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BackgroundInnovative and efficient methods are needed to identify remaining people living with HIV unaware of their status. Routine health information system (RHIS) data, widely available in high-burden HIV settings, may help target areas of high risk to deliver timely prevention services. Often underused, RHIS data were leveraged at the facility level to predict changes in HIV test positivity in Malawi.MethodsFrom District Health Information Software-2 from January 2017 to March 2023, we analysed sexually transmitted infection (STI) cases and HIV tests and test results across 563 health facilities in Malawi. A multilevel model was employed to determine whether changes in STI diagnoses were predictive of changes in HIV test positivity. We considered STI types and their incubation periods, and controlled for facility type, ownership, quarter, season, zonal HIV and STI prevalence (2016 Population-Based HIV Impact Assessment).ResultsAmong 139 million HIV tests, overall positivity was 2.8%. Blantyre facilities had the highest positivity (6.0%) while those in the central-east zone had the lowest (1.8%). Key variables—changes in syndromic STI counts (lagged and cross-sectional)—showed weak or no associations with HIV positivity (OR: 1.01, CI: 1.01 to 1.01; OR: 1.00, CI: 1.00 to 1.00). However, contextual covariates, including zonal HIV prevalence (OR: 1.04, CI: 1.04 to 1.04), genital ulcers (OR: 1.16, CI: 1.16 to 1.16) and clinical STI diagnoses (OR: 1.29, CI: 1.29 to 1.29), were positively associated with HIV positivity.ConclusionsIn settings with high STI screening uptake, RHIS data can be used to monitor changes in STI diagnoses and contextual factors to identify HIV hotspots and guide targeted testing, prevention and treatment services.

Sustained engagement in HIV care is critical to the success of Option B+ for HIV-infected pregnant women. However, monitoring women’s engagement in care across clinics and over time is challenging due to migration and clinic transfers. Improved strategies to identify and monitor women’s engagement in HIV care across a network of clinics are needed, but have not been pilot tested. We evaluated the feasibility and acceptability of biometric fingerprint scanning to identify women and monitor HIV visit attendance among women in Option B+. Over a 3-month period, we enrolled HIV-infected pregnant women receiving care at two antenatal clinics in Lilongwe, Malawi and monitored their engagement in care using biometric fingerprint scanning and the standard-of-care electronic medical record (EMR) monitoring system. Biometric data was collected by trained research assistants, who uploaded and synced data across study sites daily using wireless internet. We collected data weekly on the biometric scanner performance, reliability, and usability. We assessed the feasibility and acceptability of using biometric fingerprint scanning to record HIV visits during exit interviews with a sample of participants and healthcare workers and by comparing visit concordance between the biometric fingerprint scanning and EMR systems. We enrolled 314 HIV-infected pregnant women and 51 HCWs (n = 365 total participants). The majority of participants felt the biometric fingerprint scanning system was easy to use (64%), required no additional assistance (69%) and met their expectations (76%). No major issues with data security, privacy, or scanner functionality were reported by HIV-infected women or healthcare workers. Of the 542 HIV visits captured during the study period among women in Option B+, 80% were recorded in the biometric fingerprint system versus 51% in the EMR system (PR 1.57, 95% CI 1.43, 1.72, p-value < 0.05). Among HIV-infected pregnant women engaged in HIV care, biometric fingerprint scanning is a feasible and acceptable way to monitor HIV visits and may improve the ability to monitor women’s engagement in HIV care over time and across clinics. Biometric fingerprint scanning should be scaled-up and evaluated as an implementation strategy to support sustained engagement in HIV care for women during the perinatal period.

Malawi has 991,600 people living with HIV and has expanded access to annual HIV viral load testing to enhance care quality for clients. However, significant delays persist in returning viral load (VL) results back to facilities and to clients. To address this, we implemented a digital VL results return (VLRR) application, using existing mobile phone platforms to expedite results return to clients and healthcare providers (HCPs).VLRR is a digital SMS/USSD platform leveraging mobile phones to reduce turnaround time (TAT) and improve access to VL results. To evaluate the VLRR intervention, we: (1) estimated the TAT for digital results return, (2) calculated open rates of digital results, (3) conducted a mixed methods evaluation with VLRR users, and (4) estimated the potential cost savings from avoiding unnecessary sample redraws. From April 2022 to June 2024, HCPs registered 4,067 clients. For each client, TAT was calculated separately for the periods before and after enrollment in the VLRR system. On average during this period, clients received results in 128 days before VLRR enrollment and 48.5 days after enrollment, reflecting a 62.4% improvement. By July 2023, VLRR clients and HCPs received results in an average of 30 and 38 days. The overall open rate for digital results (opened by either a client or HCP) was 60% and nearly 100% of clients and HCPs indicated they wanted to the application to continue. Lastly, if VLRR were scaled nationally, it has the potential cost savings of $1.8-6.7 million USD.VLRR is effective in reducing TAT and improving access to VL results. To enhance uptake and achieve national scale, VLRR can be integrated into Malawi’s existing EMR systems, further reducing TAT and enabling HCPs to deliver higher quality care and improve clinical outcomes.

The COVID-19 global pandemic has had considerable health impact, including sub-Saharan Africa. In Malawi, a resource-limited setting in Africa, gaining access to data to inform the COVID-19 response is challenging. Information on adherence to physical distancing guidelines and reducing contacts are nonexistent, but critical to understanding and communicating risk, as well as allocating scarce resources. We present a case study which leverages aggregated call detail records into a daily data pipeline which summarize population density and mobility in an easy-to-use dashboard for public health officials and emergency operations. From March to April 2021, we have aggregated 6-billion calls and text messages and continue to process 12 million more daily. These data are summarized into reports which describe, quantify, and locate mass gatherings and travel between subdistricts. These reports are accessible via web dashboards for policymakers within the Ministry of Health and Emergency Operations Center to inform COVID-19 response efforts and resource allocation.

Malawi has 991,600 people living with HIV and has expanded access to annual HIV viral load testing to enhance care quality for clients. However, significant delays persist in returning viral load (VL) results back to facilities and to clients. To address this, we implemented a digital VL results return (VLRR) application, using existing mobile phone platforms to expedite results return to clients and healthcare providers (HCPs).VLRR is a digital SMS/USSD platform leveraging mobile phones to reduce turnaround time (TAT) and improve access to VL results. To evaluate the VLRR intervention, we: (1) estimated the TAT for digital results return, (2) calculated open rates of digital results, (3) conducted a mixed methods evaluation with VLRR users, and (4) estimated the potential cost savings from avoiding unnecessary sample redraws. From April 2022 to June 2024, HCPs registered 4,067 clients. For each client, TAT was calculated separately for the periods before and after enrollment in the VLRR system. On average during this period, clients received results in 128 days before VLRR enrollment and 48.5 days after enrollment, reflecting a 62.4% improvement. By July 2023, VLRR clients and HCPs received results in an average of 30 and 38 days. The overall open rate for digital results (opened by either a client or HCP) was 60% and nearly 100% of clients and HCPs indicated they wanted to the application to continue. Lastly, if VLRR were scaled nationally, it has the potential cost savings of $1.8-6.7 million USD.VLRR is effective in reducing TAT and improving access to VL results. To enhance uptake and achieve national scale, VLRR can be integrated into Malawi's existing EMR systems, further reducing TAT and enabling HCPs to deliver higher quality care and improve clinical outcomes.