POWERFUL PHOTOS: Daily struggles of the most vulnerable in Malawi

Wednesday, October 18, 2017 — MSF in Malawi

In 2016, MSF marked 30 years of presence in Malawi, initially to a refugee crisis in 1986 and then becoming heavily involved in the growing HIV response.

Today in Chiradzulu and Nsanje, two districts in Malawi’s southern region, MSF supports the health ministry to meet the health needs of those particularly vulnerable: children, adolescents and women living with HIV, severely ill people failing first-line ARV treatment, and women who identify as sex workers.  Special emphasis is placed on testing infants for HIV and a spectrum of medical care for severely ill patients living with advanced HIV.

Nsanje: Sexual & reproductive healthcare for sex workers

Since 2013, MSF supports the health ministry to provide health care and referral networks specially tailored to the needs and movements of nearly 1000 sex workers enrolled as part of a ‘sex worker program’ in Nsanje.

Sex workers are 5.4 times more at risk of contracting HIV than their counterparts in the general population. MSF data collected showed that 41% of sex workers enrolled in the program were HIV positive. Sex workers in Malawi often face violence, criminalisation and exclusion from essential reproductive healthcare, including prevention of HIV, Sexually Transmitted Infections (STIs) and unwanted pregnancy.

In MSF’s project, women are identified and supported by Peer Educators - themselves sex workers – through trusted, word-of-mouth networks.  Mobile clinics rotate between five sites, including in Bangula Trading Centre, delivering packages of HIV, TB and reproductive healthcare. HIV positive women are invited to join Sex Worker ART Groups (SWAGs) allowing them to collect their ARVs while on the move.

Nsanje: Treating advanced HIV

In this sparsely populated, largely rural area, people living with HIV face many challenges staying on lifelong treatment. Just getting to health centres for check-ups can be costly, time-consuming and difficult.

In 2016, an MSF survey of inpatient records revealed that up to 37% of admissions in the district hospital were related to HIV with 54% of inpatient deaths being due to HIV. HIV patients were five times more likely to die than HIV negative patients, despite more than 65% being on antiretroviral treatment. Nearly 30% of patients treated for HIV arrived in such severe stages of immune failure that they died within 48 hours of hospital admission. 

MSF is adapting its support to Nsanje hospital in 2017, specifically to deliver a training program for health ministry staff to improve diagnosis and clinical management of advanced HIV and related opportunistic infections, including TB. This is supplemented with laboratory, imaging and pharmacy support and supplies of essential medicines. Improved links between hospital and community ensure that patients can be referred earlier and followed up for three months after discharge.

Nsanje: Mentoring and material support

With Malawi facing an economic crisis, district health budgets have been slashed. Referral hospitals like Nsanje district hospital are experiencing critical shortages of staff, drugs, power, food and water. Fuel cuts and lack of maintenance have reduced life-saving ambulance referrals.

Through the ‘Nsanje HIV TB District Support’ model, MSF is assisting the severely underfunded district health service to strengthen its coordination and improve HIV and TB services. Along with mentoring and training of health staff in the Nsanje hospital and 14 health centres, essential hospital services, including laboratories and pharmacies are being reinforced to improve standards and ensure the continuous supply of essential drugs.

Chiradzulu: Prevention and early treatment of cervical cancer:

Malawi has the highest rates of cervical cancer in the world, with an estimated 75 of every 100 000 women newly affected each year. Yet as in many less wealthy countries, there are gaps in the prevention, diagnosis and early treatment of cervical cancer, particularly in southern Malawi. Only 10 to 20% of women in Malawi receive early screenings and no preventive vaccinations or treatments exist.

In collaboration with the Malawi health ministry, local and international partners, an integrated approach is being developed for women aged 9 to 49 years in urban Blantyre and Chiradzulu district. Starting with strengthened screenings and early treatment for pre-cancerous lesions, the project will soon include HPV vaccinations and treatment for cervical cancer.  

Chiradzulu: Teen clubs for adolescents living with HIV

Young people living with HIV, especially between ages 10 to 17 need specific support to help them adapt to their diagnosis. In 2016, the Saturday Teen Clubs space was created, promoting social activities, health education, and counselling for young people. A key focus is to create a supportive environment where adolescents  - some of whom may have lost parents due to HIV - receive support from peers and can identify with other young people living with HIV.

In the coming years, medical care for stable adolescents living with HIV will be integrated with mental health, nutrition, sexual and reproductive health support.

Chiradzulu: Complicated HIV clinic days

Many factors in the lifelong treatment for HIV can cause ‘treatment failure’, where antiretrovirals (ARVs) don’t properly suppress the virus in the blood: social and economic factors, lack of support among others can lead to poor adherence to treatment, or people can develop drug resistance.

Such people need increased attention from clinicians and dedicated diagnostics and treatment. In Chiradzulu, rural health facilities designate specific days to treat so-called ‘complicated cases’: children, adolescents and adults presenting with high viral loads, side effects and opportunistic infections. Patient education, counselling and sometimes social support is also provided.

MSF and the health ministry are also working together to implement and improve the quality of care for HIV patients at primary health care level, in order to keep patients under an effective treatment at any given time.

Selena Bishop from Ng'ombe village, undergoes her her monthly consultation at Sorgin Health Centre, Nsanje. Serena is HIV positive and has come to collect her ARV refill. The clinican has recommended a malnutrition assessment. Photographer: Luca Sola
Mbulumbuzi Health CentreAdolescent HIV project. Patients and MSF staff perform a dance to start the "six-months-meeting day" in which the supporting staff welcome new members and monitor all the girls and boy who already joined the program. Photographer: Luca Sola
Zuze Bingala, 54 years, from Mozambique, has been admitted to Nsanje district hospital with advanced HIV with opportunistic infections TB and cryptococcal meningitis. He is unconscious, and is being aided by his wife Abesi (age not known) and MSF clinician Kenwood Kumwenda, 32 years and.<br/><br/>Zuze and Abesi are both from Mozambique; they have four children. His brother Stephen has also accompanied him. Stephen says: <br/><br/>“We have been here for a month due to the sickness of my brother. The nearest hospital to us is Nsanje other than the Shire hospital in Mozambique which is far. He was getting better and better but just last week when he developed diarrhea and stopped walking on his own. We come here from Mozambique, everything has stopped at home. We support each other caring for him since we can’t move from here.”<br/>Abesi says: “In our community stigma and discrimination are too much that when found positive, its difficult to share even to your relatives.”<br/><br/>In 2016, an MSF survey of 1183 admissions in hospital over six months revealed that HIV inpatients accounted for 26 % of all admissions in male and female wards, and HIV deaths made up 54 % of all deaths. Over 80% of HIV admissions arrived in advanced stages of the disease (defined as a CD4 count. Photographer: Luca Sola
Main entrance of Nsanje District Hospital, Nsanje district, Malawi<br/><br/>MSF has been present in Nsanje district since early 2011 working in close collaboration with the Nsanje District Health Management Team (DHMT) with the aim to provide support and mentorship to ensure capacity building for health care workers so they can deliver quality services at the different health facilities.<br/><br/>MSF financially supports the district by complementing its budget to provide for an additional meal for the admitted patients, fuel for ambulances for patients to be referred to hospital, fuel for the generator, maintenance support for ambulances as well as the provision of essential medical equipment at health centres among other things. Photographer: Luca Sola
Alfred Nema, 18 years old, from Ntweya village is an MSF patient (HIV and TBC positive). Due to the medical protocol, despite his hilliness, he can study and work.<br/><br/><br/><br/>How do you feel living with HIV? <br/>I don’t feel comfortable especially when am alone, sometime back people used to mock me about the my status.<br/><br/>Do you think people’s look changed when they look about you?<br/>People feel sad about my status.<br/><br/>What is the main constraint for someone living with HIV?<br/>To me going to hospital monthly to collect drugs is constraint and also mixing with older people waiting for drugs gives me headache.<br/><br/>Is there anything you don’t do because you have HIV?<br/>I do anything.<br/><br/>What changed in your life since you know you have HIV?<br/>Nothing really changed but sometimes am stressed when I think about my status and I don’t feel comfortable and I spend much of my time worrying about my future.<br/><br/>Greatest regret-having HIV without knowing where I got the it from, it makes me sad.<br/>Greatest hope- I heard that sometime back a lot of people had to opportunity to receive treatment and now a days drugs are available it gives me hope and I see the bright future. Photograher: Luca Sola
lfred Nema, 18 years old, from Ntweya village is an MSF patient (HIV and TBC positive).<br/><br/><br/><br/>How do you feel living with HIV? <br/>I don’t feel comfortable especially when am alone, sometime back people used to mock me about the my status.<br/><br/>Do you think people’s look changed when they look about you?<br/>People feel sad about my status.<br/><br/>What is the main constraint for someone living with HIV?<br/>To me going to hospital monthly to collect drugs is constraint and also mixing with older people waiting for drugs gives me headache.<br/><br/>Is there anything you don’t do because you have HIV?<br/>I do anything.<br/><br/>What changed in your life since you know you have HIV?<br/>Nothing really changed but sometimes am stressed when I think about my status and I don’t feel comfortable and I spend much of my time worrying about my future.<br/><br/>Greatest regret-having HIV without knowing where I got the it from, it makes me sad.<br/>Greatest hope- I heard that sometime back a lot of people had to opportunity to receive treatment and now a days drugs are available it gives me hope and I see the bright future. Photographer: Luca Sola
16 years old, from Ntipasonje Village is an MSF patient (HIV and TBC positive). <br/><br/><br/><br/>How do you feel living with HIV?<br/>At first, it was difficult to accept that I have HIV. So I was living with stress and sometime I was mad with my mother, and sometime people could mock me saying am a patient. But now I accepted my status and I don’t complain.<br/><br/>Do you think peoples face changed when they look at you?<br/>Yes some people look changed when they look at me. <br/><br/>What is the main constraint for someone living with HIV?<br/>The only constraint I face on day to day life is discrimination. People sometimes discriminate you because you have HIV. They will not let you participate some activities and this has been happening to me.<br/><br/>Is there anything you don’t do because you have HIV?<br/>YES, during the wedding ceremonies the organisers do not put me in bridal party just because am HIV. Sometimes it is hard to play with friends they discriminate me.<br/><br/>What changed in your life since you know you have HIV?<br/>Nothing has changed.<br/><br/>Greatest regret – I don’t have any regret<br/>Greatest hope – I will finish my school and get a job. Photographer: Luca Sola
Women sitting in Milepa Health Centre waiting room to be screened for cervical cancer. Photographer: Luca Sola
Selena Bishop from Ng'ombe village, undergoes her her monthly consultation at Sorgin Health Centre, Nsanje. Serena is HIV positive and has come to collect her ARV refill. The clinican has recommended a malnutrition assessment. Photographer: Luca Sola
Evelyn Shaibu, 46 years old, is an MSF's HIV and TBC patients. Photographer: Luca Sola
Hills in Lulwe, Nsanje district. <br/><br/>Nsanje is the southernmost district in Malawi and lies in the Lower Shire River Valley, surrounded on all sides by Mozambique. The 1,942 km2 area has a population of nearly 200,000 people<br/>Nsanje has an estimated adult HIV prevalence rate of 11.8%, with 44,792 people living with HIV.<br/><br/>People living with HIV still face many difficulties accessing regular treatment. In this sparsely populated, largely rural area, just getting to health centres can be costly, time consuming and difficult. At the same time, severe shortages of health staff and over-congested waiting rooms mean that health centres struggle to manage the growing number of people on anti-retrovirals needing lifelong care. Photographer: Luca Sola
Misheki Nguni, 42 years (second from left) talks about the importance of good treatment adherence with Felizhi Nkhofe, 59 years (left), Nasiyo Bizeke, 51 years, Eveln Daimon, 32 years and Gladys Daimon, 37 years. All are members of a trans-border CAGs<br/><br/>Nsanje has an estimated adult HIV prevalence rate of 12.1%, with 44,792 people living with HIV.<br/><br/>A large number of patients accessing Antiretroviral Treatment (ART) and HIV care come from Mozambique. <br/><br/>An MSF assessment showed that 10 out of the 14 health centres have registered patients from Mozambique, with on facility alone having 81% of total patients on ART being Mozambican. About 28% of the total patients alive on ART (in Nsanje are estimated to be from Mozambique.)<br/><br/>As a result, MSF started piloting trans-border CAGs at the end of 2016. These are intended to serve HIV patients from Mozambique who have to walk long distances to access health care in neighbouring Malawi, thus minimising the number of patients lost to care as well as saving them time, money and additional risks. So far, MSF has piloted trans-border CAGs on three health centres and hopes to scale up to other health centres. Linkage and referral between neighbouring health facilities along the border would ease follow up of patients.<br/><br/>About CAGS: In 2015, Community ART Groups (CAGs) were introduced into Nsanje District through a partnership between the Malawian Health Ministry and MSF. CAGS are a model of ART distribution, where groups of patients who are stable on treatment rotate for clinic visits and drug refill collection at the clinic. At home, members distribute the drugs to their peers and provide each other with support. <br/><br/>Demand by stable patients to join CAGs has steadily grown and by April 2017, there were 2,964 CAG members in total, representing 16 % of the total HIV cohort of 16,856 people from Nsanje’s 14 health centres which MSF supports through the Nsanje HIV TB District Support programme. Photographer: Luca Sola
Evelyn Shaibu, 46 years old, is an MSF's HIV and TBC patients. Photographer: Luca Sola
Simbazako Thove, 19 years, who has HIV and TB is prepared for an X-ray in the X-ray room, Nsanje district hospital. <br/><br/>Simbazako was forced to leave school due to financial problems. He lost both parents and now stays with his elder brother who is a small scale farmer. He has had two previous chest X-rays in Nsanje hospital, and has come again due to pains in his chest.<br/>Simbazako, who came alone, tested HIV positive last year and takes his antiretrovirals regularly. He had heard about HIV and because he was continually sick, decided to for an HIV test. Members of his local church sometimes support him, but he can go a day or so without food sometimes. His sister lives far away.<br/><br/>Simbazako says “I feel too much pain in my ribs. I take my ARVs without skipping even a day but my health is not improving as I had expected.” <br/><br/>Through the Nsanje HIV TB District Support programme, MSF is working with medical teams in Nsanje district hospital to improve diagnosis and clinical care of AIDS, including imaging, laboratory and pharmacy support. Photographer: Luca Sola
Sylvester, 31 years (left), an MSF staff member and Chrissy, 36 years, MSF staff nurse (middle) during a consultation with Shira Khani who identifies as a sexworker and is attending MSF’s sex worker clinic at Bangula Trading Center<br/><br/>The national prevalence of HIV among women who engage in commercial or transactional sex in Malawi is estimated at 73% (NAC, 2012). <br/><br/>Sex workers are 5.4 times more at risk of contracting HIV than their counterparts in the general population. MSF data collected showed that 41% of sex workers enrolled in the program were HIV positive. Sex workers in Malawi often face violence, criminalisation and exclusion from essential reproductive healthcare, including prevention of HIV, Sexually Transmitted Infections (STIs) and unwanted pregnancy. <br/><br/>Started in May 2013, the ‘sex worker programme’ in Nsanje is an MSF and Ministry of Health partnership which aims to develop a model of care for women who identify as sex workers, who are considered as a group at high risk of contracting HIV. <br/>The programme runs outreach clinics in five pre-identified sites, including Bangula Trading centre. Sex workers from this area travel to Nchalo, Nsanje town as well as Mozambique according to the regions’ seasonal economic activities.<br/><br/>Women are mobilised to attend mobile clinics that rotate between five different sites and provide a standard package of sexual and reproductive health services. The package includes HIV testing, viral load monitoring, counselling; TB screening & referrals; testing & treatment for sexually transmitted infections (STIs), family planning, condom and lubricant distribution, and referrals for termination of pregnancy. Women who test positive with HIV are navigated to a local clinic to register and start treatment.) Photographer: Luca Sola
Sugar plantation's seasonal workers are among the clients of the local sex workers. Sex workers from this area travel to Nchalo, Nsanje town as well as Mozambique according to the regions’ seasonal economic activities.<br/><br/>Sex workers’ are 5.4 times (95% CI; 4.7 – 6.1) more at risk of contracting HIV than their counterparts in the general population, according to MSF routine data collection, recording that 41,4% (414 out of 999) of sex workers were HIV positive on enrolment in Nsanje sex worker program. Photographer: Luca Sola
Selena Bishop from Ng'ombe village, undergoes her her monthly consultation at Sorgin Health Centre, Nsanje. Serena is HIV positive and has come to collect her ARV refill. The clinican has recommended a malnutrition assessment. Photographer: Luca Sola
Lying in the inpatient department in Nsanje district hospital, Misheck Kushiteka, 29 years, from Mozambique come to Malawi for work. After one month, he had a malaria attack. His neighbours helped to accompany him to Nsanje Hospital During his stay at Nsanje district hospital, he was diagnosed HIV positive with severe immune failure. Misheck has been on antiretrovirals since February 2017 and his CD4 count (a measure of the body’s immunity) is 680.<br/><br/>“I am feeling a bit better but I still cannot move. When I get better, I plan to stay in Malawi because where I come from, stigma is very high towards people who are HIV positive like me. Here in Malawi, people support each other.”<br/><br/>In 2016, an MSF survey of 1183 admissions in hospital over six months revealed that HIV inpatients accounted for 26 % of all admissions in male and female wards, and HIV deaths made up 54 % of all deaths. Over 80% of HIV admissions arrived in advanced stages of the disease (defined as a CD4 count. Photgrapher: Luca Sola