COVID-19 Disruptions to the HIV Program

The first cases of COVID-19 in Malawi were confirmed on 2nd April 2020, one week before the scheduled start of integrated HIV program supervision for Q1 2020. Early epidemiological models predicted rapid spread and severe impact of COVID-19 in Malawi. Fragile health services were not well prepared to prevent infections and deal with cases.

The DHA therefore decided to suspend the established quarterly supportive supervision activity in April 2020 in order not to contribute to transmission at visited health facilities and to protect staff. The following report is based on data collected during the following supervision round in July 2020, which combined the Q1 and Q2 reporting periods. This combined quarterly supervision round was extended by one week (13-31 July) to cope with the added workload and the service disruptions. However, considerable challenges have affected the usual completeness and quality of service data.

The DHA issued 3 editions of a circular to all HIV service delivery sites (on 3rd, 17th April and 15th June) with specific infection prevention guidance for COVID-19, and policy recommendations aimed at decongesting facilities, and reducing travel and contact exposure for patients and health workers. This included a temporary suspension of non-essential services: routine scheduled viral load monitoring for stable adult patients; VMMC; active index partner tracing; new initiation of IPT and PrEP; Teen clubs and other ART support groups involving social gatherings. The DHA also recommended an enhanced implementation of 6-month ARV dispensing for almost all patient groups. As the COVID-19 impact remained much lower than initially feared, the suspended services were successively reintroduced.

There was a noticeable reduction in some HIV service outputs in Q2 compared with Q1 2020: Total HTS outputs declined by 35% New ART initiations declined by 32% The number of blood units collected reduced by 23% The number of routine viral load samples collected reduced by 5%

However, program reports showed no indication for increased ART program attrition or lower adherence compared with previous quarters.

Scale-up of integrated Program performance highlights by the end of June 2020 * HIV services had reached the following number of sites: o 765 static and 68 outreach HIV testing sites. o 755 (static) ART sites; 590 of these started at least one pregnant or breastfeeding woman. o 691 sites with HIV-exposed children in follow-up. • 634,564 persons were tested for HIV and received their results; 107,507 (17%) accessed HIV testing for the first time; 527,057 (80%) were repeat testers and 21,049 Malawi Integrated HIV Program Report (April-June2020) Page | 4 (4%) of these received confirmatory testing (after having tested positive in the past). 18,882 (3.1%) clients received a positive result for the first time1. • A total of 63,600 people received 105,211 self-test kits for either primary or secondary use. • 16,049 (94%) of 17,095 blood units collected were screened for (at least) HIV, hepatitis B and syphilis. • 162,127 (99%) of 164,354 women at ANC had their HIV status ascertained; 10,695 (7%) of these were HIV positive. 138,394 (95%) of 145,981 at maternity had their HIV status ascertained 10,075 (7%) of these were HIV positive. • 18,804 patients started ART this quarter; 88% were classified as asymptomatic / in WHO stage 1 and started under the “Test & Treat” policy. • 846,164 patients were alive and on ART by end of June 2020.2 This means that 79% of the estimated 1,072,534 HIV positive population was on ART. 3 ART coverage was 75% (44,355/ 58,752) for children4 and 79% (801,909 / 1,013,782) for adults. • 76,921 (94%) of viral load results from routine monitoring were 99%) of an estimated 10,3643 HIV infected pregnant women in Malawi were on ART this quarter. 9,943 (84%) of these were already on ART when getting pregnant and 2,293 (24%) started ART during pregnancy/delivery. • An additional 798 breastfeeding women started ART in WHO stage 1 or 2. • 76% and 70% of women started while pregnant or breastfeeding were retained on ART at 6 and 12 months after initiation, respectively. • 9,112 (7%) of infants discharged alive from maternity were known to be HIV exposed, 8,808 (97%) of these received ARV prophylaxis (nevirapine). A total of 12,413 HIV exposed children were newly enrolled for follow-up this quarter; 10,417 (84%) of these were enrolled before age 2 months. • Out of the total 1,072,534 estimated PLHIV by end June 2020: o An estimated 91% of PLHIV knew their status (diagnosed)