Implementing a WASH Package Within Prevention of Vertical Transmission of HIV Programming in Lilongwe, Malawi: A Program Evaluation

Background: Access to safe drinking water is a considerable problem in Malawi. Contaminated water plays a major role in diarrheal disease, particularly for people living with HIV and their families. Water, sanitation, and hygiene (WASH) interventions can reduce the risk of diarrhea among children by up to 50%. However, few published reports describe WASH integration in routine HIV care programming in Africa.

Objective: To evaluate a WASH program integrated within the prevention of vertical transmission of HIV (PVTH) care in Lilongwe, Malawi.

Methods: The University of North Carolina’s Project Malawi, the Proctor & Gamble Company (P&G), and the Malawi Ministry of Health implemented a safe drinking water program from 2008 to 2023, integrated within the national PVTH program in Lilongwe, Malawi. We provided a point‑of‑use WASH package to pregnant and breastfeeding women (PBFW) with HIV and their families that included soap, sieves, closed‑water containers, and P&G water purification packets. We examine program impact by describing trends in childhood diarrhea and retention in care at 33 program facilities and 29 non‑program facilities from 2018 to 2022.

Findings: Over the program’s final 5 years, an estimated 2 million water purification packets were distributed annually. From 2018 to 2022 in program facilities, non‑bloody diarrhea rates among children under 5 years remained constant, while bloody‑diarrhea rates fell at both program and non‑program facilities. A small association was found between facility participation in the program and retention in care among PBFW living with HIV (incidence rate ratio: 1.05, 95% CI: 0.99–1.12), but of borderline statistical significance.

Conclusions: In an environment where access to clean water is not assured, we demonstrated the feasibility of delivering a WASH package in HIV care settings over 15 consecutive years. The collaboration between government, academic, and industry partners provides an example for how to integrate WASH within PVTH programming.