Notes from the Field: Public Health Response to Surveillance for Recent HIV Infections — Malawi, May 2024

Investigation and Outcomes

As part of routine recent HIV infection surveillance in Malawi, data collected during April–September 2023 were analyzed using spatial scan statistics, a method for detecting signals (clusters of health care facilities with rates of recent HIV infections that are statistically significantly higher than those expected due to random variation) (3). Rates of recent infection were calculated as the number of recent HIV infections per 100,000 persons at risk for HIV.^† Among 289 facilities implementing recent HIV infection surveillance, 26 facilities were identified through eight signals with rates of recent HIV infections that were higher than expected; public health responses were initiated at all 26 facilities. This report details the response at one of two public health facilities in Malawi’s southern region within a signal (expected recent HIV infection rate = 3.36 per 100,000; actual recent HIV infection rate = 16 per 100,000). These activities were reviewed by CDC, deemed not research, and were conducted consistent with applicable federal law and CDC policy.^§

After verifying facility-level HIV testing and diagnosis data using nationally reported data, a multidisciplinary public health team, including governmental and nongovernmental interest holders and facility health care workers (HCWs), initiated response activities. Data were reviewed from seven predetermined program indicators included in the U.S. President’s Emergency Plan for AIDS Relief Monitoring Evaluation and Reporting Database^¶ (covering testing, prevention, and treatment programs during April 2022–September 2023) alongside site-level data to identify gaps in HIV service delivery.** Two focus groups including 19 community representatives used a semistructured interview guide to discuss the identified gaps. Community representatives included faith-based community leaders, shop owners, and leaders from HIV community groups. The program indicators, identified service gaps, and interview findings were summarized and presented to the multidisciplinary public health team, which developed recommendations and action plans to address the identified service gaps.

One service gap identified at the public health facility was that levels of viral load suppression^†† among persons receiving antiretroviral therapy (ART) were consistently lower than the established target of ≥95%. This issue was particularly apparent among adolescents and young adults aged 15–19 years, whose viral load suppression range was 53%–59%. ART adherence is central to achieving viral load suppression. Although adherence to ART was not measured, barriers identified through qualitative interviews with interest holders included parental hesitancy to disclose HIV status to adolescents and young adults who had acquired HIV infection perinatally (4,5), inaccurate care and treatment information from faith-based community leaders, and a lack of privacy during ART adherence counseling.^§§

A second identified service gap was stagnation at low levels in the number of preexposure prophylaxis (PrEP) prescriptions despite a general increase in availability of PrEP during the preceding 18 months. The number of persons newly initiated on PrEP fluctuated from 13 to 36 clients with no increase during the 18-month period. Semistructured interviews revealed that slow adoption of PrEP use might be attributed to HIV-related stigma, low awareness of PrEP availability in the community, and insufficient numbers of HCWs trained in PrEP provision. PrEP services had been relocated away from ART services in early 2023, in an effort to address HIV-associated stigma; however, this action and the continued availability of PrEP were not well communicated to the community.

Preliminary Conclusions and Actions

To increase levels of viral load suppression, the response team recommended enhanced adherence counseling,^¶¶ educating and involving faith-based community organization leaders in ART advocacy, and promoting HIV disclosure sessions among parents and adolescents. To improve adoption of PrEP, interest holders agreed to train more HCWs as PrEP providers, integrate PrEP provision at multiple service points, and conduct community awareness campaigns. This application of a public health response to recent HIV infection surveillance highlights one way to use timely surveillance data to identify service delivery gaps and contribute toward a goal of controlling the HIV/AIDS epidemic.