The HIV diagnostic assistant: early findings from a novel HIV testing cadre in Malawi

AIDS. 2019 Jun 1;33(7):1215-1224. doi: 10.1097/QAD.0000000000002159.


Objectives: In 2015, Malawi piloted the HIV diagnostic assistant (HDA), a cadre of lay health workers focused primarily on HIV testing services. Our objective is to measure the effect of HDA deployment on country-level HIV testing measures.

Design: Interrupted time series analysis of routinely collected data to assess immediate change in absolute numbers and longitudinal changes in trends.

Methods: Data from all HDA sites were divided into two periods: predeployment (October 2013 to June 2015) and postdeployment (July 2015 to December 2017). Monthly rates of several key HIV testing measures were evaluated: HIV testing, including all tests done, new positives, and confirmatory testing. Syphilis testing at antenatal clinic (ANC) and early infant diagnosis were also assessed.

Findings: The number of patients tested for HIV per month increased after HDA deployment across all sex, age, and testing subgroups. The number of tests immediately increased by 35 588 (P = 0.031), and the postintervention trend was significantly greater than the preintervention slope (+3442 per month, P = 0.001). Of 7.4 million patients tested for HIV in the postdeployment period, 2.6 million (34%) were attributable to the intervention. The proportion of new positives receiving confirmatory tests increased from 28% preintervention to 98% postintervention (P < 0.0001). Syphilis testing rates at ANC improved, with 98% of all tests attributable to HDA deployment. The number and proportion of infants receiving DNA-PCR testing at 2 months experienced significant trend increases (P < 0.0001).

Interpretation: HDA deployment is associated with significant increases in total HIV testing, identification of new positives, confirmatory testing, syphilis testing at ANC, and early infant diagnosis testing.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Child
  • Child, Preschool
  • Diagnostic Tests, Routine
  • Female
  • HIV Infections / diagnosis*
  • HIV Infections / transmission
  • Health Personnel*
  • Humans
  • Infant
  • Infant, Newborn
  • Infectious Disease Transmission, Vertical / prevention & control
  • Malawi / epidemiology
  • Male
  • Mass Screening*
  • Outcome Assessment, Health Care
  • Patient Acceptance of Health Care / statistics & numerical data*
  • Pregnancy
  • Pregnancy Complications, Infectious / diagnosis
  • Pregnancy Complications, Infectious / prevention & control
  • Pregnancy Outcome
  • Prenatal Care
  • Syphilis / diagnosis*
  • Syphilis / transmission
  • Workforce
  • Young Adult