Malawi's progress towards the UNAIDS 95-95-95 HIV testing and treatment targets: comparison of the 2015-16 and 2020-21 Malawi Population-based HIV Impact Assessments (MPHIA)


BACKGROUND: The 2015-16 Malawi Population-based HIV Impact Assessment showed notable coverage gaps in HIV diagnosis, antiretroviral therapy access and retention, and viral load suppression (VLS). Targeted interventions were implemented by the Government of Malawi, PEPFAR and other partners to close these gaps. The second MPHIA was conducted between January 2020 and April 2021 to measure progress towards the UNAIDS 90-90-90 goals.
METHODS: MPHIA is a nationally representative survey, which enrolled over 23,000 participants. Participants were interviewed and a blood sample was tested for HIV infection using the national algorithm. Results were returned to participants. All HIV positive samples were tested for viral load (VL) and presence of antiretrovirals (ARV); a suppressed VL was defined as <1,000 viral copies per milliliter. All results were weighted and self-reported awareness and treatment status were adjusted to account for ARV detection results. This analysis was restricted to participants aged 15-64 years with HIV test results.
RESULTS: HIV prevalence decreased significantly from 10.6 % [95% confidence interval (CI): 9.9%-11.2%] in MPHIA 2015-16 to 8.9% (95% CI: 8.4%-9.5%) in MPHIA 2020-21. Awareness of HIV status among all adults increased from 76.8% (95%CI: 74.7%-79.0%) to 88.4% (95% CI: 86.7%-90.1%), with females increasing from 80.2% (95%CI: 77.8%-82.5%) to 90.4% (95%CI: 88.5%-92.2%). Among 15-24-year-olds, awareness increased from 53.7% (95%CI: 45.3%-62.0%) to 76.2% (95%CI: 69.4%-83.1%). Among all adults aware of their HIV status, ART use increased from 91.4% (95%CI: 89.8%-93.0%) to 97.8% (95%CI: 97.1%-98.5%). Viral suppression (VLS) among those on treatment increased from 91.3% (95% CI: 89.3%-93.3%) to 96.9% (95% CI: 96.0%-97.8%). Population VLS among all adults living with HIV increased from 68.3% (95%CI: 66.0%-70.7%) to 87.0% (95%CI: 85.4%-88.6%). However, VLS remained lowest in the major urban centers of Lilongwe and Blantyre cities, and among participants aged 15'24 years.
CONCLUSIONS: Targeted investments by district and subpopulation in HIV testing, ART linkage, adherence, and retention have resulted in significant progress towards achievement of the UNAIDS 90-90-90 targets. These results show that Malawi has exceeded the more recent UNAIDS 95-95-95 treatment and VLS targets. Continued targeted efforts and tailored interventions are needed to close remaining gaps, particularly among young people and in urban centers.