV/AIDS affects every
workplace. Absenteeism and death have an impact on productivity, employee
benefits, production costs and workplace morale.
One
of the most effective ways of reducing and managing the impact of HIV/AIDS in
the workplace is through the implementation of an HIV/AIDS policy and a
prevention, treatment, care, support and impact mitigation programme.
Policy Statements
·
Government and
partners shall ensure that all public and private sector workplaces shall
develop and implement an HIV/AIDS workplace policy and an HIV prevention,
treatment, care, support and impact mitigation programme.
·
Government shall
ensure that all public and private sector workplace policies provide that:
·
No employer shall
require, whether directly or indirectly, any person to undergo testing for HIV
as a precondition for employment. The criteria for employment shall be fitness
to do the job for which employment is sought. No person shall be excluded from
employment solely on the basis of HIV status.
·
No employee shall
be compelled to disclose his or her HIV status to the employer or other employees.
Where an employee chooses to voluntarily disclose his or her HIV status to the
employer or to another employee, such information shall not be disclosed to
others without that employee's express written consent.
·
No employer shall
terminate the employment of an employee solely on the grounds of HIV status or
family responsibilities relating to HIV/AIDS.
·
Employees living
with HIV shall continue working in their current employment for as long as they
are medically fit to do so. When on medical grounds they cannot continue with
normal employment, verifiable efforts should be made to offer them alternative
employment or other reasonable accommodation without prejudice to their
benefits.
·
Where an employee
becomes too ill to perform any work, an employer may terminate his or her
employment for incapacity in accordance with the procedure set out in the law.
·
An employee
living with HIV shall not be unfairly discriminated against or in any way
prejudiced within the employment relationship or within any employment policies
or practices with regard to appointments, and the appointment process,
including job placement, job classification or grading, remuneration,
employment benefits, terms and conditions of employment, employee assistance
programmes, the workplace and facilities, occupational health and safety,
training and development, performance evaluation systems, promotion, transfer
or demotion, disciplinary measures short of dismissal and dismissal, or
termination of services, including retrenchment and early retirement.
·
The HIV status of
an employee shall not affect his or her eligibility for any occupational
insurance or other benefit schemes provided for employees by an employer. Where
in terms of any law the eligibility of a person for any occupational or other benefit
scheme is conditional upon an HIV test, the conditions attaching to HIV and
AIDS shall be the same as those applicable in respect to comparable lifethreatening
illnesses.
·
An employee
living with or affected by HIV/AIDS shall be subject to the same conditions
relating to sick or compassionate leave as those applicable to any other
employee in terms of the law, or conditions of service applicable.
·
Employees shall
be proactive in safeguarding their health and that of their families by
actively participating in HIV/AIDS programmes and taking the lessons learnt to
their homes and communities.
Chapter 8: Establishing and Sustaining a National
HIV/AIDS Research Agenda
Rationale
HIV/AIDS
research is required to address gaps in existing knowledge about HIV/AIDS and
to inform policy, practice and HIV/AIDS-related interventions.
Policy
Statements
·
Government and
partners shall promote both biomedical and social sciences research in order to
provide sound, scientific and reliable information to guide national HIV/AIDS
policy, practice and interventions.
·
Government shall
ensure that all HIV/AIDS-related research involving human subjects satisfies
ethical and human rights considerations of partner and Malawi-based
institutions, according to international best practices, whilst respecting
national cultural sensitivities and norms.
·
Government shall
strenghten the capacity of the National Research Council. Council
representation shall include individuals from government, academia and the
community to advise and monitor HIV/AIDS-related research.
·
Government shall
ensure that the National Research Council establishes an HIV/AIDS prioritised
research agenda, which shall be reviewed periodically to guide all research
activities.
·
Government shall
ensure that the National Research Council keeps an inventory of past and
ongoing HIV/AIDS research undertaken in Malawi.
·
Government shall
ensure wide and timely dissemination of national and international HIV/AIDS
research results.
·
Government shall
ensure that researchers genuinely involve the community in the
planning
and execution of research involving human subjects.
·
Government shall
ensure that the results of HIV/AIDS research are equitably distributed
and
benefit the participating communities.
·
Government shall
ensure that international HIV/AIDS researchers in Malawi collaborate
with
and develop the research capacity of existing institutions.
·
Government shall
foster collaboration with traditional healers for research on traditional
medicine
for the management of HIV/AIDS.
·
Government shall
mobilise and ensure the availability of adequate resources for HIV/AIDS
research.
Chapter
9: Monitoring and Evaluation
Rationale
Monitoring and evaluation is essential to assessing
the success of the national response to HIV/AIDS and guiding future strategy
and interventions. Public health surveillance is important to monitor the
progression of the epidemic so as to inform new policies, strategies and plans.
Unlinked anonymous testing is an effective way of HIV screening for public
health surveillance. Using a variety of social science methods, behavioural
data can also be collected to monitor behavioural changes in communities
regarding HIV/AIDS. Easily accessible low-risk populations-such as women
receiving antenatal care, and voluntary nonremunerated blood donors-are a good
source of surveillance data on HIV prevalence.
Policy Statements
·
Government and
partners shall implement a national HIV/AIDS Monitoring and Evaluation
(M&E) plan to assess the success of the national response to HIV/AIDS and
to inform and guide future strategy and interventions. In particular, M&E
shall assess:
·
Mitigation of the
impact of HIV/AIDS on individuals, the family and communities;
·
Reduction of
individual and societal vulnerability to HIV/AIDS; and
co-ordination
and implementation of HIV/AIDS programmes in the country.
·
Government shall
ensure that the necessary capacity building is carried out so that all
partners
are able to provide the necessary information for the national M&E system.
·
Government and
partners shall promote efficient use of data and resources by making
sure
that indicators and sampling methodologies are comparable over time.
·
Government shall
conduct anonymous, unlinked HIV/AIDS/STI sentinel surveillance.
·
Government and
partners shall carry out periodic behavioural surveillance among target
groups.
·
Government shall
improve surveillance data management and use, including regular dissemination
of relevant surveillance data to its partners and to the general public.