By Collins Mtika
On a warm morning in Lilongwe, the queue outside the Lighthouse Clinic at Kamuzu Central Hospital bends around the courtyard like a quiet testament to a national triumph.
Inside, nurses celebrate what once seemed impossible: nearly every Malawian who starts HIV treatment now suppresses the virus. At 94% viral suppression, Malawi has become one of Africa’s most consistent HIV success stories.
But deep inside the same clinic, a quieter, more troubling story is emerging, one that threatens to erode the very progress Malawi proudly holds aloft.
When the government switched almost its entire cohort of 838,000 people on ART to dolutegravir, the newer, globally recommended antiretroviral drug, the change was billed as another bold step forward.
Dolutegravir is easy to take, potent, and resistant to treatment failure. By December 2024, 96% of all ART patients in Malawi were on dolutegravir-based regimens.
But for Dr Melani Ratih Mahanani, a medical epidemiologist working at the Lighthouse Trust, a WHO-recognised centre of excellence, the transition came with unexpected ripples.
Her research followed 432 patients, most of them women, who had switched from older regimens. What she found unsettled her: new hypertension diagnoses doubled, rising from 5.4% on previous medications to 11% on Dolutegravir.
Weight gain followed a similar trajectory, quietly pushing some patients into far more dangerous cardiovascular terrain.
“These changes do not mean the treatment is failing,” Mahanani says. “But they expose a gap we can no longer ignore: Malawi must integrate HIV and chronic disease care.”
The study lands at a moment when Malawi has achieved the UNAIDS 95-95-95 targets, slashed AIDS-related deaths from 80,000 at their 2003 peak to 14,000 in 2024, and built one of the continent’s most reliable HIV treatment programmes.
Yet that very success has ushered in a new challenge: people living with HIV are now surviving long enough to develop chronic illnesses that the health system is ill-prepared to treat.
This is most visible in the way the system itself is arranged. HIV services operate like a well-oiled machine, separate rooms, separate staff, an efficient electronic system, and stable drug supply.
Hypertension care, by contrast, is scattered across understaffed clinics, unreliable drug shelves, and paper records that rarely meet.
Patients with both conditions must visit two clinics on different days, carrying their own files between departments because the system cannot carry them.
It is a division that no longer makes sense.
In October 2025, health leaders admitted publicly what clinicians have whispered for years: stockouts of antihypertensive drugs have become routine, even as ARVs remain reliably available and free.
One senior official put it bluntly: “Central Medical Stores supply is erratic. We prioritise maternity, theatre, emergencies. Chronic disease is not seen as something to prioritise.”
Across Mulanje, Phalombe, Blantyre and rural health centres countrywide, essential hypertension drugs, Hydrochlorothiazide among them, disappear for weeks. Patients are told to “buy from town,” often with money they do not have.
In Dowa district, 43-year-old farmer Daniel Phiri was turned away twice for lack of antibiotics to treat an infected wound. “I had to go home,” he said. “There was nothing I could do.”
About 94% of Malawian adults living with hypertension are either undiagnosed or untreated, a staggering figure in any country, but devastating in one where cardiovascular disease already accounts for 12% of adult deaths.
Among people living with HIV, studies show that 20–24% have hypertension, but only 19–28% of those on treatment manage to control it. The contrast with HIV outcomes is stark:
- 94% viral suppression versus
- near-systemic failure in blood pressure control
Dolutegravir’s side effects are landing on this fragile ground, pushing some patients deeper into risk.
Mahanani’s research shows clear patterns: More vulnerable:
- Patients who were already overweight
- Those starting treatment with elevated blood pressure
- Young people aged 15–24, who face a 50% higher risk of rapid weight gain on dolutegravir
- Women, who shoulder disproportionate psychosocial and economic burdens
Less vulnerable:
- Patients entering ART at lower weights
- Those with strong kidney function
For Malawian women, who form the backbone of the HIV treatment programme (with a 96% ART initiation rate), these effects compound existing pressures: stigma, caregiving responsibilities, and chronic household insecurity.
HIV treatment is free. Hypertension treatment often is not. Interviews with patients reveal a pattern: 45% believe hypertension is more dangerous than HIV, yet many stop treatment because they cannot afford the pills.
The decision becomes heartbreakingly simple: Do you pay for food, school fees, or blood pressure medication?
Malawi’s Ministry of Health is not blind to the problem. For the first time in the country’s history, the 2024–2025 budget prioritised health spending above agriculture and education. A national NCD scale-up strategy was launched in May 2024.
But the ambitions collide with tough realities:
- A health budget K75 billion short of required drug funding
- A system 55% reliant on external donors
- An overwhelmed workforce
- Poor integration between digital systems
Where integration has occurred, the results are transformative.
In Neno District, Partners in Health and the Ministry of Health run an Integrated Chronic Care Clinic that uses HIV infrastructure to manage multiple chronic diseases.
The model has enrolled over 7,000 patients, with blood pressure and diabetes outcomes comparable to those in high-income countries. But Neno remains an island of innovation in a sea of fragmentation.
Patients like Evelyn Siula, a long-time HIV advocate, embody Malawi’s successes. But for her and millions like her, the future is uncertain.
If Mahanani’s findings represent the broader trend, and all signs suggest they do, many Malawians surviving HIV will develop cardiovascular complications the system is not yet built to treat.
“The benefits of ART far outweigh the side effects,” Mahanani stresses. “But we cannot ignore the impact on cardiometabolic health.”
Malawi’s HIV story is far from over. The next chapter will depend on whether the country can merge its celebrated HIV machinery with a chronic disease system that has long sat in its shadow.
If not, the silent complication unfolding now may become the next major health crisis, one measured not in viral loads, but in rising blood pressure, stalled supply chains, and preventable deaths.
