Malawi Leads the Way

As 2021 comes to a close, we are addressing a rapidly evolving and complex global health landscape—demonstrated most starkly by the emergence of the COVID-19 Omicron variant. Yet, as we respond to such challenges head-on, it is also important to acknowledge hard-won progress and success. In this case, the success is in Malawi, where they are not only making huge strides toward controlling their HIV epidemic—but also using their years of experience in HIV to fight COVID-19. That success is a tribute to the resolve, resilience, and perseverance of health teams, government, donors, and partners and it is worth reflecting upon. Malawi provides hope in this 40-year effort as the nation continues its rapid progress toward eliminating AIDS by the end of this decade.

Over the last decade, significant efforts have been made by the Malawian government to reduce the HIV epidemic at both national and local levels, which brought a dramatic decline in new infections -- from 98,000 in 2005 to 21,000 in 2020. As a result, Malawi is performing exceptionally well towards achieving the UNAIDS 95:95:95 treatment targets.[1] In fact, this month Malawi announced that the country has achieved 88-97-96 respective to those targets. This progress has been driven by a combination of political will, national leadership, strategic partnership, targeted efforts to reach vulnerable populations, as well as technical and programmatic excellence.

While impressive, the progress is not surprising, as Malawi has long led the way in HIV prevention efforts, particularly as they related to HIV-positive pregnant women.

Since 2001, EGPAF has had the great fortune to serve as a key partner with Malawi’s Ministry of Health, the U.S. Center for Disease Control and Prevention (CDC), the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), and local partners. Initially serving one of Malawi’s first programs to provide PMTCT services, EGPAF has gone on to forge strong partnerships with many other stakeholders in-country, regularly liaising with Ministry of Health counterparts; actively participating in national technical working groups; and providing technical assistance, including support in the adaptation of WHO recommendations to local country contexts and mentoring health workers.

In 2011, Malawi introduced Option B+, in which lifelong ART is initiated for all HIV+ pregnant and breastfeeding women regardless of CD4+?cell count or clinical stage. Option B+ simplified Malawi’s national program by removing diagnostic steps and standardizing services; the subsequent impact and ripple effect of that policy has been tremendous. Between 2011 and 2018, the proportion of Malawian women living with HIV who were diagnosed spiked from 49% to 94%. As of 2018, more than 95% of pregnant women have been tested for HIV and more than 95% of those testing positive are on treatment.

In the same year, more than 95% of at-risk newborns were tested for HIV within the first six weeks of life through early infant diagnosis. In addition to protecting the health of mothers, the policy has enabled Malawi to avert an estimated 71,000 new infections among children between 2010 and 2018, which resulted in a more than 70% decline in new HIV infections among infants and children during that period. Malawi’s creation and implementation of the Option B+ policy for pregnant women showed what can be achieved by national prioritization of a treat-all program while demonstrating the type of healthy system reforms needed to deliver on the established UNAIDS targets.

Over the past two years, Malawi has been responding to the COVID-19 pandemic alongside HIV. Despite?a?slow introduction, Malawi has not escaped the trauma of this highly contagious virus.?From June through August 2021, Malawi experienced its third major COVID-19 wave, propelled by the Delta variant. At its peak,?close to 200?deaths per day were attributed to COVID-19 in this nation of 19 million. Accurately determining the impact of COVID-19 is a challenge in Malawi, where most of the population lives in rural?villages.?Conveying accurate information and?ensuring that all people have access to health care has been difficult during this time.

Fortunately, Malawi public health officials were not starting from scratch. Decades of response to the ongoing HIV pandemic have?resulted in the country having the necessary public health tools and expertise to meet the challenge.?EGPAF’s years of experience in Malawi, including collaboration with the Ministry of Health and other partners across the PEPFAR platform, as well as highly transferable skills made us well placed to support the government’s efforts to address COVID-19.

We’ve used that experience to quickly pivot to offering?COVID-19 support, with a focus on continuing to provide?people living with HIV?access?to?antiretroviral therapy while minimizing their risk of COVID-19. Today, EGPAF collaborates with the Ministry of Health and CDC in implementing a phone-based surveillance system to monitor trends of signs and symptoms for COVID-19 and its impact on healthcare access for people living with HIV as well as for the general population.

Working with the Malawi government and the CDC, the?Lab Information System Team has rapidly integrated diagnostics equipment, allowing real-time tracking of COVID-19 testing across the country. In partnership with Luke International, an?existing?disease surveillance reporting tool is being upgraded for systematic monitoring of disease outbreaks. This?has made it?faster?to transmit and access data across the country—allowing?for collection in the?facility?and in the?community?as well as national analysis—to?improve?patient care?and?support clinical decision making,?while also?monitoring disease outbreaks.

In close collaboration with our partners, EGPAF is supporting the government’s response to COVID-19, while also thinking through what this means?for a broad system-strengthening approach that can more precisely address all health challenges, including HIV.

As I’ve said recently, I believe that this is a special moment in the global AIDS movement where know-how, innovative tools, and the force of community can come together to end inequities in the response as we simultaneously address the threat of COVID-19. Malawi is seizing that moment. Let us not take it for granted or remain complacent—rather, let’s build on the momentum in Malawi to maintain our fragile progress, finish the job, and create the first AIDS-free generation.

EGPAF will continue to support Malawi to sustain its gains and end AIDS as a public health threat by 2030 as we design, test, and scale implementation models and innovations that will further reduce new infections, support lifelong care, and ensure innovations in diagnostics and therapeutics to accelerate the end of HIV.

[1] 95% of individuals living with HIV tested; 95% of those diagnosed on antiretroviral therapy (ART), and 95% of individuals in ART virally suppressed.