Malawi PMTCT Trainer Manual

Module 1Introduction to HIV and AIDS

/ Total Time: 130 minutes

After completing the module, the participant will be able to:

  • Discuss the global impact of HIV and AIDS.
  • Discuss the magnitude and impact of HIV in Malawi.
  • Define HIV.
  • Define AIDS.
  • Provide an overview of the natural history of HIV infection.
  • Describe strategies to prevent HIV transmission.

Have the following additional materials available, whenever possible:

  • Malawi Demographic and Health Survey 2004
  • Small prizes (such as sweets, condoms, pens, pencils, erasers/rubbers) for prizes for Exercise 1.1. winning team (Optional)

UNIT 1Magnitude, Impact and Response to HIV and AIDS

Activity/Method / Time
Interactive lecture / 25 minutes
Questions and answers / 10 minutes
TOTAL UNIT TIME / 35 minutes

UNIT 2Basic Facts about HIV and AIDS

Activity/Method / Time
Interactive lecture / 45 minutes
Questions and answers / 10 minutes
Exercise 1.1 Understanding HIV: interactive game / 40 minutes
TOTAL UNIT TIME / 95 minutes
/ Trainer Instructions
Slides 1-2

Begin by reviewing the module objectives listed above.

UNIT 1Magnitude, Impact and Response to HIV and AIDS

/ Advance Preparation
The trainer should become familiar with the current situation in Malawi, including the magnitude and impact of the HIV epidemic and the country’s response to HIV and AIDS.
/ Total Unit Time: 35 minutes
/ Trainer Instructions
Slides 3-4

Introduce the unit and review objectives.

After completing the unit, the participant will be able to:

  • Discuss the global and national impact of HIV and AIDS.
  • Discuss the magnitude and impact of HIV in Malawi.

/ Trainer Instructions
Slides 5-12

Introduce information on the global magnitude of HIV and AIDS by reviewing Figure 1.1 and Appendices 1-A and 1-B. These appendices appear in the Participant Manual so you need not discuss the information in detail.

/ Make These Points
  • More than 90% of people living with HIV (PLHIV) are in resource-constrained settings.
  • 95% of all HIV-related deaths have been in resource-constrained settings, largely among young adults.

Overview of global pandemic

The HIV pandemic remains a major public health problem worldwide, with especially devastating effects in sub-Saharan Africa. In 2005, approximately 65% of the estimated 40.3 million adults and children living with HIV were from sub-Saharan Africa (25.8 million). It is important to note that sub-Saharan Africa is home to just over 10% of the world’s population.

The majority of the people living with HIV are aged 15 to 49 years, and nearly 50% are women of reproductive age. Heterosexual transmission is the most common mode by which the virus spreads in developing countries, resulting in large numbers of HIV-infected women of childbearing age. The paediatric HIV epidemic is largely the result of transmission from mother-to-child (MTCT). Use of the term MTCT attaches no blame or stigma to the woman who gives birth to a child infected with HIV. It does not suggest deliberate transmission by the mother, who is often unaware of her own infection and unfamiliar with the risk of transmission to her infant.

The high prevalence of MTCT is threatening to reverse the gains in child survival on the African continent. The impact of the HIV epidemic is felt at virtually every level in Africa —the individual, the family and the community.

HIV prevalence: The proportion of individuals in a population who have HIV at a specific point in time (e.g. the proportion of people with HIV on December 31, 2005). Prevalence is calculated by dividing the number of existing cases at a given point in time divided by the total population.
HIV incidence: The proportion of individuals newly infected with HIV within a certain time period (e.g. between 1 January and 31 December 2005). Incidence is calculated by dividing the number of new cases during a certain time period by the total population at risk.
/ Make These Points
  • Discuss the number of new infections using the most recently available data. See Figure 1.1.
  • Briefly highlight the regional HIV and AIDS data as detailed in Appendix 1-A.
  • Discuss the spread of HIV among women in different parts of the world. Refer participants to Appendix 1-B for data on HIV in women.

HIV and AIDS worldwide and in Africa

  • During 2005, 40 million people worldwide were living with HIV.
  • 85% of people living with HIV and AIDS (PLHIV) in 2005 were in Africa and Asia.
  • HIV prevalence remains exceptionally high in southern Africa and the epidemic is continuing to expand, notably in Mozambique and Swaziland.
  • West and Central Africa show no signs of changing HIV infection levels.

HIV and AIDS among women, 2005

  • During 2005, 17.5 million women worldwide were living with HIV and AIDS.
  • 90% of women living with HIV and AIDS in 2005 were in Africa and Asia.
  • 50% or more of people living with HIV (PLHIV) were women in sub-Saharan Africa, Oceania and the Caribbean.
  • In many countries in sub-Saharan Africa, more women (15-24 years old) than men have HIV

HIV and AIDS in children, 2005

UNAIDS estimates that at the end of 2005:

  • 2.3 million people with HIV and AIDS were children younger than 15 years old.
  • 90% of the children living with HIV and AIDS were from sub-Saharan Africa.
  • 700,000 children worldwide were newly infected with HIV.
  • 570,000 child deaths are estimated to have occurred worldwide from HIV and AIDS during 2005.
  • Recent data (UNICEF, 2004) show that about 15 million children have lost one or both parents to AIDS – the vast majority of these children are in Africa.

HIV and AIDS in adults and children, 2005

  • Almost 5 million adults and children were newly infected with HIV in 2005.
  • From 2003 to 2005, new HIV infections increased by almost 7%.
  • From 2003 to 2005, new HIV infections increased the most in East Asia (40%), Latin America (18%) and South and Southeast Asia (17%).
  • 3.1 million deaths in adults and children were because of AIDS.

New infections, 2005

According to UNAIDS, about 13,000 new infections occurred each day in 2005. Of these new infections:

  • About 6,000 each day were among persons 15 to 24 years old
  • Almost 2,000 each day were in children younger than 15 years old
  • Most of the infections in children younger than 15 years old occurred through mother-to-child transmission of HIV (MTCT)

Figure 1.1: Adults and children estimated to be living with HIV and AIDS worldwide, 2005

Source: UNAIDS, WHO 2005. AIDS Epidemic Update, December 2005. UNAIDS: Geneva.

/ Trainer Instructions

Explain that HIV prevalence estimates for the general population are often based on HIV prevalence among women attending antenatal clinics (ANC). Figure 1.2 below includes the results of prevalence studies among pregnant women, illustrating HIV prevalence in sub-Saharan Africa.

Similar studies have been undertaken in Malawi, where there are presently 19 sentinel surveillance sites monitoring HIV prevalence trends.

Figure 1.2 HIV-prevalence among pregnant women attending antenatal clinics in sub-Saharan Africa, 1997/98-2004.

(Source: UNAIDS, 2005)

Most of these estimates are based on surveillance systems that focus on pregnant women who attend selected antenatal clinics. This method assumes that HIV prevalence among pregnant women is a good approximation of prevalence among the adult population (aged 15–49 years). A direct comparison of HIV prevalence among pregnant women at antenatal clinics and the adult population in the same community in a number of African communities has provided evidence for this method of estimating HIV prevalence.

In Malawi, there are presently 19 sentinel surveillance sites representing the three regions of the country and the urban, semi-urban and rural areas.

/ Trainer Instructions
Slides13-15

Explain that the impact of HIV cuts across all socio-economic sectors and affects people at the individual, the family and the country levels of society. Explain the effects of HIV on individuals, families and children.

Begin a group discussion about some of the pandemic's global outcomes, based on the information below. You could start the discussion by asking “What are the ways that HIV has impacted, or had an effect, on our lives?” or “How do you think our country is different now in comparison to how it was before the HIV epidemic (before the mid/late 1980s)?”

/ Make These Points
  • HIV affects every region of the world.
  • Millions of people are infected with HIV or live in families affected by HIV.
  • The number of new infections continues to grow.
  • The social and economic consequences of the virus on national development are far-reaching.
  • The HIV epidemic contributes to:
  • Childhood malnutrition
  • Shortened life span with illness and suffering
  • Personal and countrywide economic loss
  • A weakened family system

Impact of HIV

Global impact of HIV

The global impact of the HIV epidemic is especially severe in resource-constrained settings and results in the following:

  • Negative impact on economic development
  • Overwhelmed healthcare systems
  • Decreasing life expectancy
  • Deteriorating child survival rates
  • Increasing number of orphans

Impact on individuals

  • Illness and suffering
  • Shortened life span
  • Loss of work and income
  • Death of family members, grief, poverty and despair
  • Barriers to health care related to stigma and discrimination
  • Weakened integrity and support structure of the family unit

Impact on families

  • As people of reproductive age die of HIV-related illnesses, the elderly are increasingly taking on the responsibility of raising their grandchildren, despite the fact that they may not have the capacity to do so.
  • The household income has been significantly reduced and whatever is available gets diverted into medical and palliative care as well as funeral expenses.
  • Households headed by children are on the increase as a result of both parents and the immediate relatives dying of HIV-related illnesses.
  • Families are being forced to sell their limited assets and divert their resources to the care of sick family members, which worsens the existing poverty.
  • The burden of home-based care may put the emotional and physical health of carers at risk.
  • Children’s vocational training and schooling may be interrupted, and their human rights violated. (Please see last bullet below in the “Development” section.)

/ Trainer Instructions
Slides16-22

Introduce the information below on the magnitude and impact of HIV/AIDS in Malawi.

HIV and AIDS in Malawi

The first case of AIDS in Malawi was reported and confirmed in 1985. The median HIV prevalence increased until 1999, after which prevalence declined and stabilized (see Figure 1.3). Presently, HIV prevalence in adults (15 to 49 years of age) in Malawi is one of the highest in the world, estimated in 2005 at approximately 14%, with a range from 12% to 17%. This represents a total of 790,000 infected adults (age 15-49) and a total of 932,000 persons (of all ages) living with HIV and AIDS in the population. The 2005 prevalence estimates also indicate that HIV infection among adults in urban areas is higher (21.6%) than in rural areas (12.1%).


Figure 1.3Trend in median HIV prevalence, 1992-2005

Source: Ministry of Health: Draft Report for the Malawi 2005 HIV and Syphilis Sero-Survey and National HIV Prevalence Estimates

Table 1.1 National HIV prevalence estimates, 2005

Indicator / Value / Low / High
National adult prevalence (15-49) / 14.0% / 12% / 17%
Number of infected adults / 790,000 / 660,000 / 950,000
Number of infected adult women / 440,000 / 370,000 / 530,000
Urban adult prevalence / 21.6% / 18% / 26%
Number of infected urban adults / 240,000 / 200,000 / 290,000
Rural adult prevalence / 12.1% / 10% / 15%
Number of infected rural adults / 550,000 / 458,000 / 660,000
Number of infected children (0-14) / 83,000 / 69,000 / 100,000
Number infected over age 50 / 59,000 / 49,000 / 71,000
Total HIV+ population / 932,000 / 778,000 / 1,121,000

Source: Ministry of Health: Draft Report for the Malawi 2005 HIV and Syphilis Sero-Survey and National HIV Prevalence Estimates

Impact of HIV in Malawi

Development

  • In Malawi, AIDS is now recognized as one of the major causes of death among young adults. Life expectancy at birth has dropped from 45 in 1995 to 39 years in 1998 and HIV infection is one of the main contributing factors to this trend.
  • There is evidence that trained and experienced professional cadres in the country have been dying of AIDS-related illnesses. Replacement of these lost cadres is slow and if it occurs, will involve mostly young and inexperienced workers.
  • Production costs are increasing due to high costs of HIV treatment and absenteeism.
  • The disease primarily strikes people during the years when they are most productive. Therefore, the overall productivity at local and national level is affected, causing a negative impact on the economy
  • There has been an increase in the number of orphans. These children are not adequately cared for because of overloading of the extended family structures.
  • They end up as heads of households with responsibility for their siblings or end up living on the streets.

Health sector

  • The demand for health care has risen as a result of the HIV epidemic. For example, tuberculosis has increased from 5,000 cases per year in 1985 to more than 25,000 in 2000. This has led to a dramatically heavier workload for the health staff and to more stress, which may increase the risk of occupational exposure to HIV.
  • The health workers themselves have succumbed to HIV-related illnesses, compounding the problem.
  • The healthcare system is stretched beyond its limit, given the increase in demand without a corresponding increase in capacity to deliver services.
  • There is burnout and reduced morale among health workers from physical and emotional stress, including fear accidental exposure to HIV/AIDS.

Education sector

  • Teachers, policemen/women and other skilled service providers are dying of HIV- related illnesses.
  • The resources being invested in their education are not being fully returned.
  • Children, especially girls, are being kept out of school to care for infected parents, guardians, and/or siblings. This poses a challenge to the national universal education policy.
  • There is reluctance by organizations and institutions to invest in staff education due to the increased turnover of personnel as a result of HIV-related illnesses.

Agriculture sector

  • Agriculture is a major sector of Malawi’s economy and about 10% of the gross domestic product comes from estate agriculture (tobacco and tea). HIV-related illness is affecting the capacity and productivity of this sector.
  • Families are being forced to abandon labour-intensive agriculture due to illness among adults who would otherwise be productive.
  • Livestock and equipment are being sold to divert resources to immediate healthcare needs, at the expense of agricultural production and economic stability.

Labour sector

  • Child labour is becoming normal as children struggle to cope and maintain the family income.
  • The labour sector has to cope with a rise in labour costs from increased turnover (caused by illness and deaths), re-training expenses, as well as staff welfare costs (medical expenses, benefits), and funeral costs for workers.
  • Absenteeism due to illness and the need to care for sick relatives affects the productivity of this sector.

/ Make These Points
  • In Africa, HIV-infected children develop the disease early in life. One study of over 200 HIV-infected children in Rwanda found a 45% risk of death by age 2 years.
  • Healthcare workers (HCWs) trained in PMTCT can help to reverse the course of this epidemic in Malawi.

Mother-to-Child transmission of HIV

Mother-to-child transmission of HIV (MTCT) is responsible for more than 90% of childhood HIV infections worldwide, and is the second most common mode of transmission in Malawi. A significant population of women may die within the next decade leaving behind orphaned children, who may also be infected with HIV.

MTCT may occur during pregnancy, labour and delivery, and breastfeeding. Mothers and pregnant women need to know without intervention there is a 25-50% risk of HIV transmission from HIV-infected mothers to newborns. It is estimated that in the absence of breastfeeding, about 30% of MTCT occurs during pregnancy and 70% during labour and delivery.

In sub-Saharan Africa, the HIV epidemic is reversing the gains in child health and survival, and has made caring for HIV-infected children costly for families and health systems. Prevention efforts can slow the spread of HIV. However, pregnant women in countries heavily affected by HIV often do not have access to PMTCT services. PMTCT services and other vital prevention services must be extended as a matter of urgency.

Malawi national response to the epidemic

Reducing the incidence of HIV infections, particularly in children, requires comprehensive interventions that include:

  • Preventing new infections by targeting the general population, especially parents-to-be.
  • Offering HIV testing and counselling
  • Offering supportive family planning services to prevent unintended pregnancies among HIV-infected women
  • Providing PMTCT interventions during pregnancy, labour and delivery, and in the postnatal period, specifically infant-feeding counselling and support

In order to reduce rates of MTCT, PMTCT services have to achieve adequate coverage across the country, high rates of adherence to interventions (drug regimens, infant feeding and delivery in a healthcare setting), and sufficient follow-up. To facilitate this, it is essential to address the learning needs of HCWs that affect the quality of PMTCT services. Slow action or no action can result in millions of new infections and unnecessary deaths. Consequently, a great effort and dedication of resources will be required to bring the epidemic under control.

Despite the mounting crisis, the situation is far from hopeless.

  • More than 80% of the general population is not infected.
  • Studies have shown that specific interventions including testing and counselling, condom social marketing, peer education as well as treatment of STIs and changing risky sexual behaviours can reduce the risk of HIV transmission.
  • Infant mortality has declined from 104 in 2000 to 76 in 2004, while under-5 mortality has declined from 189 in 2000 to 133 in 2004. Neonatal mortality has dropped from 42 in 1992 to 27 in 2004.
  • The maternal mortality ratio has declined from 1120 per 100,000 live births in 2000 to 984 per 100,000 live births in 2004, a good development but still one of the highest in the world.

The main pillar in the national response to the HIV epidemic in Malawi has been the adoption of a multi-sectoral approach, which includes the involvement of all stakeholders from governmental and non-governmental organizations, civil society donors, and bilateral and multilateral institutions.