Malawi
By Dr. Visopo Harawa
Interim Malawi Country Director
As we celebrate World AIDS Day in Malawi, we renew our commitment to developing Malawi's capacity to fight HIV/AIDS. The University of Maryland, Baltimore (UMB) through Ciheb is the primary PEPFAR laboratory strengthening implementing partner through the Accelerating Malawi’s PEPFAR Laboratory Logistics and Infrastructure for Quality (AMPLIFY) project. The main focus of AMPLIFY has been to strengthen and expand lab capacity and quality diagnosis of HIV, tuberculosis, and more recently, COVID-19. The program is only one year old but has made significant impact with regard to supporting the Ministry of Health (MOH) to improve the capacity and quality of lab services.
Ciheb Malawi is proud to be part of Malawi’s HIV program success story. Currently, 1,074,888 people are suspected to be living with HIV; of these people, 975,877 (91%) have been tested, 849,615 (87%) of the tested population has been initiated on treatment, and 798,638 (94%) of those on treatment have viral load suppression (Malawi HIV Program Report Sept. 2020).
Reducing Mortality, Increasing Access to Treatment
UNAIDS reported in 2018 that Malawi had seen a 55% decrease in deaths and a 30% decrease in new cases of HIV between 2010-2018 compared to the prior period. By 2018, the HIV program had hit the first 90-90-90 target, that 90% of people living with HIV knew their status. Although women are disproportionately infected (59.79%), more adult women (86%) than adult men (68%) are on treatment. Furthermore, 95% of pregnant women living with HIV accessed antiretroviral medication, which led to the prevention of 9,600 new infections. The success is a direct result of huge investment in human, equipment, and infrastructural capacity through PEPFAR funding, The Global Fund, and other donors’ investment.
In 2017, the viral load and early infant diagnosis (EID) implementation plan was revised to include universal access to EID testing, and the target was set at 85% of all newborns by 2020. To achieve this, EID testing migrated from conventional testing to point of care (POC) and near point of care (near-POC) testing. The aim of the intervention was to increase access, reduce the turnaround time of test results, improve EID test result use, and improve linkage to care. Ciheb Malawi is leveraging this capacity to eliminate the current challenges of long turnaround time of results, inadequate test result utilization, and inadequate laboratory quality management systems (QMS). Ciheb seeks to overcome these challenges by implementing an automated sample and result tracking system, integrating laboratory information management systems, harmonizing reporting via the adoption of quality indicators, and implementing QMS. The ultimate goal is to implement informed interventions through effective and efficient data management and utilization.
Laboratory Infrastructure
The investments into lab infrastructure prior to the COVID-19 pandemic outbreak has helped Malawi get a head start on testing. To support the MOH’s response to the COVID-19 pandemic, Ciheb supported the MOH in activation of 11 HIV testing molecular labs to enable them to perform COVID-19 polymerase chain reaction (PCR) testing. Malawi utilized the infrastructure (testing platforms and physical buildings) and human resources that were already in place for HIV testing. The lab technologists that perform HIV PCR tests were already familiar with PCR technology and were therefore ideal for COVID-19 PCR testing.
To build capacity in COVID-19 testing, 66 laboratory technologists were trained and certified as competent to conduct COVID-19 PCR testing. Through PEFAR funding and CDC’s COVID-19 International Taskforce funding, Ciheb Malawi procured reagents and supplies for COVID-19 testing. Riders for Health International, an NGO, has been a key partner to ensure the safe and efficient transportation of samples across Malawi. The primary samples that are transported are HIV viral load, HIV EID, TB, and COVID-19.
On the contrary, the use of HIV lab infrastructure negatively impacted HIV testing services because COVID-19 samples were prioritized over HIV samples. The quantity of HIV samples collected and tested decreased, yet the turnaround time of results increased because samples were prioritized and the workload associated with COVID-19 testing was increased. Additionally, supplies that were planned for HIV testing were used for COVID-19 testing.
Ciheb Malawi collaborated with the MOH to introduce additional work shifts to accommodate the increased workload that was brought about by COVID-19 testing in HIV PCR labs. Also, COVID testing was extended to POC sites to reduce the workload in HIV testing PCR labs. The combination of interventions helped eliminate the viral load testing backlog.
Tackling COVID-19
Malawi has enormously benefited from the global solidarity in the fight against COVID-19, which contributed to control of the pandemic in Malawi. The MOH received significant donations in the form of funds and reagents from the WHO, Africa CDC, World Bank, US government, The Global Fund, UNICEF, and the Chinese government, just to mention a few. These donations helped to expand access to COVID-19 testing across the country. Malawi needs additional testing kits for COVID-19; however, we have thankfully worked with companies, Africa CDC, and the US Ambassador in Malawi to procure more tests.
One of the lessons learned during the COVID-19 pandemic has been the need for labs to use open testing platforms that can accommodate more than one disease. POC testing is a game changer regarding increasing access to testing during pandemics. Again, the world is a global village: countries need to work together to fight pandemics if the world is going to succeed.
I am thankful for the support Malawi received and the support that Ciheb Malawi is able to provide in the fight against COVID-19 and HIV/AIDS. We stand in global solidarity to help each other overcome these public health crises.
Visopo Harawa, PhD, is the interim country director for Malawi. He has more than 10 years of experience in implementation of laboratory strengthening programs and research. Prior to joining Ciheb, Dr. Harawa worked as a post-doctoral research fellow at the University of Malawi College of Medicine in Blantyre, Malawi. His research interest was to understand the role of innate immunity in the pathogenesis of cerebral malaria in Malawian children.