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Malawi has made notable progress in the fight against HIV. The nation is on track to surpass the ambitious UNAIDS 95-95 -95 antiretroviral treatment (ART) and viral suppression targets, set for 2025, which aim to close gaps in HIV treatment coverage and outcomes across sub-populations, age groups, and geographic settings. These targets, adopted by UN Member States in June 2021, represent a bold commitment: ensuring at least 95% of people living with HIV are aware of their status, 95% of those diagnosed are on treatment, and 95% of those receiving treatment achieve viral suppression. Malawi’s strides indicate that surpassing these milestones is potentially within reach.

This progress highlights Malawi’s commitment to combatting the epidemic, and evidence indicates a large decline in new infections. However, the fight is not over. Continued surveillance remains critical for identifying emerging trends, understanding evolving epidemic dynamics, and formulating evidence-based interventions.

Why HIV surveillance matters

As we envision a future free of HIV, traditional methods of surveillance, such as national household surveys with HIV testing, are still important, but they have limitations—especially in settings where the incidence of new infections is lower or falling, making it harder to track changes and emerging hotspots. This, therefore, entails the need for new surveillance approaches.

Surveillance uses innovative approaches of tracking and controlling the epidemic. It helps to monitor sustained HIV epidemic control in countries that have seen low and declining new infections. Ongoing surveillance is essential in identifying trends, understanding the shifting dynamics of the epidemic, and developing evidence-based interventions.

The Kuzama pa Kalondo (KpK) project

In countries like Malawi, where new infections are declining, the traditional “one-size-fits-all” surveillance approach might not capture the granular data necessary for specific, targeted interventions. The Kuzama pa Kalondo (KpK) project aims to fill this gap by using more innovative and tailored methods to provide real-time data that inform targeted national and local health strategies.

KpK is designed to employ future-oriented approaches to address existing gaps in surveillance and ensure efficient, sustainable monitoring. The project started in 2023 and is being implemented through a collaboration of the Kamuzu University of Health Sciences (KUHeS), Harvard T.H. Chan School of Public Health (HSPH), Nyanja Health Research Institute, African Institute for Development Policy (AFIDEP), and University of Cape Town (UCT), in partnership with the Directorate of HIV, STIs, and Viral Hepatitis (DHA), the Public Health Institute of Malawi (PHIM), the US Centers for Disease Control (CDC), and others.

The project combines routine health system data, targeted surveillance, and the power of mathematical and statistical modelling to create a more efficient and sustainable method of tracking HIV infections and responses. This leads to more effective, timely interventions, tailored to the specific needs of various communities.

The project is establishing a comprehensive and forward-looking framework for monitoring HIV epidemic trends and transmission dynamics. Mathematical and statistical modelling techniques are used to define the key indicators to track, allowing anticipation for future epidemic trends and understanding how changes in routine programme metrics reflect broader epidemiological shifts. The AFIDEP team specifically looks into integrating stratified aggregate and individual-level routine monitoring data to generate key HIV strategic information outcomes at district and national levels. By leveraging new data systems, individual-level HIV treatment, testing, and case surveillance, data is being incorporated into tools that enable more accurate subnational epidemic estimates.

The KpK project aims to ensure broader adoption, by sharing tools as open-source R packages and disseminating methods and findings widely through publications, scientific events, and presentations to advisory groups. Moreover, working with relevant authorities and national research partners, such as the Directorate of HIV, STIs, and Viral Hepatitis (DHA), the Public Health Institute of Malawi (PHIM), and Kamuzu University of Health Sciences (KUHES) in Malawi, the project convenes stakeholders to design a surveillance strategy tailored to HIV epidemic control priorities. This includes piloting innovative surveillance methods—such as targeted surveys built on routine health data, antenatal data, case investigations, and adaptive household surveys.

Harnessing the power of data

One of the key strengths of the KpK project is its emphasis on data. By integrating routine health data with advanced modelling techniques, the project analyses large-scale patterns and predicts future trends in HIV infections. This allows for more responsive and timely interventions, ensuring that resources are directed where they are most needed.

Through the use of health system data, the project can quickly detect any new spikes in infections or identify populations not responding well to current interventions. This proactive approach means that the government and health organisations can act swiftly to address issues before they become widespread.

Innovation is key

What sets the KpK project apart is its focus on future sustainability. As countries move towards controlling and eventually eliminating HIV, surveillance methods need to evolve. KpK’s model, which incorporates predictive analytics and targeted surveillance, provides a blueprint for how low-incidence countries can maintain epidemic control in a cost-effective and data-driven way.

By focusing on continuous improvement and adapting to the realities of a changing epidemic, the project ensures that Malawi and other countries are not just fighting HIV today but are prepared to face the challenges of tomorrow.

Further opportunities to end the HIV epidemic

As countries progress toward achieving the 95-95-95 targets, ensuring that no one is left behind is critical. Efforts should go beyond focusing solely on key populations and include comprehensive strategies such as modelling viral load suppression data while addressing confounding biases. Additionally, triangulating HIV data by comparing trends from primary models with other related datasets will provide a more accurate and holistic understanding of progress and gaps.

The KpK project exemplifies an inclusive approach by identifying underserved populations beyond the key groups and ensuring comprehensive representation. By modeling viral load suppression data and mitigating confounding biases, the project delivers precise insights into treatment success. Additionally, triangulating data from multiple sources—such as routine health system data enables a thorough understanding of both achievements and challenges. This thus supports targeted interventions, optimised resource allocation, and ongoing monitoring to enhance program effectiveness.