Findings from the 2016 Zambia Population-based HIV Impact Assessment (ZAMPHIA): HIV prevalence, incidence and progress towards the 90-90-90 goals Danielle T. Barradas, Ph.D. U.S. Centers for Disease Control and Prevention – Lusaka, Zambia 25 July 2017

Disclosures and Disclaimers I have no financial interests or any other conflicts of interest to disclose. The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of the U.S. Centers for Disease Control and Prevention or other participating institutions. These findings are preliminary and may be subject to change.

Zambia Sociodemographic Overview 2015 midyear population: 15.4 million Average household size: 5.1 members 68% households have access to improved sources of drinking water; 40% have access to improved sanitation Life expectancy at birth: 53 y Total fertility: 5.3 births per woman Under 5 mortality: 75 per 1000 births Source: 2015 Selected Socio‐economic Indicators Report, CSO (pulls from 2015 Census projections [based on 2010 census] and ZDHS 2012-14) Source: 2015 Selected Socio‐economic Indicators Report

HIV/AIDS in Zambia HIV/AIDS is the #1 health threat in Zambia and the leading cause of morbidity and mortality among adults (15-49 y) In 2014, 13 out of 100 adults were living with HIV in Zambia The lifetime risk of dying from HIV in Zambia is over 60%. 13 people living with HIV 87 people without HIV Based on modeled estimates Source: Zambia DHS, 2013-14

of those with HIV know their status of those diagnosed are on ART TARGETS FOR ENDING THE AIDS EPIDEMIC BY 2030 of those with HIV know their status of those diagnosed are on ART of those on ART are virally suppressed

What is ZAMPHIA? ZAMbia Population-based HIV Impact Assessment A household-based national survey led by the Ministry of Health Collection of behavioral and biomarker data with HIV testing with return of results and counseling In collaboration with Central Statistical Office, Tropical Diseases Research Centre, University Teaching Hospital, University of Zambia, ICAP at Columbia University, and U.S. Centers for Disease Control and Prevention

ZAMPHIA Objectives To estimate the following in a household-based, nationally representative sample of adults age 15-59: HIV incidence at national level Sub-national (provincial) prevalence of HIV viral load suppression (VLS) Suppressed viral load = <1000 copies/mL, suggests successful treatment and lower chance of transmission Measure progress toward meeting UNAIDS 90-90-90 targets

Methods 12,310 eligible households in 511 enumeration areas Behavioral and clinical information collected via adult and adolescent individual-level questionnaires Demographic information collected via household questionnaire Blood samples for HIV testing collected per national guidelines.

Methods Confirmation of HIV-seropositive results using the Geenius supplemental assay For this analysis, antiretroviral treatment is based on self-report. Viral load and limiting antigen (LAg) avidity EIA testing were performed at a central lab on all HIV-seropositive samples. VLS was defined as HIV RNA <1000 copies/ml Incidence was determined using results of LAg avidity and viral load testing Statistical analyses completed using SAS v9.4 survey procedures

Scope of Presentation Adult (15-59 y) and pediatric (0-14 y) HIV prevalence estimates Adult HIV incidence estimates Progress toward meeting the UNAIDS 90-90-90 targets among adults All at the national level

ZAMPHIA Response Rates 69% target overall adult response – 68% actual 77%* Analytic sample comprised of 19,029 adults and 7,959 children provided interviews and blood samples (response rate: 68%). Participation by eligible adults was higher for women than men (71% vs 63%, P<0.0001) Overall Response Rate *Adolescents 10-14

HIV Prevalence by Age and Sex: ZAMPHIA, 2016 Overall adult HIV prevalence: 12.0% Adult prevalence among 15-59 y = 12%. This corresponds to an estimated 960,000 persons living with HIV in Zambia. The prevalence was higher among females (14.6%) compared to males (9.3%).

Pediatric HIV Prevalence by Age and Sex: ZAMPHIA, 2016 Overall pediatric HIV prevalence: 0.9% Add CI for overall estimate

HIV Incidence by Sex and Age: ZAMPHIA, 2016 Female % [95% CI] Male Total 15–59 years 1.02% [0.66, 1.37] 0.32% [0.10, 0.54] 0.67% [0.45, 0.88] 15–49 years 1.10% [0.71, 1.48] 0.31% [0.09, 0.54] 0.70% [0.47, 0.93] Reminder that survey was designed to estimate incidence at the national level only (hence the relatively wide CIs) Add 2017 UNAIDS #s when available UNAIDS (2015) Total (15–49 y): 0.85 [0.73, 0.99]

Viral Load Suppression among PLHIV by Sex and Age: ZAMPHIA, 2016* Overall adult VLS: 59.1% * Denominator is all PLHIV with viral load results.

Status of 90-90-90 Targets: ZAMPHIA, 2016 Conditional percentages shown here

Conclusions Zambia is making progress toward the UNAIDS’ 90-90-90 targets Declining national HIV incidence; however, incidence among women remains unacceptably high Further exploration of gaps in testing, ART, and viral load suppression is needed Preliminary findings point toward the need to increase HIV testing, treatment, retention and adherence for both young men and young women. Examples of policy and programmatic implications: Self-testing, expanded hours, more (male) healthcare workers Minimizing delays in ART initiation by maximizing the number of ART sites Full implementation of Test and Start, PrEP …Large undertaking… data has been made available in waves. The final dataset will include additional information including ARV biomarker, drug resistance, TB, and HIV knowledge/attitudes/beliefs data…

Acknowledgements ZAMPHIA participants GRZ Ministry of Health (MOH): Crispin Moyo, Wezi Kaonga Central Statistical Office (CSO): Nchimunya Nkombo Tropical Diseases Research Centre (TDRC): Webster Kasongo ICAP: Karampreet Sachathep, David Hoos, Kumbutso Dzekedzeke CDC: Sundeep Gupta, Dan B. Williams, Bharat Parekh, Hetal Patel, Stanley Kamocha, Clement B. Ndongmo, Kathy Hageman, Margaret A. Riggs ZAMPHIA study team