A 15-year review of the PEPFAR support to Malawi: How Has it Succeeded?

Monday, October 7, the Petrie-Flom Center is co-sponsoring “15+ Years of PEPFAR: How U.S. Action on HIV/AIDS Has Changed Global Health,” from 8:30 AM to 6:00 PM. The event is free and open to the public, but registration is required. This event is cosponsored by the Harvard Global Health Institute, the Harvard University Center for AIDS Research, the Center for Health Law Policy and Innovation at Harvard Law School, and the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School.

By Maureen Luba

Malawi was listed as one of the six locations that have made remarkable progress towards ending the AIDS epidemic in a recent report produced by AmfAR, AVAC, and Friends of the Global Fight. Being one of the poorest countries on the list, Malawi has proven that ending the epidemic is possible anywhere.

But one would want to know what has contributed to this success!

Well, there are many factors. And funding from donors is one of them. The HIV/AIDS response in Malawi is largely funded by the Global Fund and PEPFAR. But for the sake of this blog I will focus on PEPFAR, a U.S. government program launched in 2003 by then President George W. Bush. In 15 years of support, PEPFAR has led the world in funding the global HIV response.

In Malawi, PEPFAR has invested nearly $700 million since 2003, which has brought significant improvements in the HIV/AIDS response.

But as you know, funding alone does not guarantee success. There are other factors that have played a role, such as increasing efficiency in the use of the resources, linking funding to performance and impact, having the right policies in place, and widening stakeholder involvement, just to mention a few.

PEPFAR’s attention to geographical locations that carry a high burden of HIV incidence has resulted in funds going where they are needed most. PEPFAR has fought hard for the adoption of evidence-based policies, which in turn led to the implementation of the highest impact interventions.

PEPFAR’s strong recommendation to shift from paper to electronic medical records (EMR) has been another game changer for the HIV response in Malawi. Shifting to EMR improved real time access to data throughout the health care system.

Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS), a PEPFAR program meant to reduce HIV infections among adolescent girls and young women, has been another remarkable initiative rolled out to three districts in Malawi. The program has helped improved the socio-economic wellbeing of adolescent girls and young women, thereby reducing their HIV risk.

The HIV response took another important leap forward when PEPFAR opened up its doors to civil society organizations (CSOs). For me, this was proof of the principle that the best results come when funding and policy decisions are made in the presence of everyone who matters.

I remember attending the first country operational plan (COP) meeting where CSOs were invited. It was a revolutionary moment. Having CSOs in the room changed the course of the discussion. For the first time, we had everyone who mattered in the room. The following year we did it again and we are still doing it now.

But there have been challenges too! The first two years following PEPFAR’s inclusion of CSOs, civil society received limited access to PEPFAR data — it was shared late or not at all. This made it difficult for CSOs to effectively engage in the process. CSOs advocated for a change, and PEPFAR leadership has responded by making the data available, though not always timely. But we are getting there.

The other challenge has been getting policies fully implemented. A policy on paper alone is as good as no policy at all. This has been a big challenge for Malawi largely due to limited funding. Malawians can point to a full range of policies now in place, but yet some of them are live only on the books such as the Pre-Exposure Prophylaxis (PrEP) and the T=T/U=U campaigns, both of which have proven to be highest impact interventions elsewhere!

Moving forward a few things need more attention.

We all love the DREAMS program, but only focusing on three districts is not enough. It is time to scale it up!

As we get closer to epidemic control it’s important that we start thinking about how are we going to sustain the gains made so far. PEPFAR has committed to direct 70% of the funding to host country governments or organizations by the end of 2020 — this is highly commendable. However, this should not only be on paper, it has to be fully implemented. Lack of capacity should not be an excuse. Deliberate effort must be made to fill any gaps in capacity.

We need to embrace the model of differentiated service delivery to meet the diverse needs of the community members! To date we still have community members who travel a distance of more than 20 kilometers on foot just to get their ART refill! This is not acceptable! We need to get the services closer to them!

And, above all, policies must be fully implemented.

Maureen Luba is the African Region Advocacy Advisor for AIDS Vaccine Advocacy Coalition (AVAC), Malawi and 2019 Jane Jie Sun Women in Global Health LEAD Fellow, Harvard T. H. Chan School of Public Health.