Article Text

Download PDFPDF

Delivering comprehensive HIV services across the HIV care continuum: a comparative analysis of survival and progress towards 90-90-90 in rural Malawi
  1. Emily B Wroe1,
  2. Elizabeth L Dunbar1,
  3. Noel Kalanga2,
  4. Luckson Dullie1,
  5. Chiyembekezo Kachimanga1,
  6. Andrew Mganga3,
  7. Michael Herce4,
  8. Jason Beste5,
  9. Jonas Rigodon6,
  10. Lawrence Nazimera7,
  11. Ryan K McBain8
  1. 1Partners In Health, Neno, Malawi
  2. 2Health Systems and Policy, College of Medicine, Blantyre, Malawi
  3. 3Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
  4. 4Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
  5. 5Partners In Health, Harper, Liberia
  6. 6Haiti Delegation, American Red Cross, Port-au-Prince, Haiti
  7. 7Ministry of Health, Neno, Malawi
  8. 8Partners In Health, Boston, Massachusetts, USA
  1. Correspondence to Dr Emily B Wroe; emwroe{at}


Introduction Partners In Health and the Malawi Ministry of Health collaborate on comprehensive HIV services in Neno, Malawi, featuring community health workers, interventions addressing social determinants of health and health systems strengthening. We conducted an observational study to describe the HIV care continuum in Neno and to compare facility-level HIV outcomes against health facilities nationally.

Methods We compared facility-level outcomes in Neno (n=13) with all other districts (n=682) from 2013 to 2015 using mixed-effects linear regression modelling. We selected four outcomes that are practically useful and roughly mapped on to the 90-90-90 targets: facility-based HIV screenings relative to population, new antiretroviral therapy (ART)enrolments relative to population, 1-year survival rates and per cent retained in care at 1 year.

Results In 2013, the average number of HIV tests performed, as a per cent of the adult population, was 11.75%, while the average newly enrolled patients was 10.03%. Percent receiving testing increased by 4.23% over 3 years (P<0.001, 95% CI 2.98% to 5.49%), while percent enrolled did not change (P=0.28). These results did not differ between Neno and other districts (P=0.52), despite Neno having a higher proportion of expected patients enrolled. In 2013, the average ART 1-year survival was 80.41% nationally and 91.51% in Neno, which is 11.10% higher (P=0.002, 95% CI 4.13% to 18.07%). One-year survival declined by 1.75% from 2013 to 2015 (P<0.001, 95% CI −2.61% to −0.89%); this was similar in Neno (P=0.83). Facility-level 1-year retention was 85.43% nationally in 2013 (P<0.001, 95% CI 84.2% to 86.62%) and 12.07% higher at 97.50% in Neno (P=0.001, 95% CI 5.08% to19.05%). Retention declined by 2.92% (P<0.001, 95% CI −3.69% to −2.14%) between 2013 and 2015, both nationally and in Neno.

Conclusion The Neno HIV programme demonstrated significantly higher survival and retention rates compared with all other districts in Malawi. Incorporating community health workers, strengthening health systems and addressing social determinants of health within the HIV programme may help Malawi and other countries accelerate progress towards 90-90-90.

  • Hiv
  • health systems

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Handling editor Sanni Yaya

  • Contributors EBW, NK and ELD conceptualised the study. ELD, RKM and AM provided data curation and expertise, and RKM led data analysis and methodology. EBW, NK, LD, CK and LN provided programme contextualisation. MH, JB and JR provided additional technical expertise. EBW and RKM prepared the first draft of the manuscript, and all authors edited and reviewed the manuscript.

  • Funding HIV programme activities in Neno District are funded by private charity donors to Partners In Health.

  • Competing interests None declared.

  • Ethics approval We obtained IRB approval from Malawi’s National Health Science Research Committee based in Lilongwe, Malawi, as well as Partners Healthcare Institutional Review Board in Boston, Massachusetts, USA. As no data were collected at the patient level, this study was exempt from full review.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All authors had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. Full data set and statistical code can be requested from the corresponding author at Aggregate facility-level data were used, and no patient-level data were part of this study.