---
title: "Strategies to Improve Access to HIV Services for Children in Malawi: Study Protocol"
id: "plos-one-23-investigating-strategies-to-enhance-access-to-hiv-services-among-children-in"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-23-investigating-strategies-to-enhance-access-to-hiv-services-among-children-in"
content_type: "clinical_feed_article"
specialty: "Pediatrics"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357408"
published_at: "2026-09-03T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Strategies to Improve Access to HIV Services for Children in Malawi: Study Protocol
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-23-investigating-strategies-to-enhance-access-to-hiv-services-among-children-in
- **Specialty:** [Pediatrics](https://medichelpline.com/clinical-feed/pediatrics.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357408)
- **Published At:** 2026-09-03T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This study protocol outlines a multifaceted research programme to identify and develop strategies to improve **HIV** service access for children (<15 years) in **Malawi**. It responds to persistent gaps in paediatric outcomes despite national progress toward UNAIDS targets. - National data show a marked disparity: about **55%** viral suppression among children versus **87%** among adults by the end of 2023. Children experience losses at every stage of the care continuum. - The study is guided by the **Socio-Ecological Model** and the **HIV care cascade** framework to examine determinants of access from individual to policy levels. - Four complementary sub-studies are planned: (1) secondary analysis of national HIV programme data and Spectrum estimates (2012–2023) to map trends and attrition points; (2) a scoping review of health-system interventions that improve paediatric HIV access in sub-Saharan Africa (2015–2025); (3) a modified e-Delphi with 15–30 experts to prioritise and adapt interventions into a context-appropriate package; and (4) a feasibility and acceptability assessment at Kabudula Community Hospital using questionnaires and qualitative interviews with healthcare workers, community health workers and caregivers. - The protocol emphasises pragmatic, context-specific intervention development that combines epidemiological evidence, published intervention evidence, and stakeholder prioritisation. - Ethical approval will be sought from Stellenbosch University HREC and the Malawi National Health Sciences Research Ethics Committee; written informed consent and confidentiality procedures will be followed. - The project aims to produce an evidence-informed, feasible intervention package to strengthen paediatric HIV service access and accelerate Malawi’s progress toward the **UNAIDS 95-95-95** targets for children. - No funding was reported for the work; data from the study will be made available upon study completion. The authors declared no competing interests.
## Clinical Analysis & Structured Key Points
Investigating strategies to enhance access to HIV services among children in Malawi: A multifaceted research approach, study protocol | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures Figures Abstract Background Despite major progress in HIV epidemic control, children in sub-Saharan Africa, particularly in Malawi, continue to experience poorer HIV outcomes than adults. While Malawi has made substantial progress toward the UNAIDS 95-95-95 targets, only 55% of children living with HIV are virally suppressed compared with 87% of adults. This study aims to identify and develop strategies to improve children`s access to HIV services in Malawi. Methods Guided by the Socio-Ecological Model and the HIV care cascade framework, this multi-method study comprises four sub-studies: (1) secondary analysis of national HIV program data and spectrum estimates (2012–2023) to assess trends and progress toward the 95-95-95 targets; (2) a scoping review of health system interventions that improve paediatric HIV service access in sub-Saharan Africa (2015–2025). (3) a modified e-Delphi process with 15–30 experts to develop a context-appropriate intervention package and (4) a feasibility and acceptability assessment of the package at Kabudula Community Hospital, Lilongwe, Malawi, involving healthcare workers, community health workers, and caregivers using questionnaires and qualitative interviews. Ethical considerations Ethical approval will be obtained from Stellenbosch University Health Research Ethics Committee (HREC) and the Malawi National Health Sciences Research Ethics Committee. Written informed consent and confidentiality will be ensured. Conclusion This study will identify gaps in HIV care access among children, synthesize evidence on effective interventions, and develop a feasible, context-specific intervention package to strengthern children`s access to HIV services and accelerate Malawi`s progress toward achieving UNAIDS 95-95-95 targets. Citation: Matola BW, Nyasulu JCY, Nicol E (2026) Investigating strategies to enhance access to HIV services among children in Malawi: A multifaceted research approach, study protocol. PLoS One 21(9): e0357408. https://doi.org/10.1371/journal.pone.0357408 Editor: Amos Buh, University of Ottawa, CANADA Received: March 26, 2026; Accepted: August 17, 2026; Published: September 3, 2026 Copyright: © 2026 Matola et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Introduction The HIV/AIDS epidemic remains a major global public health challenge despite remarkable progress in prevention, and treatment over the past three decades. Sub-Saharan Africa continues to bear the greatest burden of the epidemic, accounting for nearly two-thirds of all people living with HIV (PLHIV) worldwide [ 1 , 2 ]. Malawi, a low-income country in this region, remains one of the countries most affected by HIV. In 2024, the country reported an HIV prevalence of approximately 7.3% among adults aged 15 years and older and 0.6% among children under 15 years [ 3 ]. Although the scale up of HIV interventions has resulted in substantial declines in new infections and AIDS related mortality since the mid-1990s [ 1 ], important disparities in HIV outcomes persist across population groups. Global progress has been driven by coordinated efforts to expand access to HIV prevention, treatment and care services. Since its establishment in 1996, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has led the global response to HIV with the goal of ending AIDS as a public health threat by 2030 [ 4 ]. The UNAIDS Fast-Track strategy, launched in 2014, introduced the 95-95-95 targets, which aim for 95% of all people living with HIV to know their HIV positive status, 95% of those diagnosed with HIV to receive sustained antiretroviral therapy (ART), and 95% of those on treatment to achieve viral load suppression by 2025 [ 4 ]. Globally, important gains have been made toward these targets. By 2023, 86% of people living with HIV globally knew their HIV status, 77% were receiving ART, and 72% had achieved viral suppression [ 1 ]. In sub-Saharan Africa, the corresponding figures were 93%, 83% and 78%, respectively [ 1 ]. Malawi has made considerable progress towards these targets through its public health approach to HIV service delivery. Since adopting this approach in 2004 and implementing the UNAIDS 90-90-90 targets in 2015, later transitioning to the 95-95-95 targets in 2020, the country has substantially expanded HIV testing and treatment services [ 5 ]. By the end of the 90-90-90 implementation period, 88.4% of people living with HIV were aware of their HIV positive status, 97.8% of those diagnosed were receiving treatment, and 96.9% of those on treatment had achieved viral suppression [ 6 ]. These achievements demonstrate the strength of Malawi`s national HIV programme. Despite this progress, children continue to experience poorer outcomes than adults across the HIV care continuum [ 7 , 8 ]. In this study, children are defined as individuals younger than 15 years of age, consistent with the definitions adopted by the World Health Organization [ 9 ] and the Malawi National HIV Programme. The terms children and paediatric are used interchangeably throughout the manuscript. Children experience lower rates of HIV diagnosis, delayed ART initiation, poorer retention in care, suboptimal treatment adherence, and lower viral suppression than adults [ 10 – 15 ]. Access to HIV services is defined as the ability of children to obtain timely, equitable, and continuous HIV services across the care continuum, including HIV testing, diagnosis, linkage to care, ART initiation, retention in care, viral load monitoring, and achievement of sustained viral suppression [ 16 ]. Improving access therefore extends beyond the physical availability of services to include their accessibility, acceptability, affordability, and continuity throughout treatment. Achieving and sustaining epidemic control among children is critical, not only for improving child health outcomes but also for preventing HIV transmission and reducing the risk of drug resistance [ 17 ]. These disparities are particularly evident in Malawi. While viral suppression among adults reached approximately 87% by the end of 2023, suppression among children was only about 55% [ 18 ]. Children continue to experience losses at every stage of the HIV care continuum, from HIV diagnosis and linkage to care to treatment initiation, retention, and long-term viral suppression [ 19 ]. These persistent gaps threaten Malawi`s progress towards achieving the UNAIDS 95-95-95 targets and underscore the need for strategies specifically tailored to children`s needs. Numerous health system interventions have been implemented globally and in Malawi to strengthen HIV service delivery, including decentralisation of HIV services [ 20 ], task shifting and task sharing [ 20 ], universal “test and treat” policies [ 21 ], integration of HIV services into primary healthcare [ 22 , 23 ], differentiated service delivery models [ 24 ], community-based HIV programmes [ 25 ], strengthened monitoring and evaluation systems [ 20 ], as well as innovative financing through global partnerships [ 26 ]. Although these interventions have substantially improved HIV outcomes at the population level, children continue to lag because they face unique barriers, including delayed early infant diagnosis [ 27 ], poor linkage to treatment [ 28 ], inconsistent retention in care, dependence on caregivers, stigma, long travel distances [ 29 ], financial constraints, and socialeconomic disadvantage. Evidence suggests that interventions such as task shifting to lay health workers [ 30 – 33 ], integration of paediatric HIV services with maternal and child health services [ 25 , 34 , 35 ], expansion of point-of-care diagnostic technologies [ 36 – 42 ], decentralisation of ART services and differentiated service delivery models, have demonstrated potential for improving treatment uptake and retention among children [ 43 – 49 ]. However, the evidence remains fragmented and highly context-specific, with limited sysnthesis of which interventions are most effective for improving access to HIV services among children in sub-Saharan Africa. Furthermore, few national studies have comprehensively analysed routine programme data to identify where children are being lost along the HIV care continuum in Malawi. Consequently, policymakers have limited evidence to guide the development of comprehensive and contextually appropriate strategies to improve HIV service delivery in children. Addressing these gaps requires more than a single methodological approach. National HIV epidemiological analyses can identify where service delivery gaps occur but cannot determine which interventions are most effective. Conversely, evidence from published studies can identify promising interventions but may not adequately reflect the Malawian context. Moreover, evidence-based interventions require prioritisation by stakeholders and assessment of their feasibility before implementation. An integrated research approach is therefore needed to combine epidemiological evidence, evidence synthesis, stakeholder consensus, and implementation assessment. Accordingly, this study adopts a sequential multi-method design comprising four complementary methodological components. First, a national epidemiological analysis will identify service delivery gaps across the paediatric HIV care continuum. Second, a scoping review will synthesise evidence on interventions that have improved access to HIV services among children in sub-Saharn Africa. Third, a modified Delphi process will engage key stakeholders to contextualise and prioritise these interventions for Malawi through expert consensus. Finally, a feasibility assessment will evaluate the acceptability, practicality, and implementation potential of the resulting intervention framework. Fig 1 summarises the interplay between the four sub studies. Download: PNG larger image TIFF original image Fig 1. Conceptual workflow of the study. Illustrates the conceptual workflow of the study and the relationship between the individual sub studies. https://doi.org/10.1371/journal.pone.0357408.g001 Together, these four components provide a coherent pathway from identifying service delivery gaps, to identifying evidence-based solutions, adapting them to the local context, and evaluating their readiness for implementation. By integrating epidemiological analysis, evidence synthesis, stakeholder consensus, and feasibility assessment, this study aims to develop an evidence-informed and contextually appropriate framework for improving access to HIV care services among children in Malawi. The findings will inform policy and programme implementation, strengthen children HIV service delivery, and ontribute to achieving equitable progress towards the UNAIDS 95-95-95 targets and ending AIDS as a public health threat by 2030. The main research question guiding this study is: How can an evidence-informed and contextually appropriate framework of strategies be developed to improve access to HIV care services among children in Malawi? The broad objective of this study is to develop and assess the possible feasibility of an evidence-informed, contextually appropriate framework for improving access to HIV services among children in Malawi. The following are the specific objectives: 1. To assess levels and trends in access to HIV services among children in Malawi in relation to progress toward the UNAIDS 95-95-95 targets. 2. To map, through a scoping review, health system interventions that have improved uptake of HIV services among children in sub-Saharan Africa. 3. To design and develop a context-appropriate intervention package to improve access to HIV services among children in Malawi. 4. To assess the possible feasibility and acceptability of the proposed intervention package at Kabudula Community Hospital in Lilongwe district, Malawi. Materials and methods This study will use a sequential multi-method study design [ 50 ]. The study comprises four interrelated sub-studies in line with the objectives. Below are the details: Sub-study 1: To examine the current level of access to HIV services and trend among children in Malawi in relation to achieving the UNAIDS 95-95-95 fast track targets Study design. This study employed a descriptive quantitative design [ 51 ] using secondary data derived from routinely collected Malawi national HIV programme database and UNAIDS spectrum estimates. The study systematically analysed existing programme data to describe temporal trends, quantify progress, and identify gaps in HIV service delivery across the HIV care continuum. Statistical analyses were conducted to objectively assess Malawi`s progress towards achieving the UNAIDS 95-95-95 targets, with particular emphasis on examining disparities in HIV testing, antiretroviral therapy (ART) coverage, and viral load suppression across key population subgroups, including age and sex. The use of routinely collected national data enabled a comprehensive evaluation of programme performance under real-world implementation conditions and provided evidence to inform policy and programme improvement. Data sources. This study utilized secondary data obtained from Malawi’s national HIV programme and UNAIDS spectrum estimates. Routine programme data were extracted from the Department of HIV/AIDS Management Information System (DHAMIS), the national repository for HIV programme data maintained by the Ministry of health. DHAMIS receives routinely reported, aggregated data from all health facilities providing HIV prevention, testing, treatment, and care services across the country. The analysis included programme data collected between 2012 and 2023, enabling the assessment of longitudinal trends in HIV service delivery and programme performance. To complement the routine programme data, UNAIDS spectrum estimates were used to obtain epidemiological parameters that are not routinely captured through health facility reporting, including national estimates of the total number of people living with HIV (PLHIV). Spectrum is a globally recognized mathematical modelling tool that generates country-specific HIV estimates by integrating surveillance, demographic, and programme data [ 52 ]. The combined use of routine programme data and spectrum estimates provided a more comprehensive assessment of Malawi`s progress towards the UNAIDS 95-95-95 targets by integrating observed programme performance with modelled population-level estimates. Study variables. The primary outcome variables were the three indicators of the UNAIDS 95-95-95 HIV care cascade: HIV status awareness, antiretroviral therapy (ART) uptake, and HIV viral load suppression. These indicators were assessed longitudinally to evaluate trends in HIV programme performance between 2012 and 2023. HIV status awareness was defined as the proportion of people living with HIV (PLHIV) who were aware of their HIV-positive status. ART uptake was defined as the proportion of individuals diagnosed with HIV who were receiving antiretroviral therapy. Viral load suppression was defined as the proportion of individuals receiving ART who achieved viral suppression, as defined by the Malawi National HIV Programme and UNAIDS monitoring guidelines. To assess equity in HIV service delivery, all outcome variables were disaggregated by age and sex. Age was categorized into children (under 15 years) and adults (15 years and older), consistent with national HIV programme reporting, while sex was categorized as male and female. Stratified analyses were undertaken to identify temporal differences in programme performance across demographic subgroups and to quantify disparities in access to HIV diagnosis, treatment and treatment outcomes. This disaggregation enabled the identification of population groups experiencing suboptimal performance across the HIV care continuum, thereby informing targeted policy and program interventions. Data analysis tools. Data were pre-processed through systematic cleaning, validation, and consistency checks to ensure completeness, accuracy and internal consistency prior to analysis. initial data management, including data verification, coding, and tabulation, was conducted using Microsoft Excel. Statistical analyses were performed using Stata version 15.1. Statistical analysis. Descriptive statistical analyses were conducted to summarize the characteristics of the study population and describe temporal trends in the three UNAIDS 95-95-95 indicators: HIV status awareness, antiretroviral therapy (ART) coverage, and viral load suppression. Categorical variables were summarized using frequencies and proportions, while trends in programme performance from 2012 to 2023 were presented graphically and in tabular form. Comparative analyses were undertaken to assess differences in HIV programme outcomes across demographic subgroups. For the 2023 cross-sectional analysis, proportions of HIV status awareness, ART coverage, and viral load suppression were compared by age group (children <15 years and adults ≥15 years) and sex. Pearson`s chi-square test was used to compare proportions between groups, while Fisher`s exact test was applied where expected cell counts were insufficient to satisfy the assumptions of the chi-square test. Corresponding 95% confidence intervals were reported for key proportions and estimated differences where appropriate. All statistical tests were two-sided, and statistical significance was determined using an alpha level of 0.05 (p < 0.05). Timelines. The UNAIDS 95-95-95 targets were originally set for achievement by December 2025. To maintain relevance to this timeline, this sub-study was completed and its findings published in May 2025. The full publication and data set are publicly accessible online at the following link: https://www.tandfonline.com/doi/abs/10.2989/16085906.2025.2477090 . Sub study 2: To describe the landscape of health system interventions that have improved access to HIV services among children in sub-Saharan Africa Study design. This study will employ a scoping review design [ 53 ] to systematically map and synthesise the existing evidence on health system interventions that improve access to HIV services among children in sub-Saharan Africa. The review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews, which represents the current international standard for the conduct of scoping reviews and builds upon the foundational framework proposed by Arksey and O’Malley and its subsequent refinements [ 54 , 55 ]. Consistent with the JBI methodology, the review will follow a structured and iterative process comprising: (i) defining the review objectives and research question; (ii) developing and implementing a comprehensive search strategy; (iii) identifying and selecting eligible studies based on predefined inclusion and exclusion criteria; (iv) extracting and charting data using a standardised data extraction form; and (v) collating, summarising, and presenting the findings in relation to the review objectives. Throughout the review process, methodological decisions will be documented to
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