Characteristics of new and re-initiating antiretroviral therapy clients in Malawi: implications for client counseling in resource-constrained settings.

New antiretroviral treatment (ART) initiates and re-initiators (returning after interruption in treatment [IIT], defined as ≥28 days late for refill) are at higher risk of future IIT compared to stable clients. Counseling is a core strategy to increase retention among new initiates, but little is known about whether re-initiators may have different counseling needs. We compared sociodemographic and psychosocial characteristics of new initiates and re-initiators. We enrolled ART clients ≥15 years living in nine facility catchment areas across three regions of Malawi. We conducted a survey with domains on sociodemographics, ART history, mobility, depression (positive screen: ≥8 on WHO Self-Reporting Questionnaire), and alcohol use (hazardous use: ≥4 for men, ≥3 for women on AUDIT-C). We used Wilcoxon rank-sum and chi-squared tests to assess differences between new initiates and re-initiators. Between September 2023 and April 2025 we screened 1,332 and enrolled 840 eligible ART clients (239 new initiates [28%]). Median age was 38 years; 61% were female. New initiates were more likely than re-initiators to be younger (33 vs. 39 years, p < 0.01), pregnant (21% vs. 4%, p < 0.01), unaware of spouse's HIV status (63% vs. 4%, p < 0.01), screened positive for depression (48% vs. 26%, p < 0.01), and reporting high-risk alcohol usage (34% vs. 19%, p = 0.03). New initiates were less likely to be mobile (21% traveled ≥30 nights in last 12 months vs. 60%, p < 0.01). Counseling should address different needs for new vs. re-initiating clients, targeting depression, alcohol use and disclosure among all clients, disclosure and DSD models for new initiates, and mobility for re-initiators.