Implementing remote supervision to improve HIV service delivery in rural Malawi

Background Viral load (VL) testing is critical to monitor response to ART and optimize HIV treatment and care outcomes. Unfortunately, VL testing coverage remains suboptimal in much of sub-Saharan Africa. With the COVID-19 pandemic significantly curtailing in-person supervision of HIV services delivery, low-cost and scalable ways of conducting remote supervision are needed. We evaluated the effects of remote supervision utilizing the WhatsApp platform, a form of supervision highly applicable in the times of COVID-19, on VL testing coverage in rural Malawi. Methods Remote supervision via WhatsApp was introduced at all 36 health facilities in Mangochi district in three phases from December 2018, starting with sites with the lowest VL coverage and high client volumes. Data were collected from VL testing registers over 35 weeks (pre-intervention=17 weeks; post-intervention=18 weeks). VL coverage was defined as the proportion of VL samples collected compared to the Ministry of Health’s target estimate of the number of VL samples that should be collected in that period. We used single-group interrupted time series design to analyze the effects of WhatsApp supervision and determined whether the effects varied by facility type and ownership. All regressions incorporated Newey-West standard errors to handle problems of heteroscedasticity and autocorrelation. Results A total of 23,754 VL samples were collected during the study period with nearly two-thirds (15,788) collected post-intervention. Post-intervention, average weekly VL coverage was 123% compared with 74% pre-intervention, an increase of 49 percentage points (t=13.5, p<0.001). There was an immediate step increase of 58 percentage points (95% CI: 48-68, p<0.001) from 58% to 116% following the intervention, which was followed by an increasing and sustained post-intervention trend in VL coverage of 2.5 percentage points per week (95% CI: 1.36, 3.67, p<0.001). Of the 15,788 VL samples collected post-intervention, 6,179 (or 40%) samples were deemed attributable to the intervention. Conclusions Remote supervision via WhatsApp may offer a simple, scalable, low-cost means of optimizing HIV service delivery in rural resource-limited settings to help to achieve national and regional goals in HIV treatment and care, particularly in the era of the COVID-19 pandemic where in-person supervision has been significantly curtailed.