HIV prevalence in Malawi is declining overall with new infections reducing from 55,000 in 2011 to 34,000 in 2013. Implementation of effective prevention, treatment, care and support interventions in the national response need to take into consideration certain realities. These realities include the fact that at least half of these infections are occurring among young people aged 15-24 years; and the majority of people being infected are those who were previously considered to be at low risk, for example, couples and partners in stable sexual relationships; the lessons the country has learned through a successful public health approach treatment program, HIV testing and treatment not only improves the lives of those infected but contribute substantially to prevention and the changing legal and social landscape for key populations such as men having sex with men and sex workers.

Early Antiretroviral treatment (ART) is the most powerful intervention available to prevent HIV morbidity and mortality, particularly in the context of Malawi’s health services with limited capacity to diagnose and manage HIV-related diseases. There is overwhelming evidence, including from Malawi, that early ART reduces TB risk by 51%, AIDS-defining clinical events by 51%, and primarily clinical events by 27%.

Malawi’s rapid and successful Antiretroviral Therapy(ARV) scale-up from 2004 to 2014 has critically influenced the HIV epidemic, reducing mortality, morbidity, and transmission. In the one decade since starting the national treatment program:

1. out of every 20 Malawi adults is now on ART

2. 275,000 deaths have been averted

3. 1.4 million life-years have been gained, primarily among young adults in their peak productive life period.

In 2011, Malawi started implementing Prevention of Mother to Child Transmission (PMTCT) Option B+ policy, making life-long ART available for all HIV infected pregnant and breastfeeding women, regardless of clinical stage or CD4 count. This has resulted in a 66% reduction of vertical transmission within 3 years. This Malawi-pioneered strategy has since been included in global guidance by World Health organisation (WHO). As of February 2014, 12 other African countries were implementing Option B+.

Based on Malawi’s proven ability to sustain a rapid ART scale-up in spite of severe health system constraints, this 5 year strategic plan aims to meet the Ambitious 90-90-90 Treatment Targets released by UNAIDS in 2014, preparing to control the HIV epidemic by 2030. By the end of 2020, Malawi will have:

1. Diagnosed 90% of all people living with HIV (PLHIV)

2. Started and retained 90% of those diagnosed on ART

3. Achieved viral suppression for 90% of patients on ART

Reaching these 90-90-90 goals in 2020 will result in 760,000 (73%) of the projected 1,042,000 PLHIV being virally suppressed, leading to a dramatic reduction in sexual and vertical transmission at the population level. By 2020, this strategic plan aims to:

1. Reduce adult (15-49 years) HIV incidence to 0.2, equivalent to 17,000 new infections annually

2. Reduce the number of children infected by their mothers to 3,900 annually

Within the 5 year period covered by this plan, Malawi will have:

1. Prevented an additional 78,000 new adult (15-49 years) infections, compared with a scenario of maintaining the ART cohort at the 2014 level

2. Prevented 75,000 child infections through Option B+

This 2015-2020 National Strategic Plan (NSP) for HIV will focus on meeting the 90-90-90 targets through identifying critical program and system gaps and ensuring those gaps are closed within the next five years. The NSP cuts across multiple sectors including health, and creates a common understanding for all HIV and AIDS stakeholders: government, civil society, the private sector, and development partners to work together towards achieving the expected results. The NSP is not intended to replace or duplicate other strategies; rather, the NSP provides the guiding or leading document and context within which other sectoral strategic plans and budgets should be formulated, monitored, and coordinated.

Given the aim of extending survival of PLHIV through early treatment, HIV prevalence targets have been replaced by a dynamic target ratio, relating incidence to treatment coverage. Treatment targets have been elaborated through the adoption of improved guidelines and programme scale-up; stigma and discrimination targets are set on the basis of routinely conducted nationally representative studies. The NSP also includes a focus on strengthening the management and coordination of the HIV response, and will be complemented by a costed action plan and other tools (e.g. the National M & E Framework) for its implementation and monitoring.