Despite interruptions in health care during the COVID-19 pandemic, there was a slight increase in the rate HIV virologic suppression during the pandemic among some patients in Malawi. These findings were published in the Journal of Clinical Epidemiology.

Investigators from the University of Bern in Switzerland sourced data for this population-based cohort study from the Malawi Laboratory Management Information System. This study included all routine HIV viral load measurements obtained from patients at 650 antiretroviral therapy (ART) clinics in Malawi between July 2019 and December 2020. The investigators assessed the period before (July 2019-March 2020) and during (April-December 2020) the COVID-19 pandemic to compare differences in HIV viral monitoring and the rate of virologic suppression (HIV viral load, <1000 copies/mL) among the study population. Logistic regression was used to determine predictors of missed HIV viral load measurements. The odds of virologic suppression before vs during the pandemic were stratified by ART regimen and assessed via generalized estimation equations, with adjustments for patient age, sex, duration of ART, and type of biological sample. Population-calibrated multiple imputation was used to impute data from patients with an unknown ART regimen.

A total of 607,894 HIV viral load samples from 556,281 patients were included in this analysis, of which 364,165 were collected before and 243,729 were collected during the COVID-19 pandemic. The investigators noted that 51% of the samples were obtained from dried blood spots. Of the study population, 66% were female patients, 52% were aged 40 years and older, 94% were virologically suppressed, and 55% had been receiving ART for at least 3 years.

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Results showed a decrease in the number of samples obtained during the COVID-19 pandemic compared with those obtained before the pandemic (40% vs 60%, respectively), with the greatest decrease observed in the first quarter of the pandemic. Compared with the period before the pandemic, patients younger than 20 years and those in whom HIV viral load was previously measured via plasma rather than dried blood spots were less likely to have missing viral load data during the pandemic.

The number of samples indicating HIV virologic suppression increased from 92.5% (95% CI, 92.4-92.6) in the third quarter of 2019 to 95.1% (95% CI, 95.0-95.2) in the fourth quarter of 2020. Stratified by type of ART regimen, rates of virologic suppression before vs during the pandemic were similar among patients receiving integrase strand transfer inhibitor (INSTI)-based ART (95.0% vs 95.2%), non-nucleoside reverse transcriptase inhibitor (NNRTI)-based ART (89.7% vs 87.6%), and protease inhibitor (PI)-based ART (79.4% vs 80.3%), respectively.

Among all patients, no difference was noted in the odds of HIV virologic suppression before vs during the pandemic among those receiving NNRTI-based ART. For children and adolescents, a significantly increased odds of virologic suppression during the pandemic was noted among only those receiving PI-based ART (adjusted odds ratio [aOR], 1.25; 95% CI, 1.02-1.54). For adults, the odds of virologic suppression during the pandemic were significantly increased among those receiving INSTI-based ART. The odds of virologic suppression before vs during the pandemic did not significantly differ among children and adolescents receiving INSTI-based ART, with similar findings noted among adults receiving PI-based ART.

This study was limited by the number of samples obtained from patients with an unknown ART regimen.

These findings show “no clear evidence for a worsening of virologic suppression due to the measures taken in response to the COVID-19 pandemic,” the investigators concluded.


Kalua T, Egger M, Jahn A, Chimpandule T, Kolola R, Anderegg N. HIV suppression was maintained during the COVID-19 pandemic in Malawi: a program-level cohort study. J Clin Epidemiol. 2022;S0895-4356(22)00170-6. doi:10.1016/j.jclinepi.2022.06.019