Factors Associated with the Risk of HIV Infection among HIV-exposed Infants in Malawi: 2013-2020

Background Despite the high availability of individual-level data of infants accessing HIV DNA polymerase chain reaction (DNA-PCR) testing service, there has been little in-depth analysis of such data. Therefore, we describe spatial and temporal trends in risk of HIV infection among Malawi’s HIV-exposed infants (HEI) with DNA-PCR HIV test result from 2013 to 2020. Methods This is an implementation study using routinely collected patient-level HIV DNA-PCR test result data extracted from the national Laboratory Management Information System database managed by the Department of HIV/AIDS between 1 January 2013 and 30 June 2020. We calculated frequencies, proportions and odds ratios (OR) with their associated 95% confidence intervals (95%CI). We performed a random-effects logistic regression to determine the risk factors associated with HIV infection in infants, controlling for the spatial autocorrelation between districts and adjusting for other variables. Results We evaluated 255,229 HEI across 750 facilities in 28 districts. The overall risk of HIV infection among all tested HEI between 2013 and 2020 was 7.2% (95%CI: 7.1-7.3). We observed a decreasing trend in the proportion of HEI that tested HIV positive from 7.0% (95%CI: 6.6-7.4) in 2013 to 5.7% (95%CI: 5.4-5.9) in 2015 followed by an increase to 9.9% (95%CI: 9.6-10.2) in 2017 and then a decreasing trend to 4.2% (95%CI: 3.7-4.6) in 2020. The risk of HIV infection increased by age of the HEI. There was spatial heterogeneity of HIV prevalence between districts of Malawi. Conclusion We summarised spatial and temporal trends of risk of HIV infection amongst HEI in Malawi between 2013 and 2020. There is need for further strengthening of EID program to ensure that all the HEI are enrolled in care by eight weeks of age in order to further reduce mother-to-child transmission of HIV. Key message There is need for further strengthening of the Malawi early infant diagnosis program to ensure that all the HIV-exposed infants are enrolled in care by eight weeks of age in order to eliminate mother-to-child transmission of HIV by 2030. What is known about the study? Malawi has implemented the Early Infant Diagnosis (EID) since 2009. Most of the studies on EID in Malawi have focused on just one or two health facilities. What the study adds? This is to our knowledge the first in-depth analysis of national routine data on HIV DNA-PCR tests among HIV-exposed infants with in Malawi. Our study has shown that there is spatial and temporal heterogeneity in risk of HIV infection amongst the HEI in Malawi between 2013 and 2020.