BACKGROUND: Recent HIV infection surveillance helps determine whether newly diagnosed people living with HIV (PLHIV) were likely recently infected (<12 months) to identify potential geographic areas or subpopulations experiencing ongoing HIV transmission. We describe the process and outcomes of the identification, investigation, and response to HIV transmission in Malawi.
METHODS: Consenting newly diagnosed PLHIV in 251 health facilities underwent a recent infection testing algorithm (RITA) involving a rapid test for recent infection (RTRI) and viral load testing for all those RTRI-recent. Facilities with potential ongoing HIV transmission were identified based on: meeting or exceeding numeric thresholds of RITA-recent infections by facility category, significant increases in RITA-recent infections compared to the prior 3 months, and a Poisson-based spatiotemporal statistic with SaTScan. Facilities that met at least two of these thresholds were investigated. Interviews were conducted during hotspot investigations with health workers and stakeholders to identify possible drivers of ongoing HIV transmission. Interventions were designed and implemented to address HIV service gaps and potential contributors to HIV transmission.
RESULTS: Out of the 251 facilities implementing recent infection surveillance, 15 (6.0%) met one of three hotspot definitions; four in Blantyre (1.6%) and five in Lilongwe (2.0%) were subsequently investigated. Potential barriers to HIV testing and prevention services identified by respondents included stigma faced by key populations seeking care and unavailability of pre-exposure prophylaxis, self-test kits, and condoms. Risky behavior occurring in bars and ”shebeens” (illegal drinking establishments), at parties, and during other cultural practices were also mentioned as possible contributors to transmission. Since May 2022, interventions have been implemented to improve HIV testing and prevention, including the integration of targeted condom distribution with scaled-up index testing, and engagements with community and bar/shebeen owners to support moonlight testing and HIV services.
CONCLUSIONS: Tailored interventions may further reduce HIV new infections by identifying and targeting geographic areas and subpopulations experiencing ongoing transmission. Recent HIV surveillance and hotspot detection and response may provide opportunities to identify and address gaps in HIV services and socio-behavioral barriers for sustaining gains Malawi achieved in reaching epidemic control.

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