Malawi has had substantial success in addressing HIV/AIDS prevalence over the years, with up to 90% of those living with HIV being aware of their status and having been initiated on antiretroviral therapy (ART). That being said, stemming new infections remain a concern in the country, with an estimated 32,300 new infections in 2019 alone. Female Sex Workers (FSWs) are a key population that need to be provided with HIV/AIDS services to lessen the disease burden nationwide. This points to the importance of targeting further programming toward the FSW community. As of 2017, Malawi had approximately 36,000 FSWs with an estimated HIV prevalence around 60% with the figure growing steadily over the years. It is therefore essential that as the Government of Malawi actively works to further reduce HIV prevalence in the country, as well as manage already existent cases; interventions utilised ought to be holistic, effective and efficient.
A cost-benefit analysis conducted by the Malawi Priorities on expanding HIV prevention and treatment services to female sex workers in Malawi finds that providing HIV/AIDS services to FSWs is critical to reducing the spread of the disease. This analysis indicates that FSWs contribute approximately 15% of new cases annually. Additionally, new entrants into the profession, typically younger women, are at extremely high risk of becoming HIV-positive within the first few years of work, adding to new infections as well as potential costs to the healthcare system throughout their lifetimes. The study, therefore, recommends three interventions targeted at FSWs to reduce the disease burden.
The first intervention addresses challenges faced in the prevention and treatment of HIV/AIDS through the use of a Comprehensive Ambipolar Package (CAP). This package includes the provision of pre-exposure prophylaxis (PrEP) and ART counselling for FSWs, as well as semi-annual testing, case management and support services. Based on the results of the test, PrEP or ART would be provided through the health system. Observance of this intervention would avert over 23,500 new infections by 2025 and 63,200 infections by 2030. The analysis suggests that for every MWK 1 invested in this intervention, it generates MWK 2.30 of social benefits.
The second intervention recommends ART counselling for FSWs living with HIV/AIDS. This would comprise the targeting and testing of all FSWs in Malawi, but only those who are living with HIV would be provided with counselling. Initially, the largest benefit is avoided mortality. Subsequently, the intervention reduces transmission to male clients and their partners, leading to around 2,700 avoided infections in the first year rising to just over 3,700 by 2030.
The final intervention presented is the provision of pre-exposure prophylaxis (PrEP) for FSWs who are HIV-negative. This intervention would target and test all FSWs and provide those who are HIV-negative with PrEP. The program identifies FSWs and provides them with periodic testing, counselling for PrEP adherence and PrEP drugs for HIV-negative individuals. The study further states that this course of action would result in 39,290 cases of new HIV cases avoided in FSWs, their clients and their clients’ partners.
It is evident that to preserve lives, as well as significantly lessen government and donor spending on HIV/AIDS in Malawi, FSWs must be actively sought out and included in interventions that seek to curb the disease. The CAP approach showed to be the most cost-effective and impactful HIV/AIDS intervention. An HIV free Malawi is possible, but requires policymakers to develop health budgets targeted towards risk groups such as FSWs.
The Malawi Priorities Project, is a research-based collaborative project implemented by the National Planning Commission (NPC), with technical assistance from the African Institute for Development Policy (AFIDEP) and the Copenhagen Consensus Center, highlights most cost-effective policy interventions that can support and help the nation.
Read the full study and policy brief here:
- Cost Benefit Analysis of expanding HIV prevention and treatment services to female sex workers in Malawi – Technical Report
- Cost Benefit Analysis of expanding HIV prevention and treatment services to female sex workers in Malawi – Policy Brief