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Transcript of our interview with Dr. Owen Kaluwa

Brenda: Dr. Kaluwa, has Malawi been very affected by HIV/AIDS?

Dr. Kaluwa: Yes Malawi has been quite severely affected by HIV/AIDS. We diagnosed the first case of AIDS in 1985. Since that time HIV rates, as measured in antenatal women, have been rising. So that, by 1992, in urban cities we had already hit the 30% mark. And things have not improved too far because up to now we still have very high HIV prevalence rates in women attending antenatal clinics. And what is also most disturbing is that when you look at the young age groups of women, 19-24, the new infection rates of HIV/AIDS, continue to be very high.

Brenda: How do you think this has come about?

Dr. Kaluwa: I think that when the virus that causes AIDS got into Malawi there was a very long period before we had effectively responded. And I think during that period HIV quietly spread through the population. And because of its long incubation period it took a long time before people realized that we really do have a problem that we need to respond to. And during that period a lot of people got infected. And so when it began to be known that we have a problem we already had a number of HIV/AIDS cases.

And when you complicate that with the fact that there's a considerable amount of denial, there's a considerable amount of fear, there's a considerable amount of despair and hopelessness the situation continued.

In addition to that we have had fairly high levels of STDs in the reproductive age group. And these again, I think, have helped to feed the epidemic.

There are cultural aspects, also, which have contributed to fuelling the epidemic in Malawi. But the extent to which individual practices, issues of wife inheritance, rights of passage etc., the extent to which they have contributed individually has not been quantified. But we think these are risky practices that also contributed.

But overall, I think, it's the cultural view of sex and sexuality and the general powerlessness of women in matters of sex that, I think, matter more in the cultural context in terms of speeding up the spread of HIV in Malawi.

Brenda: What does the government plan to do about the epidemic now that it's recognized?

Dr. Kaluwa: I must say the epidemic has been recognized for some time and the government has tried to respond to HIV in a number of different ways. First of all they put in place, early in 1987, a short term plan while they were preparing a Medium Term Plan, MTP1, according to the guidelines of the WHO global program on AIDS. Now the emphasis in these plans were mostly on information, education, communication and also on ensuring blood safety by expanding health sites and health institutions that must clean blood before transfusion. And those were effectively and successfully done. And we… all the blood that is transfused in Malawi undergoes HIV screening.

On the information, education and communication front that was also quite successful because by 1992, according to the Dept. of Health Services, it was clear that over 95% of Malawians in the general population, including rural areas, including male and female, were able to know about HIV/AIDS, how it is transmitted and how it can be prevented. So in terms of giving out knowledge we are very successful.

And that was followed by an MTP2, Medium Term Plan Two, that was implemented from 1994 to 1998. And again that built upon the first MTP. In addition to that, it recognized that HIV/AIDS was more than an issue of health and therefore encouraged multi-sectoral co-ordination in responding to HIV/AIDS. And a number of things were achieved in that particular MTP.

But the question remained that we still had very high rates of HIV. In other words, we continued to have high incidence of HIV/AIDS as seen by the HIV rates in the young antenatal mothers. Despite all that knowledge, despite all the other efforts.

So it was decided, the government decided that to best respond let's go back to the people and discuss the issues of HIV/AIDS, get their views, their perspectives, look at what they're doing, how they're surviving, where they're surviving, build on what strengths are there, identify the gaps and see how we can address the gaps. So the strategic planning process was designed in a manner that was a social mobilization process. Not only to get out the ideas for drawing up a plan but to get people acting in a timely and effective fashion, using whatever capacity they have to respond to HIV/AIDS.

And, more importantly, we wanted to break the silence. There was a lot of silence surrounding the epidemic. People knew how it is spread, how you can prevent it but they never talked about it. And because of that silence it was difficult to have any meaningful consultation or program. So the program was designed to deal with that problem, the strategic planning process. And we managed to address a number of issues during that process. Because we coupled that process with a media strategy which continuously informed the nation about what was going on in the field of HIV/AIDS and what other people were doing.

At the same time there was an advocacy strategy where we basically trained traditional and civic leaders on the issues that were emerging from our social mobilization process. And how to use those issues to help others advocate for the change of attitudes or practices that were detrimental to HIV/AIDS control.

So eventually we developed a strategic framework of responding that helped to build partnerships with various players and everybody now buys and owns the strategic framework.

And, I believe, we are now on a sound footing to making a real difference because openness of the epidemic is increasing, political support is very high, dollar support is also very high and a lot of partnerships are involved. We are going to work with the private sector, the public sector and meaningfully mainstream HIV in the core business of the other sectors.

Why I say meaningfully mainstream is because we cannot look towards a situation where each and every sector, be it agriculture, health etc., is taking the traditional approach. They have to take into account the fact that HIV/AIDS is around. If agriculture, for example, is going to produce adequate food for people, make sure that it's done, they have to mainstream because one of the problems of people suffering from AIDS is poor nutrition and agriculture can contribute in that way.

Equally, if people in business produce a lot of money and engage in activities that can put them at risk of HIV infection, by getting people to promote issues of income investment you have now, in a way, removed the possibilities of them engaging in risky behaviours to meaningfully invest their funds . You have again meaningfully mainstreamed by doing what you can do best according to your comparative advantage to reduce the spread of HIV/AIDS.

So, all the associated factors that allow for HIV to be spread are dealt with within the sectors that can best deal with them.

Brenda: How is Malawi caring for the children….the orphans?

Dr. Kaluwa: The issue of orphans is a very important issue in Malawi. HIV has brought about a big increase in the number of orphans. Previously, the extended family system that is quite prevalent in Malawi managed to take care of the orphans that arose from normal causes, other than HIV/AIDS, causes of death. But now the sudden increase in orphans, because of the high numbers of death in young adults, has now brought about the issue of orphans to be very important. And in the strategic framework it's one component which has been addressed as a priority area in dealing with orphans.

But what came out from the people as the best way to respond to the question of orphans is not necessarily, at least in the Malawi view, to have orphanages. The community preferred that it's better to have these children raised in families. Because beyond their physical needs, food whatever, they need psychological support and you cannot get that at an orphanage. So Malawi has chosen that direction in terms of caring for the orphans.

Robert: Given the policy that the orphans need to be cared for by the community, what kind of stresses does that put on the community?

Dr. Kaluwa: Certainly the fact that orphans need to be cared in the community puts a lot of stresses on the community. The reasons are obvious. Because of the general poverty there is already a number of families that are not capable of looking after their own children.

Equally the same applies also to the question of home-based care. We sent… we sent patients to say OK let's have home-based care, let's link up with the hospitals. But then you still find that, when they go back to be cared for at home, not all homes are capable of meeting their needs. So the question again arises to say how much pressure is all this put onto the community. There is a lot of pressure being put on the community. That is why in the strategic framework we have emphasized community-based responses, that support must go to the communities, that we have organized communities to see how best we can support them in that strain that has basically been placed on the community.

And further to that I should say, even the psychological strains. In Malawi almost everybody, when they die, they get buried at home so all the grief gets transferred again to the communities. So not only the orphans, not only the patients but also the grief associated with death, whether village or urban, it also gets inflicted.

So our strategy of going to the ground, I think, will help to support these initiatives. We are developing district specific plans that look at the unique situation in each district and respond to that. So that the implementation plan is specific to the needs of a particular district.

And we are developing an NGO grant facility which has been clearly stated in the strategic framework because we want to support these local initiatives. Because if they're going to get funding directly they don't have the capacity in terms of accounting, of financial management etc. to be competitive in any competition granting mechanism. So we want to have a very flexible grant mechanism that will go to the CBOs, strengthen the CBOs, strengthen the role of people living with HIV in the community, strengthen the role of the traditional leaders etc. So that they help to cushion the stress that orphans, AIDS patients and everything else that HIV/AIDS brings in the community.

Brenda: Can you describe the cultural practices that are encouraging the spread of the disease?

Dr. Kaluwa: As I said earlier, I cannot give you the extent to which particular cultural practices contribute to HIV transmission but we know there are a number of cultural practices that are risky.

The issues like wife inheritance, when somebody has passed away a brother or some other relative inherits the widow. Now it's OK when everything else is fine, but in an era when HIV is likely to be the cause of death it is very risky to inherit a widow or somebody's wife because if they did die of AIDS there's a very high probability that the widow also is HIV infected. So the risk is very high.

And there are other cultural practices which are associated with the rites of passage, initiation ceremonies where sometimes you would get a particular….a man to try to have sex with a number of young girls on graduation etc. But again, if that particular person is HIV infected the chance of him passing on HIV to a good number of those girls is again high. So they'll be starting up their sexual life, their married life etc. already doomed, already infected. And there are other practices also associated with sex in other parts during death etc.

But, as I said earlier on, they are risky practices and they are putting people at risk and maybe some people are being infected through that but when you look at the HIV rates in areas where these are practiced vis a vis in areas where they are not it's not that different.

So even though they do contribute, I think the overall cultural aspect of HIV is the cultural view on sex and the society view on the value of women. And I think that could be much more important because it's much more cross cutting. You have high HIV rates in urban areas where there is urbanization without people practicing any of these cultural practices I've said.

So yes, they are risky. And yes, we do have to change them. But we should make sure that we deal very much on these gender and power relationships between men and women and the value of the woman in society. I think if we don't address that aspect and only look at whether the woman is inherited or not we'll be scratching the surface.

Brenda: How will Malawi be different in the future than in the past as a result of HIV?

Dr. Kaluwa: Apart from the impact and the problems that it will bring obviously, but I think it will change how we have viewed life and done business, How we have related to others. It will probably bring out, and I think generally, probably it will bring out the best in humankind. Maybe it will get to a point where, if people can talk freely and people can accept people living with HIV/AIDS then, people will be much more loving and caring. Um…. After the damage it will have done to us but, I think, we will be able to come out on top of that as a much better society, much more cohesive in dealing with a common problem. And therefore, maybe, much better poised to survive any other threats that might befall us.

Brenda: How do you feel young people fit into that?

Dr. Kaluwa: Young people are the most important target group that we have to deal with. First of all, they're the group of people with the least HIV infection, but also the group of people most vulnerable to getting HIV. So we have a big challenge with the youth to say: how are we going to keep them HIV negative?

This is an age group when they are starting to practice sexuality etc. And they're trying to experiment with everything else. We need to have the strategies that will address this particular group and keep it HIV negative.

If we can have a group of young people who are much more caring about the other person - because that's where it starts from, caring much more about other people, and a group of young people who are open on issues of HIV and other issues associated with HIV and other STDs, then we should be able to start moving towards a direction where we are going to have less HIV infection.

They are our hope. The other groups, those who will be infected, most of them are already infected and if we are going to have new infections in older groups they are probably few but the challenge is there. If we can maintain these young people HIV negative in the next decade or so we should be on the right road towards doing away with this terrible epidemic.

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