Final Report: LINKAGES Project in Malawi

The project was funded by the U.S. Agency for International Development (USAID) through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). The project aimed to provide differentiated, KP-friendly HIV prevention, care, and treatment services to female sex workers (FSWs), men who have sex with men (MSM), and transgender people. According to the Malawi Population-Based HIV Impact Assessment 2015-2016, an estimated 72.7% of people living with HIV in Malawi knew their status, 88.6% were on antiretroviral therapy (ART), and 90.8% of those who reported being on ART were virally suppressed. However, the country still faced an estimated 38,000 new infections annually, with the gains for KPs lagging behind those made among the general population. Compared to the general population HIV prevalence of 9.2%, the prevalence among FSWs was 55%, and nearly one in five MSM in Malawi lived with HIV. The LINKAGES project implemented programming in six of 28 districts in Malawi, including major cities and urban centers where the HIV epidemic was higher than the national average. The project partnered with four local civil society organizations (CSOs): Pakachere Institute of Health and Development Communication, Center for the Development of People, Youth Net and Counseling Organization, and Family Planning Association of Malawi. The project established 19 drop-in centers (DICs) - 15 for FSWs and four for MSM and transgender people - and gradually expanded service offerings, including the provision of antiretroviral therapy. The LINKAGES project in Malawi delivered a comprehensive package of services across the entire HIV cascade, including prevention interventions, HIV testing, linkages to and retention in care, initiation and adherence to ART, and viral load monitoring. The project supported the CSO partners to establish 19 DICs and gradually expand their service offerings. Initially, services at the DICs consisted of HIV testing and counseling (HTC), sexually transmitted infection (STI) screening and management, post-exposure prophylaxis (PEP), and referrals to ART. Family planning and gender-based violence (GBV) screening and response were later added as staff capacities were built. The project monitored service delivery via a web-based database they developed to track individual uptake of services among KPs, called "e-cascade." The system enabled the team to conduct various individual-level data analyses and generate dashboards that offered snapshots of program coverage, program performance on key outcomes, and performance by implementing partner. The project reached 28,885 individuals in its final year, exceeding the FY19 target. More than 8,000 of those reached were known positive, nearly 1,000 declined testing, and nearly 20,000 were referred for testing. The project tested 12,883 individuals, 1,750 of whom were diagnosed HIV positive, producing a case-finding rate of 14%. Of those diagnosed, 1,707 (98%) were initiated on treatment, achieving 102% of the FY19 treatment initiation target. The project provided a range of services, including peer education, risk assessment, counseling, risk reduction planning, condom use promotion, HIV testing and counseling, violence screening, post-exposure prophylaxis services, and referral to medical, psychosocial, and legal services. The project also provided family planning services for FSWs, syndromic screening and referral for sexually transmitted infections (STIs), pre-exposure prophylaxis (PrEP) services, link to care and treatment services, peer navigation to support treatment initiation and adherence, viral load testing and monitoring, tuberculosis (TB) screening and referral for treatment, assessment for STIs and other opportunistic infections (OIs) and referral, and referral for prevention of mother-to-child transmission (PMTCT) services for FSWs who are pregnant.