Measuring Impact – PHIA Findings from Malawi, Zimbabwe, and Zambia

Thokozani Kalua MBBS MScDepartment of HIV and AIDS, Ministry of Health, Malawi

11th INTEREST WorkshopLilongwe, Malawi, 19 May 2017

Nothing to disclose

What is PHIA?• Population-based HIV Impact Assessment

• Cross-sectional household-based survey

• Nationally and sub-nationally (zonal) representative

• Focused on measuring impact-level indicators of the HIV epidemic through biomarkers and self-reporting

PHIA objectives• Primary

• To estimate national HIV incidence• To estimate sub-national prevalence of viral load suppression among adults

• Secondary• To estimate national and sub-national prevalence among adults, >15 years• To estimate national prevalence of HIV among children, <15 years • To estimate presence of detectable antiretrovirals in HIV-positive adults and

children• To estimate the prevalence of transmitted drug resistance

Three-Country Overview

ZambiaPopulation: 15,967,000

ZimbabwePopulation: 16,717,000

MalawiPopulation: 17,750,000

Three countries:• Similar population sizes• Generalized HIV epidemic• Contiguous• Clade C

Survey methodsSurvey Design Cross-sectional, two-stage cluster sample to achieve nationally representative

sample

Sample size Powered for national HIV incidence and subnational viral load suppression; ~30,000 participants, incl. 5,000 – 10,000 children

Eligibility Household members who slept over the night before

Questionnaires Household, adult and adolescent interviews collecting demographic, behavioral and clinical information

Specimen Whole blood for HIV, syphilis and hepatitis B testing

Data collection Electronic data capture~ six months of field work

Weighting Adjustment for non-response at PSU, household, individual and biodata-levels;Post-stratification adjustment to make survey estimates of national age/sex counts conform to the counts given in the population projections

Laboratory methodsHousehold • Venous blood draw; finger/heel stick for <2 yrs

• HIV rapid testing per each national algorithm; CD4 for HIV+• Return of HIV rapid test results and counseling

Satellite Lab

• HIV confirmatory testing• Quality assurance testing

Central Lab(in-country)

• HIV RNA (viral load measurement)• Early infant diagnosis: detection of HIV DNA in children 0 – 18

months old • HIV-1 LAg-Avidity enzyme immunoassay

• Incidence (recency): LAg < 1.5 ODn and VL > 1000 copies/mL Other Testing

• ARV detection • Genotyping and drug resistance

Results from Malawi, Zimbabwe and Zambia

Response Rate - Household

Response Rate – Interview and blood draw with HIV testing

Adult HIV Prevalence (Females: 15-49; Males: 15-54)

HIV Prevalence in children, 0-14 years

Annual HIV Incidence (15-49 years)

Viral Suppression in Adults (15-59) Living with HIV

Progress to 90/90/90 targets in adults

Overall conclusions

• Progress toward the 90-90-90 goals in Malawi, Zambia and Zimbabwe demonstrates that the national HIV programs have made great strides in responding to their HIV epidemics

• PHIA estimates of national HIV incidence provide further evidence of epidemic control

• The goal of ending the AIDS epidemic by 2030 is within reach, provided there is targeted HIV testing, especially for men and young women and continued expansion of HIV treatment programs

Acknowledgements• Government of Zimbabwe, Ministry of Health and Child Care

• National AIDS Council, Zimbabwe

• Ministry of Health, Zambia

• National Statistics Office, Malawi

• National AIDS Commission, Malawi

• ZIMSTAT

• BRTI

• Lancet Zimbabwe

• Central Statistical Office, Zambia

• Tropical Diseases Research Centre, Zambia

• University Teaching Hospital, Zambia

• Ministry of Health, Malawi

• Blantyre Health Research and Training Trust, Johns Hopkins University Laboratories

• Centre for Social Research, Malawi

• CDC Malawi

• CDC Zimbabwe

• CDC Zambia

• CDC Atlanta

• ICAP New York

• ICAP Zimbabwe

• ICAP Zambia

• ICAP Malawi

• ICAP South Africa Reginal Office

• PHIA study participants and field teams

This project is supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through CDC under the terms of cooperative agreement #U2GGH001226. The contents are the responsibility of ICAP and do not necessarily reflect the views of the United States Government.The mark "CDC" is owned by the US Dept. of Health and Human Services and is used with permission. Use of this logo is not an endorsement by HHS or CDC of any particular product, service, or enterprise.

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