“Empowering local people on the front lines:” Dr. Gift Kawalazira, District Health Director, Blantyre, Malawi on why a successful HIV prevention strategy is like a jigsaw puzzle

Blantyre is the center of commerce and finance in Malawi. Until several years ago, it was also the center of the country’s HIV epidemic, with a prevalence rate more than twice the national average as of 2020. In collaboration with the Center for Innovation in Global Health (CIGH) at Georgetown University and with support from the Gates Foundation, the district health office launched the Blantyre Prevention Strategy (BPS) in 2020 to sustainably reduce the number of new HIV infections.

Dr. Gift Kawalazira, who has managed this effort as the director of the district health office, says the secret to BPS’s success is that it wasn’t just another siloed HIV program. Instead, it was led by the people who deliver health services in Blantyre every day and integrated into everything they do. As part of BPS, district health coordinators and health workers accessed better data tools that helped them fully understand the nature of the epidemic in the district. They also received training to interpret the data and act on their findings, with a focus on serving communities that needed the most support in ways that were tailored to them.

Not only has HIV prevalence dropped dramatically in Blantyre, but other indicators of health system performance, such as immunization coverage, have also improved. Earlier this year, when aid freezes threatened to derail progress, the Blantyre team used the skills it had gained through BPS to maintain essential services such as testing and treatment.

In this conversation, Dr. Kawalazira explains what sets BPS apart, how his district is coping with funding cuts, and what other health leaders might learn from his team’s experiences.

Before we dig into the details of the Blantyre Prevention Strategy (BPS), can you tell us about Blantyre and your work there? What is the district like, and what is your role in the health system?

Dr. Kawalazira: Blantyre is the main commercial city in Malawi. It has a population of about 1.5 million people, and 48% of them are 15 years of age and below. That means that a good proportion of the population is graduating into adolescence and becoming sexually active. Therefore, issues to do with sexual and reproductive health take center stage in the planning as well as implementation of programs in the district, which includes the central part of the city, some peri-urban townships, and some typical rural villages. My job is to coordinate all health activities in Blantyre, whether from government or nongovernmental players.

In 2020, Blantyre had a higher HIV prevalence than any of the country’s 28 other districts: about 17%, almost double the national average. Because of that, we attracted a lot of attention from national as well as international players who started asking, “Can we do something about Blantyre?”

What is BPS, and what sets it apart from other health systems strengthening efforts you’ve seen?

Dr. Kawalazira: What was fundamental with BPS was that the approach was developed by the people who actually implement the activities in Blantyre. It was developed by us, with expert technical support from the BPS partners, led by CIGH. We invested a lot in operational research and made sure frontline workers were at the center throughout the process. Because of that bottom-up way of working, we were able to devise solutions that resonated with the needs of the district.

Specifically, BPS introduced four pillars:

First, data. BPS helped bring many data sources into one platform, so it was easy to access and interpret the data.

Second, creating demand for HIV and AIDS primary prevention services. We had to do that according to the needs of the populations that needed the services. Because the way you would work with small-scale businesswomen, for example, would be different from how you’d approach university students, even though both would require similar services.

Third, we strengthened our district quality improvement unit to train our team to share challenges, develop solutions, and deliver products and services in a way that would work for the targeted populations.

And fourth, integration. We tried to integrate all this into the mainstream operation of the government’s health system. We even included our local elected officials in the work. We were trying to run away from the siloed approach to project implementation, which was very common with the HIV and AIDS response.

Can you give us a before and after picture? How did those four pillars change day-to-day prevention efforts in the district?

Dr. Kawalazira: We had a lot of players in the HIV and AIDS field, and they each had their own reporting channel. We had more than 14 reporting channels. An organization would come to the district, collect data, send it through their own channel, and review it without sharing what was actually happening with the other players on the ground. There was a lot of duplication as well as wastage of resources. BPS gave us what we call the Preventive Adaptive Learning Management System, PALMS, which brought together all these data streams onto one real-time platform. That helped a lot in terms of decision-making. Now everyone knows the hotspots for Blantyre and what specifically is going wrong.

In terms of demand creation, BPS helped us set up community labs where we got feedback from the community. Before, we had people designing these programs on their own and then kind of pushing them down to the communities, and there was no way for the community to tell us what they thought.

While delivering the services, we were trained to look at the data, determine what was happening at the health facility level, ask ourselves questions, and come up with solutions to what we thought the bottlenecks were. I said earlier that the setup of Blantyre is quite heterogeneous. You have urban, peri-urban, and rural areas. The way you would implement the activities in the city slums would definitely be different from the way you would implement them in the villages. It was important that the implementing units have this skill so they could actually plan and implement the programs in accordance with the area and the type of people they were working with.

One of the great things is that we have seen an improvement in service delivery overall, not just for HIV, because of our systems approach to quality improvement. It’s the same people who work on HIV and AIDS programs, the same people who work with immunizations, the same people who work on malaria, the same people who work on everything. Once they get the skills, they can use them for other programs as well and improve health service delivery across the board. The district won an award for immunization coverage, and I don’t think we would have won it if not for BPS.

What achievements are you proudest of as a result of the BPS work?

Dr. Kawalazira: Foremost is the system-strengthening aspect of it, because that is going to remain with us long after BPS is gone. We have gotten a score of 100 on our local government performance assessment three years in a row. And that’s not just about HIV. That’s about our overall performance.

Specifically, we managed to reduce HIV prevalence from about 17% in 2018 to about 10% in 2025, which is quite dramatic. We are no longer the district with the highest prevalence of HIV in Malawi.

You mentioned that Malawi’s HIV prevention work has been supported by donors over the years. Obviously, there have been really steep cuts this year. How have those cuts affected you?

Dr. Kawalazira: What I think has been affected the most is the key populations activities—working with high-risk groups like sex workers or men having sex with men—because they were 100% being managed in a vertical fashion by donors. My worry is that if we lose our link to these groups, we could lose all these gains in no time.

We had four players in this field. Two were running clinics and the other two were doing demand creation with those groups. After the aid cuts, the two organizations for demand creation closed up shop. We managed to get support from other partners for the clinics, but we don’t know for how long they can sustain their work.

The other challenge is treatment monitoring. It’s important to follow up to determine if treatment is working or not, so we can switch people to different medicines if necessary. But the lab equipment for testing things like viral load and CD4 count is very high tech, and when aid was frozen, the labs just closed down. No one had access to the computers; no one had access to the equipment.

But there is good news. In terms of the human aspect of it, looking at the data, getting to people, giving them treatment—we are in good shape. If we can’t run the labs and can’t replenish the machines and the reagents, then that becomes problematic. But thanks in part to BPS, our health workers know what to do and we are able to sustain the provision of antiretroviral treatment and testing for clients.

Other districts are looking to adopt parts of your model. What are the key lessons from the Blantyre experience you would highlight for others?

Dr. Kawalazira: I think they need the entire spectrum. The data piece is interesting, but data is not useful if there is nothing you can do about it. That’s what demand creation and service delivery are all about. And the integration aspect ensures that you are able to improve quality across the board and sustain those improvements.

It’s kind of a jigsaw puzzle. You’ve got all the pieces in front of you, but you’ve got to arrange them in a proper fashion, and then at the end of the day you’ll have a picture of what you’re working toward.

Building on the successes of BPS, the Government of Malawi convened a high-level working group—chaired by the National AIDS Commission Programmes Director—to develop a plan for engaging other high-incidence districts with the goal of adapting the BPS model. The group has commissioned multiple district needs assessments, and implementation plans are being developed with district leaders. This will lead to the benefits of BPS reaching additional districts and generate relevant lessons for the entire region.