A context-responsive health systems intervention improves the uptake of early infant HIV diagnosis: Controlled before and after study in Malawi

Health system challenges limit uptake of early infant diagnosis of HIV (EID). Context-appropriate strategies are required to achieve global 95% six-week testing target. We evaluated a co-designed context-appropriate enhanced health system (EEHS) intervention to strengthen client identification, appointment booking systems, leadership, and facility-based training to improve enrolment of Infants Exposed to HIV (IEH) in HIV care and testing at six weeks. We conducted a before-after intervention evaluation (15 October 2022-5 June 2023) at one urban and rural primary health facilities in Blantyre, Malawi. During pre-intervention period (15 October 2022-18 January 2023), women received standard-of-care EID services. In post-intervention period (19 January to 5 June 2023), women received EID services with EEHS intervention. Data was extracted for women living with HIV and IEH at birth to six weeks. Outcomes were proportion of IEH tested at six weeks (primary) and enrolled in HIV care at birth (Secondary). Logistic regression models were fitted to compute odds ratios (ORs) and 95% confidence intervals (CI). We enrolled 60 women with IEH: 11/60 (18.3%) in rural and 11/60 (18.3%) urban before intervention versus 6/60 (10%) in rural and 54/60 (90%) in urban post-intervention. Median age was 27.5 (interquartile range (IQR), 23-31) pre-intervention and 28 (IQR, 23-32) post-intervention. Six-weeks HIV testing of IEH improved post intervention versus pre-intervention from 46/58 (79%) to 43/46 (93%) (OR 3.74, 95% CI: 1.10-17.23; p = 0.052), with a statistically significant association in adjusted analysis (aOR 4.35, 95% CI: 1.21-21.25) p = 0.038). Enrolment of IEH in HIV care at birth post-intervention increased from 47/60 (78%) to 55/60 (92%) (OR 3.04: 95% CI 1.06-10.06, p = 0.048), with a statistically significant association in adjusted analysis (aOR 3.33: 95% CI 1.13-11.25, p = 0.036). EEHS intervention, potentially improves IEHs' enrolment in HIV care and six-weeks HIV testing, addressing health system challenges, however it requires validation through randomised studies.