**3. Results**

#### *3.1. COVID-19 Cases and Deaths and General Effects on Health Services*

COVID-19 cases and deaths as reported to WHO gradually increased to 31,798 and 1037, respectively, during the 12-month period (see Figure 1).

In terms of the general effects of COVID-19 on health services, the governmen<sup>t</sup> of Malawi declared a national disaster in March 2020 and ordered a national lockdown. This was challenged in the High Court by the civil society, who were anxious about their livelihoods, and a partial lockdown was then put in place from 23 March to 9 October 2020. This included travel restrictions, a suspension of public meetings, health facilities being asked to restrict numbers of patients accessing the premises, and closure of some HIV testing service delivery points. In response to a dramatic increase in notified COVID-19 cases, on 17 January 2021, the governmen<sup>t</sup> again ordered a full national lockdown (which was not challenged by civil society), and this included a night-time curfew. During these times, there was widespread community fear about contracting COVID-19 and being diagnosed with the disease, and there was a large decline in general out-patient attendances between January and February 2021.

**Figure 1.** Cumulative number of COVID-19 cases and deaths in Malawi between March 2020 and February 2021 as reported to the World Health Organization.

#### *3.2. TB Case Finding, Diagnosis, and Registration*

There was an overall decrease in persons presenting with presumptive PTB (45.6%), being diagnosed bacteriologically positive (2.6%) and registered for TB treatment (19.1%) in the COVID-19 period compared with the pre-COVID-19 period (Table 1).

**Table 1.** Characteristics of persons with presumptive pulmonary TB and registered TB in eight selected health facilities in Lilongwe, Malawi, during pre-COVID-19 and COVID-19 periods.


\* Absolute change (increase or decrease); TB = tuberculosis; PTB = pulmonary tuberculosis; CI = confidence interval.

For those with presumptive PTB, the overall decrease was greater in children (67.8%) compared with adults (44.1%) and greater in females (52.0%) compared with males (39.4%). While the absolute numbers diagnosed bacteriologically positive were almost similar in the two periods, the bacteriological positivity rate nearly doubled (from 5.8% to 10.3%). For those with registered TB, the overall decrease was almost similar between bacteriologically positive PTB (23.9%) and EPTB (25.7%) and less pronounced for clinically diagnosed PTB (17.1%).

The monthly numbers presenting with presumptive PTB and registered TB in the pre-COVID-19 and COVID-19 periods are shown in Figures 2 and 3. The TB programme attempted to keep TB services running, and from November 2020 onwards, it asked health care workers to pro-actively screen those attending outpatients for TB symptoms. Compared with the pre-COVID-19 period, the decline in presumptive PTB in the first 6 months of COVID-19 was 49.7% which was greater than the 40.0% decline in the second 6 months. The decline in registered TB in the first 6 months of COVID-19 (March 2020 to August 2020) was 22.6%, which was greater than the 15.2% decline in the second 6 months (September 2020 to February 2021).

**Figure 2.** Numbers presenting each month with presumptive PTB in eight health facilities in Lilongwe, Malawi, during the pre-COVID-19 and COVID-19 periods. From October 2020 onwards, health workers were asked to pro-actively ask about symptoms of TB in those attending outpatient departments; there was an active tracing of patients needing to be registered.

**Figure 3.** Numbers presenting each month with registered TB in eight health facilities in Lilongwe, Malawi, during the pre-COVID-19 and COVID-19 periods. From October 2020 onwards, health workers were asked to pro-actively ask about symptoms of TB in those attending outpatient departments; there was an active tracing of patients needing to be registered.

#### *3.3. TB Treatment Outcomes*

The overall aggregate treatment outcomes between the Pre-COVID-19 and COVID-19 periods are shown in Table 2. Treatment success was almost similar between the two periods, with small but insignificant differences in the other four adverse treatment outcomes (lost to follow-up, death, failed treatment, and not evaluated).

**Table 2.** Treatment outcomes of patients enrolled in TB treatment in eight selected health facilities in Malawi, during pre-COVID-19 and COVID-19 periods.


\* Absolute change (increase or decrease); TB = tuberculosis; CI = confidence interval; *p*-value for treatment outcomes = 0.25. 'Treatment success' was defined if the TB patient was either cured or had 'treatment completed'. The success rate and other treatment outcomes were calculated for the month-wise cohort of TB patients who commenced on treatment 8 months prior to the reporting month (this accounts for 6 months of treatment being completed and another 2 months for finalizing the recording of outcomes).

The monthly treatment success rates in the pre-COVID-19 and COVID-19 periods are shown in Figure 4. Treatment success was 93% or higher during the two 12-month periods as a result of active follow-up of patients and ensuring complete recording of outcomes as possible. Compared with the pre-COVID-19 period, there was an increase in treatment success in the first 6 months of COVID-19 (March 2020 to August 2020) of 0.8%, which was similar to the 0.7% increase observed in the second 6 months (September 2020 to February 2021).

**Figure 4.** Treatment success amongs<sup>t</sup> those enrolled each month in eight health facilities in Lilongwe, Malawi, during pre-COVID-19 and COVID-19 periods. Enrolment occurred 8 months prior to the month of reporting (to allow for 6-months treatment and 2-months to follow-up and record the final outcome).

#### *3.4. HIV Testing at Health Facilities and Referral to ART*

Results are shown in Table 3. There was an overall decrease (39.0%) in the numbers of persons tested for HIV in the COVID-19 period compared with the pre-COVID-19 period. Part of this decline was associated with increased distribution of HIV self-test kits from May 2020 onwards (where facilities then only performed confirmatory testing on those found HIV positive) and intensified use of a verbal screening tool to identify persons more likely to be HIV positive. The overall decrease in HIV testing was greater in adults (40.4%) than in children (13.5%) and greater in males (42.9%) than females (37.3%). While there was an overall decline in the number of persons diagnosed HIV positive (30.4%), the HIV positivity rate increased slightly in the COVID-19 period (0.4%), possibly as a result of the measures described above. The numbers of HIV-positive persons referred to ART was high (100%) in the pre-COVID-19 period, although this decreased slightly by 1.4% in the COVID-19 period.


**Table 3.** Characteristics of persons tested for HIV and referred to antiretroviral therapy in eight health facilities in Lilongwe, Malawi, during the pre-COVID-19 and COVID-19 periods.

> \* Absolute change (increase or decrease); ART= antiretroviral therapy; CI = confidence interval.

> > The monthly numbers tested for HIV in the pre-COVID-19 and COVID-19 periods are shown in Figure 5. Compared with the pre-COVID-19 period, the decline in HIV testing in the first 6 months of COVID-19 (March 2020 to August 2020) was 46.4%, which was greater than the 31.1% decline observed in the second 6 months (September 2020 to February 2021).
