AIDS 2026: Malawi Program Achieves 10-fold Reduction in HIV Positivity Among Exposed Infants

(Editor’s note: This is the entire interview. Over the next few days, Infection Control Today^® will be posting the interview in installments. Stay tuned!)

A community-based care program in Malawi has achieved remarkably low HIV positivity among HIV-exposed infants while substantially reducing the number of children who miss critical testing milestones, according to findings presented at AIDS 2026 in Rio de Janeiro.

Endale Tilahun, MD, MPH, chief of party in Malawi for Project HOPE Namibia, spoke with Infection Control Today^® (ICT^®) about how household follow-up, individualized case management, and coordination between health facilities and community systems are helping children born to mothers living with HIV begin life HIV-free.

“Our job is to avert new HIV infections so that children are born and grow HIV-free,” Tilahun told ICT. “It’s the start of their life, so it’s a big responsibility.”

Nationally, approximately 39% of HIV-exposed infants in Malawi reach their second birthday without a documented final HIV status, according to Tilahun. Without testing, children who acquire HIV may miss the opportunity to begin treatment promptly.

Through the program, the default rate fell from 39% to 13%. Teams tracked testing milestones at 6 weeks, 12 months, and 24 months and tested more than 7000 HIV-exposed infants. Only 12 tested positive.

“Those 12 HIV positives constitute an HIV positivity rate of only 0.2%, compared to a national average positivity rate of 2%,” Tilahun said. “So, it’s a 10-fold improvement from the national average.”

Addressing More Than Medical Care

Tilahun attributed the program’s success to combining biomedical interventions with support addressing the social and economic conditions affecting treatment adherence.

When a mother has a high viral load, community health workers investigate the barriers preventing viral suppression. Those barriers may include difficulty adhering to treatment, household food insecurity, parenting challenges, transportation problems, or limited access to health facilities.

“The approach that we follow is a household-level and individual-level case management plan,” Tilahun explained. “Our community health care workers conduct a household-level assessment. They also come up with an action plan.”

The program pairs mothers and infants in care and conducts multidisciplinary case conferences when a child acquires HIV. Community members, local structures, caregivers, and health professionals examine what barriers remained unresolved and apply those lessons to other children facing similar risks.

All 12 children who tested positive were placed on antiretroviral treatment and continue receiving support.

“Treatment is so powerful,” Tilahun said. “They can lead a healthier life with the support of the parents and the household.”

Bridging Communities and Health Facilities

Traditional facility-based care may identify that a child has missed an HIV test, but it cannot always determine why. Tilahun said community health workers provide the missing connection.

“We bridge between the facility and the community,” he said.

When a clinic identifies a child who missed a testing milestone, the program receives that information, locates the family, and assesses the obstacles preventing care. Transportation may be arranged, when necessary, particularly if a child is sick or experiencing an opportunistic infection.

Malawi has achieved the UNAIDS 95-95-95 targets among much of its adult population, but pediatric outcomes continue to lag. The target means 95% of people living with HIV know their HIV status, at least 95% who know they are positive are on treatment, and at least 95% of those on treatment have achieved a suppressed viral load. Tilahun said viral suppression among children is approximately 84%, reinforcing the need for targeted household interventions.

“It’s like the best way to describe it is a last-mile intervention for epidemic control,” he said.

Protecting Fragile Gains

Malawi aims to reduce vertical HIV transmission to below 5%. At the time of the assessment, the rate was approximately 6.5%.

Tilahun believes the program’s low positivity rate has significant potential to help close that gap, but scaling the approach will require government ownership, sustained donor engagement, and careful transition planning.

“These gains are very fragile,” he cautioned. “We gain them today. Tomorrow, we might lose them.”

As international funding models shift toward government-led implementation, Tilahun emphasized that transitions must be carried out responsibly and take into account each country’s capacity and circumstances.

“It’s very important to have partnership across the donor community, mainly with the government of Malawi in the driver’s seat, and collaboratively with implementing partners,” he said.

The challenges families face rarely fit neatly into a single health program. Tilahun described one household coping simultaneously with HIV, illness, bereavement, food insecurity, interrupted benefits, and parenting responsibilities across multiple generations. The program coordinated directly observed treatment, emergency nutrition assistance, agricultural support, savings opportunities, education services, and social protection referrals.

“The issues are multiple, and they are interwoven,” he said. “When we talk about viral suppression, we think of the biomedical aspects, but there are multiple health determinants that we need to deal with.”

A Call to Follow the Evidence

Tilahun urged governments, philanthropists, and private-sector partners to direct resources according to evidence and the remaining gaps in care.

“Let’s follow the evidence,” he said. “Let’s follow the gaps.”

He also stressed the importance of preparing for outbreaks and natural disasters that could disrupt care for vulnerable children. Existing community health infrastructure, he said, can support HIV services while strengthening responses to cholera, polio, Ebola, malaria, and maternal and child health emergencies.

“The investment infrastructure is still there,” Tilahun said. “Let’s not miss a chance. Let’s bring our innovation. Let’s bring our resources. Let’s bring our impact to this platform.”

For infection prevention professionals, Malawi’s experience demonstrates that preventing vertical HIV transmission requires more than testing and medication. It requires finding families where they live, understanding why care has been interrupted, and mobilizing health and social systems around the needs of each child.