Background: To date, national pediatric HIV burden estimates in Malawi were derived from modeling using clinic-based data. In 2015, an estimated 84,000 children 0-14 years old were living with HIV in Malawi. The Malawi Population-based HIV Impact Assessment (MPHIA), a national household survey conducted from 2015 - 2016, provides the first direct measurement of national HIV prevalence and viral suppression (VS) prevalence among children 0-14 years.
Methods: MPHIA tested children in every other surveyed household (n=13,234) using the national HIV rapid test (RT) algorithm consisting of Determine? (screening RT) and UniGold? (confirmatory RT). Children >18 months who tested positive by both RTs were confirmed by laboratory-based testing using Geenius? HIV 1/2 Confirmatory Assay (Bio-Rad). Children ≤18 months screening reactive on Determine underwent DNA PCR testing for HIV diagnosis. HIV RNA viral load suppression was defined as < 1,000 copies/mL. Weighted national pediatric HIV prevalence and VS prevalence were measured using SI-CHAID weights. Jackknife Replication method was used to calculate 95% confidence interval (CI). Number of children living with HIV was estimated using population projections from the Malawi National Statistics Office (NSO).
Results: Of 9,952 eligible children, 6,143 (61.7%) provided blood for HIV testing. Of those tested, 99 children were HIV positive; 2 were DNA PCR positive. Overall prevalence was 1.6% (95% CI: 1.2% - 2.0%), equivalent to 122,721 children living with HIV (95% CI: 90,868 - 154,573). Among those infected, VS prevalence was 42.9% (95% CI: 30.5% - 55.4%). HIV prevalence was greater in urban compared to rural areas; VS was considerably low among children< 5 years, and those residing in urban areas.

VariableUnweighted number of children who tested HIV positive/Number testedPrevalence (%)95% CIWeighted number of children living with HIV95% CINumber of children (NSO projection)Viral suppression (%)95% CI
0-4 years20/1,8541.20.6 - 1.830,54114,492 - 46,5912,583,79121.93.6 - 40.4
5-9 years37/2,1971.60.9 - 2.349,27127,076 - 71,4663,063,66649.131.2 - 67.0
10-14 years42/2,0922.01.3 - 2.742,90927,069 - 58,7492,143,28750.329.7 - 70.9
Urban residence37/1,9112.31.4 - 3.126,82613,621 - 40,0321,181,94028.912.2 - 45.5
Rural residence62/6,1431.51.0 - 1.995,89465,917 - 125,8726,608,80447.032.2 - 61.9
[HIV prevalence and viral suppression in children]

Conclusions: The MPHIA estimate of the number of children living with HIV is 46% greater than the current estimate which is currently being used for planning of pediatric HIV interventions. Low rates of viral suppression seen in children indicate the need for uptake of effective HIV treatment and adherence interventions to achieve the UNAIDS target of 73% viral suppression among children.