Before COVID-19, Malawi was on its way to ending AIDS. Now what?

Community Health Workers conduct door-to-door screening for COVID-19 in Limpopo, South Africa.

In Christopher Mlotha’s health district, Lilongwe, clinic visits for HIV treatment declined sharply when the country declared a COVID-19 state of emergency in early April this year.

Mlotha coordinates HIV care and treatment (the ART program) for a district that covers 94 ART sites. He worries about what the pandemic will mean for his clients. Even as clients begin to trickle back in, stockouts of HIV medications and other essential drugs persist, sometimes making it difficult for Mlotha to provide proper care to the people waiting in line to see him. He wonders whether the new hand-washing stations installed outside of clinics will be enough to keep his clients and staff healthy, and about how long the district can afford to replenish its supplies of masks and other protective equipment.

Across Malawi, the number of deaths due to HIV plummeted by 75% over the past 15 years, largely due to the increased availability of lifesaving antiretroviral treatment. But a recent survey shows that lockdowns, transport interruptions and other COVID-19-related disruptions have affected carefully built treatment programs in the vast majority of countries served by the Global Fund, including Malawi. If these disruptions continue, UNAIDS and WHO estimate that more than half a million people in Africa will die of AIDS-related illnesses in the next year — setting Malawi and its neighbors back to where they were in 2008.

Still, up to now most of Mlotha’s clients have been able to keep up with their medications despite the pandemic. That’s because Malawi has developed far-sighted guidance for HIV treatment, allowing people who have been taking HIV medication for at least six months and have a stable viral load to take home a multi-month supply of medications, which reduces the need to travel to the clinic. In the context of COVID-19, a growing number of programs around the world are shifting to these client-centered solutions, also known as differentiated service delivery. Making it easy for people to access the HIV treatment they need always made sense. Today, these models of service delivery have proven to be an essential lifeline.

For Mlotha they are a stake in ground against resurging AIDS. But supporting people already on treatment is only part of the story. Mlotha’s greatest concern is for the people he’s never seen at the clinic: young men who avoid health care visits; sex workers; gay men afraid to be seen at an HIV facility. Even before COVID-19 hit, a quarter of the district’s clients were lost to follow-up. Now, with ongoing travel restrictions making it impossible for teams of community health workers and volunteers to fan out into neighborhoods providing information and support, Mlotha is afraid some people may fall out of care altogether – and new infections will go undiagnosed and untreated.

“Before COVID, we were out in the communities, so more and more people were learning about their infections and starting and staying on treatment,” says Mlotha. “COVID is staying. But so is HIV. We still need to do everything we can to keep people with HIV healthy and prevent new infections.”

The models for differentiated service delivery , the teams of community health worker teams, the mobile clinics, the support networks and the supply chain — the entire apparatus that Malawi built to combat HIV will be instrumental to the fight against COVID-19 too. These are the systems and services that people already know and trust, and they are the tools. to effectively confront COVID-19 — and pandemics to come. Safeguarding this capacity and investing to make it even stronger is how the world protects, sustains, and builds on these crucial global health gains.

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UNAIDS and WHO project that COVID-19-related service disruptions could lead to hundreds of thousands of AIDS-related deaths, setting back progress by more than a decade.

Posha Ndelemani and her son, Felix, in Zomba, Malawi.

Community Health Workers conduct door-to-door screening for COVID-19 in Limpopo, South Africa

Lilongwe District ART Coordinator Christopher Mlotha uses a hand-washing station before entering a clinic.

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Advocate for continued national and global investment in efforts to end the HIV epidemic. Donors and implementing countries should increase investment in the HIV response; donors should also support the Global Fund’s COVID-19 Response Mechanism.

Advocate for policies and programs that make it easier for people to access health care, testing and treatment, including for HIV and for COVID-19.

Advocate for inclusion and prioritization of vulnerable and marginalized groups in HIV programming and in the COVID-19 response

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Examine the data showing how deaths from HIV, TB and malaria could almost double unless urgent action is taken

Learn about client-centered approaches to HIV service delivery, and see what policies your country has implemented

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