Charlotte Ryan reports from Malawi
IN ONE OF the consultation rooms tucked in the belly of the Centre for the Development of People’s (CEDEP) drop-in centre, Angela Souza demonstrates how to put on a condom using a simplistic wooden model.
As a district coordinator in this part of Malawi, it’s a practice she’s carried out many times for visitors to the centre. In the mid-afternoon light, the walls are lined with graphic photos of advanced STIs and genital diseases, and signs instructing visitors to “wash your hands”.
CEDEP’s main function is to raise awareness about HIV and STIs among people. The centre offers a safe space for LGBT+ people and sex workers to access healthcare, as well as to socialise and receive advice about sexual matters.
As they offer services such as STI and HIV screening, treatment and contraception, they are one organisation plugging the gap in Malawi’s healthcare system worsened by the global gag rule.
The global gag rule is an American policy limiting US funding to overseas NGOs that provide family planning services, from abortion – which is illegal in Malawi – to contraception, counselling and similar services.
In the time since it was reinstated in 2017 by President Donald Trump, it has placed inordinate strain on NGOs that try to provide much-needed healthcare to vulnerable populations.
“We are a cheaper option”, says Mphatso Mpoma, a manager of the drop-in centre.
One in five
Despite impressive work to suppress the spread of HIV and AIDS in recent years, Malawi remains one of the most HIV-prevalent countries in the world, with 9.2% of the adult population infected.
According to Ministry of Health spokesperson Joshua Malonga, Malawi is on track to meet its 90-90-90 targets set by UNAIDS, whereby 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment and 90% of people on treatment have suppressed viral loads by 2020.
Still, there are concerning statistics. According to USAID, almost one in five men who have sex with men are living with HIV (17.3%), and stigma and discrimination towards the community, as well as a low uptake of condoms, hinder progress.
However, the fight is worsened by barriers that are less easy to mitigate.
Homosexuality is illegal in Malawi, with the Penal Code forbidding “carnal knowledge against the order of nature”, a catch-all penalty that could charge men with up to 14 years imprisonment, with or without corporal punishment, and up to five years imprisonment for women.
Although a moratorium has been placed on the arrest of people engaged in such activities since 2015, the community continues to face discrimination.
Exacerbating efforts to stop the spread of HIV are deeply ingrained traditional beliefs, including the teachings of influential religious leaders across communities, misinformation spread by herbalists and witchdoctors and troubling misconceptions that have their roots in Malawi’s colonised past.
“Our society, regardless of the law that is there, thinks that same sex relationships are not Malawian, they are not Africans”, Rodney Chalera, the programmes manager at CEDEP, explains. “And therefore it’s like, ‘some westerners come in to teach African people how to do it’. You find out that even if the law isn’t enabling, we still have a lot to do in changing the attitudes of the society.”
Where there are no signs
Reaching the centre requires some insider knowledge, a link to a location that must remain clandestine. No sign adorns the rust-coloured steel gate, and it isn’t until you reach the front lobby that the purpose of the building becomes clear. On the wall behind the front desk, a simple print-out reads: “This is a stigma free environment.” Outside, chicken wire tops the towering stone walls.
“We don’t hide what we do, despite the fact that you didn’t find a signpost here”, Chalera says, adding that such measures are to protect clients and staff from homophobic attacks. “It’s deliberate, but at the moment I wouldn’t say that our work is some sort of hidden work.”
As proud of their work the centre is, Chalera and his team must be furtive about reaching LGBT+ people in need. Through their peer navigator model – whereby HIV positive men in the centre establish links with other HIV positive men – they have created an effective, albeit underground, service channel.
“The whole purpose was to come up with this supported group”, Chalera explains, “a group that is entact, that should be able to be following up on one another, encouraging each other to adhere to treatment.” They test each new peer for HIV, and track them with an identifying number, ensuring identities are concealed.
“We are dealing with a hidden population”, he says, “so it is not easy for us to go into the marketplace and [speak] on the loudspeaker, ‘come, come here, there is a service for men who have sex with men.’ It won’t work.”
A sense of purpose
Outside a nightclub in Lilongwe, plumes of smoke rise from an open grill, the club’s shadowy interior starkly contrasted with the blue neon lights snaking across its facade. Under an awning lit only by a television playing a football match, we meet Asale* and Bante*.
They are two gay men living with HIV, and they are peer navigators. They are also the first gay men my fixer and driver have met in person.
Speaking under the condition of anonymity and only in Chewa, the national language of Malawi, Asale explains how he was referred to CEDEP by another HIV positive man.
After some time in the centre, Asale was approached to become a peer navigator, a role he took to with relish. “I used to only go for the gym or for a place to be myself. I would wake up depressed and alone”, he says. “Now, I wake up with purpose. It gives me something better to do.”
Asale referred Bante to the centre. Now on anti-retroviral treatment, both men are in relationships, though their families do not know of their sexual orientation.
Dark corners of society
The global gag rule tightens the constraints on this vulnerable community, limiting access to already scarce resources and further pushing them into the dark corners of society. The Ministry of Health last year introduced self-testing kits that are available for free in pharmacies and health clinics.
“Any time of day, they can just go get the test they need, and they conduct the test on their own”, Malonga explains. Once they get that test, we If the results are positive, patients can approach a health centre for a second test to confirm the results. If both tests are positive, the patient is immediately referred for treatment.
While such initiatives are welcome in the effort to reach more at-risk people, questions remain as to how the government of any country affected by the global gag rule can adequately plug the gap in funding.
Malonga asserts that the Ministry will manage to reach the 90-90-90 goals and curb the spread of HIV. However, he concedes that the global gag rule will have an indelible affect on the country’s healthcare.
“There’s too big a gap. The gap will still be there. The government can come in, but still there’ll be some gap, because you know, these NGOs and some of these donor partners, they are doing some of the community work to the health sector, most especially.”
This article was supported by the Simon Cumbers Media Fund.
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