Rio de Janeiro, Brazil — Malawi is making impressive strides towards the elimination of mother-to-child transmission of HIV. New evidence shows a very low HIV positivity rate among HIV-exposed infants enrolled in a community-based care and treatment programme across nine districts.
A community-led HIV programme operating in nine of Malawi's highest-burden districts is reducing HIV infections among exposed infants to levels well below the national average, offering a potential blueprint for countries seeking to eliminate mother-to-child transmission.
Dr. Endale Tilahun, Chief of Party and Country Representative for Project HOPE's Malawi office, and a leader within the Africa Public Health Network, has spent recent years overseeing a program called Ana Ndi Achinyamata Patsogolo (ANAPA), meaning Children and Youth First.
ANAPA aims to prevent new HIV infections, improve youth health and well-being, and strengthen social service systems.
Follow us on WhatsApp | LinkedIn for the latest headlines
The initiative operates across 189 facilities and their surrounding communities in nine districts that together account for roughly 90% of Malawi's HIV burden. It combines facility-based HIV services with community-led household follow-up, integrating HIV care with tuberculosis, malaria and maternal, newborn and child health services to ensure mothers and HIV-exposed infants remain in care, and ensure infants receive HIV testing at six weeks, 12 months, and 24 months. More than 7,000 HIV-exposed infants have been tested through the programme.
The findings were presented in Rio de Janeiro at the 26th International AIDS Conference (AIDS 2026), a time when countries are seeking sustainable ways to maintain HIV gains despite shrinking donor funding. The findings suggest that household follow-up of mothers and HIV-exposed infants can play a critical role in keeping families engaged in care, improving early infant diagnosis, and preventing new infections. Researchers say scaling up these community-led best practices could accelerate Malawi's progress towards achieving its national targets for the elimination of vertical HIV transmission.
Beyond the clinic
For Tilahun, the results show that eliminating paediatric HIV will depend not only on medicines and diagnostics, but also on reaching families where they live.
He attributed the programme's success to an HIV-sensitive case management approach that follows mothers and infants beyond the health facility and into their homes. Community health workers pull line lists from facilities, then go door to door to identify HIV-exposed infants, children living with HIV, and children of HIV-positive caregivers who are at elevated risk.
"The case management approach is allowing us to achieve key milestones," said Tilahun. "Once we identify these HIV-exposed infants, we come up with a case plan after identifying the barriers that are really leading to the child becoming HIV positive."
The programme tracks infants at critical testing milestones - six weeks, 12 months and 24 months - while also supporting mothers to remain virally suppressed. If a mother's viral load is high, healthcare workers investigate the underlying causes, such as poor treatment adherence, and provide enhanced adherence counselling. Where families face food insecurity or other social challenges, they receive additional support, including emergency food assistance and nutritional monitoring for children.
Tilahun said addressing these social and household-level barriers is just as important as providing medical care.
"One of the factors for a child to acquire HIV is the mother having a high viral load," he said. "If it is an adherence issue, we put the mother on enhanced adherence counselling. If it is household food insecurity, we address that. If it is a parenting issue, we make sure the child is monitored nutritionally."
Tilahun frames the programme's community structures, households, local health workers, agricultural extension officers, school networks, and district councils as central to its sustainability, describing them as producers, not just recipients, of health outcomes. He argues that biomedical progress alone can't close the remaining gaps; social determinants like household food security and stable income are just as decisive.
"Community structures are producers of health," he said. "These gains are fragile. If the social determinants are not addressed, they can decline. We have to maintain them carefully."
The programme also places strong emphasis on ensuring HIV-exposed infants complete their final HIV test at 24 months, a stage where many children are often lost to follow-up. Tilahun said this comprehensive approach has enabled the programme to maintain high testing coverage and achieve HIV positivity rates that are ten times lower than the national average.
Building on Malawi's HIV legacy
Malawi has long been a reference point in the region's HIV response, having pioneered the Option B+ approach to prevention of mother-to-child transmission. Tilahun sees the current program, if scaled from its nine districts to Malawi's full 28 districts and adapted elsewhere, as a way to close a persistent gap in the region's HIV response: even in countries that have met the UNAIDS 95-95-95 targets overall, children often lag.
The Option B+ approach, which provides lifelong antiretroviral treatment for all pregnant and breastfeeding women living with HIV, has since been adopted by many countries.
"Malawi is actually a pioneer country when it comes to prevention of mother-to-child transmission, now towards the elimination of mother-to-child transmission," Tilahun said. "We are making progress. Still, the game is not over."
Malawi's overall mother-to-child transmission rate currently sits at 5.5%, down from 6.5% when the underlying study was conducted. The national goal is to push that figure below 5% - the threshold associated with eliminating mother-to-child transmission as a public health concern. Tilahun said that scaling the program nationally could meaningfully accelerate that timeline.
He said expanding community-based initiatives such as ANAPA could help close the remaining gap by reaching children who are still being missed by conventional health services.
"If we scale up such programmes, we could accelerate filling the epidemic control gaps among children living with HIV and facilitate the achievement of eliminating mother-to-child transmission," he said.
A model built for transition
The shifting global funding landscape for HIV programmes, marked by major donor cuts, greater reliance on domestic financing and growing threats to community-led service delivery, took centre stage at AIDS 2026 in Rio de Janeiro, Brazil, where delegates stressed that community-led responses are more critical than ever.
With international HIV funding becoming increasingly uncertain, Tilahun said the priority is to preserve the programme's gains while transitioning it into a government-led model that can be sustained over the long term.
According to Tilahun, close collaboration with Malawi's Ministry of Health and the Ministry of Gender, Community, Disability and Social Welfare, particularly its Department of Social Welfare, has been key, with child protection programming helping to close some of the remaining epidemic control gaps. He said this positions the initiative for scaling through government ownership, with Project HOPE's role evolving toward technical assistance and transition support rather than direct implementation.
"The funding landscape is changing. The model is changing," Tilahun said. "We are following the route of transition and sustainability."
He said government ownership will be critical to expanding the initiative beyond the current nine districts and ensuring that services continue uninterrupted. As part of the transition, the programme has aligned its human resources with government structures so that health workers can eventually be absorbed into the public health system.
"The roadmap is to transition the human resources towards the government while we continue to provide support, so that there is no service interruption," he said.
Tilahun said that the model could also provide a blueprint for other countries in the region. Through the Africa Public Health Network, he said, organisations are exploring how community-led approaches can be adapted and scaled under government leadership to strengthen HIV programmes across Africa.
Communities as partners in health
He said that researchers say community-based household follow-up and local support structures act as "producers of health," helping HIV-exposed infants stay connected to care and strengthening efforts to eliminate vertical HIV transmission.
The findings also reinforce one of the central themes of AIDS 2026: that community-led approaches will be essential to sustaining HIV gains as the global funding landscape shifts.
"Householders and community structures are producers of health."
Tilahun said that eliminating mother-to-child HIV transmission requires far more than medicines and diagnostics. Community structures, he said, play a critical role in identifying and addressing the social and economic barriers that prevent families from remaining in care.
"Households and community structures are producers of health," he said. "They are sustainable, and they are really critical pieces to bridge the broader health system."
He said these structures are sustainable by nature, and serve as a critical bridge to the broader health system. He said that while biomedical interventions are vital, they are often undermined by challenges such as poverty, food insecurity and poor treatment adherence. The programme therefore works beyond the health sector, coordinating with local government, agriculture, schools and community leaders to help families overcome those barriers and keep mothers virally suppressed while ensuring HIV-exposed infants complete testing and remain HIV-free.
"Our goal is for children to be born free of HIV, for those who test positive to start treatment, and for people living with HIV to achieve viral load suppression," he said. "Those outcomes are not only determined by biomedical interventions. There are also social determinants that we need to address."
Tilahun said the programme draws on coordination structures at the community level, including decentralized Ministry of Agriculture extension workers, schools, and district councils - partners who help resolve the barriers identified through case management. "Once we address those challenges, we can achieve the key milestones that show we are sustaining and maintaining the gains," he said.
"These gains are fragile... They are not written in stone. If the social determinants are not addressed, they can decline. We have to handle them delicately. We have to be careful"
A blueprint for Africa
Tilahun said the programme's success can be replicated across Malawi and other high HIV burden countries by strengthening community systems rather than relying solely on health facilities.
He pointed first to the program's footprint.
The initiative works across 187 facilities, 62 of them government-led and the remaining 125 supported through direct service delivery. Those facilities, he said, serve as a springboard, but the real difference comes from "leveraging the community structures." He said the real impact comes from extending care into communities, where community health workers engage directly with caregivers, identify barriers to care, and connect families with the support they need.
"The facilities are the springboard, but what's making the difference is leveraging community structures and community engagement," he said. "The case management approach is allowing us to achieve key milestones and such successes."
He credited the case management approach with creating the opening to hit key milestones, describing household-level engagement with caregivers and the mobilization of community stakeholders as valuable not just for financial resource mobilization but for surfacing resources already available locally. "Working at the household level is making a difference in bridging the health system with the community," he said. "The system architecture is now landed at the community structures level, which is more sustainable."
Tilahun said another critical element of the programme is its case management approach: identifying the specific barriers standing between a household and a milestone, and resolving them before they lead to missed appointments, poor treatment adherence or HIV transmission. He said that evidence consistently shows that identifying and addressing barriers is key to achieving better outcomes.
"The power of community health workers working closely with households, caregivers and children is really making a difference," he said.
Looking ahead, Tilahun urged governments across Africa to build on evidence-based community programmes and strengthen government ownership to sustain HIV gains, particularly for children, who continue to lag behind adults in the HIV response.
He said Malawi's government has already expressed interest in scaling up the programme after reviewing the findings at AIDS 2026. The long-term goal, he added, is to expand the model from the current nine districts to all 28 districts by integrating community-based health workers into existing government systems.
Sign up for free AllAfrica Newsletters
Get the latest in African news delivered straight to your inbox
"The commitment is there, and building on the evidence is going to help," he said. "The government will be in a position to absorb that workforce and take it to scale from nine districts to 28 districts of Malawi."
"We have come a long way to achieve the UNAIDS 95-95-95, but children are behind."
He said he's had similar conversations with other countries and sees growing regional interest in the approach, particularly around closing a persistent gap. He believes the approach also offers valuable lessons for other high HIV burden countries. He said that while many have achieved the 95-95-95 treatment targets, children continue to fall behind. "Such approaches are important to be scaled because they help fill the epidemic control gaps among children and HIV-exposed infants," said Tilahun.
Of the roughly 12 infants who tested positive out of more than 7,000 screened, all were placed on treatment. The kind of outcome he said is needed to close remaining epidemic-control gaps after two decades of progress toward 95-95-95.
Tilahun said the final stretch towards eliminating mother-to-child transmission would require innovative, evidence-based approaches. "How do we fill the gap for target populations like children and HIV-exposed infants? How do we do the last-mile interventions? The remaining 5% is not business as usual. We have to be creative. We also have to leverage what the science is giving us."
He said that scientific breakthroughs alone will not be enough to end paediatric HIV unless countries also address the policy and implementation barriers that limit access to innovations.
He pointed to lenacapavir, the long-acting HIV prevention medicine that dominated discussions at the conference, as an example of how promising scientific advances can be slowed by regulatory hurdles, high costs and challenges in integrating new products into health systems.
"We have to leverage what science is giving us," he said. "When the science and the product are there, there are also policy barriers, from regulation and costing to how we integrate these innovations into health systems. We need to advance those discussions as we scale such programmes."
The future lies in government-owned, community-led programmes supported by innovation.
At the same time, he said, the changing HIV funding landscape requires a fundamental shift in how programmes are financed and delivered. He described the shift away from donor-driven models toward government ownership as "a bold move." Rather than relying indefinitely on donor support, countries should strengthen government leadership and ownership. "Our role is to facilitate the government-to-government framework, the implementation plan and the operational plan, while ensuring these fragile, delicate gains are maintained," he said.
Tilahun said the challenge now is to ensure that the progress already achieved is not lost. "How do we ensure these fragile, delicate gains are maintained?" he said, arguing that sustaining success will require continued investment in community-led approaches and innovative "last-mile" interventions to reach every HIV-exposed infant.
