Despite major progress in HIV epidemic control globally and in Malawi, children living with HIV in sub-Saharan Africa continue to have poorer outcomes than adults. Malawi has made substantial advances toward the UNAIDS 95-95-95 targets; however, a pronounced pediatric gap remains: only 55% of children living with HIV are virally suppressed, compared with 87% of adults. This disparity motivates a focused investigation of barriers and system-level solutions to improve children’s access to HIV services in Malawi.
The overall aim of the study is to identify and develop strategies to improve access to HIV services for children in Malawi. Specific goals implicit in the protocol include: mapping trends and progress toward 95-95-95 for children using national program data; synthesizing evidence on health system interventions that improve pediatric HIV service access in sub-Saharan Africa; achieving expert consensus on a context-appropriate intervention package via a modified e-Delphi; and assessing the feasibility and acceptability of that package at a district-level hospital in Lilongwe.
The study will be guided by two complementary frameworks. The Socio-Ecological Model will permit analysis across multiple levels that influence service access — from individual and caregiver factors to community networks and health system structures. The HIV care cascade framework will structure assessment of steps from diagnosis and linkage to treatment and viral suppression, enabling identification of gaps and targeted interventions along that cascade.
This is a multi-method research program composed of four sequential and interlinked sub-studies. Together these sub-studies combine quantitative secondary data analysis, evidence synthesis, expert consensus methods, and primary feasibility testing with mixed methods. The program is intended to move from problem characterisation to evidence-informed design and local feasibility assessment of an intervention package tailored to the Malawian context.
The first component uses existing national HIV program data and Spectrum model estimates covering 2012–2023 to assess temporal trends and progress toward the UNAIDS 95-95-95 targets for children. This analysis will quantify current gaps in detection, treatment coverage, and viral suppression among children, and provide an epidemiological foundation for subsequent evidence synthesis and intervention design.
A scoping review will identify and map health system interventions implemented in sub-Saharan Africa between 2015 and 2025 that aim to improve pediatric HIV service access. The review will synthesise intervention types, target populations, reported outcomes relevant to the care cascade, and implementation characteristics to inform selection of candidate strategies suitable for adaptation in Malawi.
A modified electronic Delphi (e-Delphi) process will engage 15–30 experts to reach consensus on a context-appropriate package of interventions for improving children’s access to HIV services in Malawi. The e-Delphi will use findings from sub-studies 1 and 2 as inputs, and the expert panel will iteratively rate and refine intervention components until a feasible, evidence-aligned package is developed for local testing.
The final sub-study will evaluate the feasibility and acceptability of the developed intervention package at Kabudula Community Hospital in Lilongwe. The assessment will involve healthcare workers, community health workers, and caregivers and will employ questionnaires and qualitative interviews to capture perceptions of acceptability, practicability, and contextual barriers or facilitators to implementation. This mixed-methods approach will provide pragmatic data on whether the package can be implemented and accepted in routine service settings.
Ethical approval for the study will be obtained from the Stellenbosch University Health Research Ethics Committee (HREC) and the Malawi National Health Sciences Research Ethics Committee. The protocol states that written informed consent and confidentiality protections will be ensured for participants in primary data collection components of the project.
By combining national program analysis, a scoping synthesis of interventions, expert consensus, and local feasibility testing, the study aims to (1) identify gaps in pediatric HIV care access; (2) synthesise evidence on effective health system interventions; and (3) develop and preliminarily test a feasible, context-specific intervention package to strengthen children’s access to HIV services in Malawi. The authors propose that these outputs will contribute to accelerated progress toward achieving UNAIDS 95-95-95 targets for children in Malawi.