Correlates of being outside the 90-90-90 cascade among adults aged 15-64 years in Zimbabwe: Results from the 2015-2016 Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) Avi J Hakim1, Elizabeth Radin2, Leala Ruangtragool1, Amy Herman-Roloff1, Nahima Ahmed2, Godfrey Musuka2, Hazel Dube2, Mutsa Mhangara3, Lovemore Gwanzura4, Shungu Munyati4, Elizabeth Gonese1, Amaka Nwankwo-Igomu1, Hetal Patel1, Katrina Sleeman1, Steven Kinchen1, Jessica Justman2, Beth A Tippett-Barr1 for the ZIMPHIA Survey Team 1 U. S. Centers for Disease Control and Prevention; 2 ICAP at Columbia University; 3 Ministry of Health and Child Care, Zimbabwe; 4 Biomedical Research and Training Institute, Zimbabwe 25 July 2017 9th IAS Conference on HIV Science Center for Global Health Division of Global HIV & TB

Zimbabwe Population: 14.5 million 2015 UNAIDS HIV prevalence: 14.7% among 15-49 year olds HIV treatment is free for Zimbabweans HIV treatment eligibility 2013: CD4<500 cells/µL December 2016: Treat all

Objective ZIMPHIA conducted October 2015-August 2016 to assess national HIV incidence and the 90-90-90 cascade at a subnational level To describe the 90-90-90 cascade among 15-64 year olds in Zimbabwe and correlates of being outside each level of the cascade (or, being in the 10-10-10 cascade)

METHODS

Sampling Method Two-stage cluster-based nationally representative household survey using population-proportional to size within strata Stage 1: 500 enumeration areas across 10 strata Stage 2: 15,009 households

Data Collection Household and individual interview HIV-related testing Rapid testing with: Determine, First Response (confirmation), Stat-Pak (tie breaker) Results returned same day Laboratory: Geenius for quality assurance Viral load with Roche Cobas AmpliPrep/Cobas TaqMan platform Results returned to health facility in participant’s district after ~10 weeks

Analytic Methods Data weighted for survey design and non-response Multivariate models: p<0.10 in bivariate analysis p<0.05 in multivariate analysis Variables considered: age, gender, urban/rural, province, education, marital status, condom use last sex 12 months, number sex partners last 12 months, sold sex last 12 months

Outcome Measures First 10: HIV-infected and unaware of HIV status Second 10: Aware of HIV infection but not on treatment Third 10: On treatment but not virally suppressed All outcomes measures save for viral suppression were self-reported

Results

Response Rate Among Individuals Aged 15-64 Years, ZIMPHIA 2015-2016 15,009 HH Selected 13,828 HH Occupied 83.9% Interviewed Males Rostered 11,923 Males Eligible 11,098 Males Interviewed 9,271 (82.3%) Males Tested for HIV 8,395 (90.2%) Females Rostered 14,534 Females Eligible 14,033 Females Interviewed 13,219 (93.9%) Females Tested for HIV 12,182 (91.8%)

Response Rate Among Individuals Aged 15-64 Years, ZIMPHIA 2015-2016 15,009 HH Selected 13,828 HH Occupied 83.9% Interviewed Males Rostered 11,923 Males Eligible 11,098 Males Interviewed 9,271 (82.3%) Males Tested for HIV 8,395 (90.2%) Females Rostered 14,534 Females Eligible 14,033 Females Interviewed 13,219 (93.9%) Females Tested for HIV 12,182 (91.8%)

Response Rate Among Individuals Aged 15-64 Years, ZIMPHIA 2015-2016 15,009 HH Selected 13,828 HH Occupied 83.9% Interviewed Males Rostered 11,923 Males Eligible 11,098 Males Interviewed 82.3% Males Tested for HIV 90.2% Females Rostered 14,534 Females Eligible 14,033 Females Interviewed 93.9% Females Tested for HIV 91.8%

ZIMPHIA National HIV Prevalence: 14.1%

Zimbabwe Testing and Treatment Cascade 27.1% 13.2% 13.5% 72.9% 86.8% 86.5% 63.3% 59.6%

1. Correlates of being unaware of HIV Age aOR (95% CI) 15-24 4.8 (2.9-7.8) 25-34 1.8 (1.2-2.7) 35-44 0.9 (0.6-1.4) 45-54 0.9 (0.6-1.3) 55-64 ref 15

1. Correlates of being unaware of HIV Gender aOR (95% CI) Female ref Male 1.9 (1.5-2.3) 16

1. Correlates of being unaware of HIV Marital status aOR (95% CI) Never married 1.7 (1.1-2.6) Married or living together 0.9 (0.6-1.3) Divorced or separated 1.5 (1.0-2.3) Widowed ref 17

1. Correlates of being unaware of HIV Condom use at last sex in last 12 months aOR (95% CI) Used 0.7 (0.4-1.2) Did not use 3.5 (2.3-5.5) Did not have sex ref Not significant in multivariate analysis: Education Number sex partners last 12 months 18

2. Correlates of being aware but not on treatment Age aOR (95% CI) 15-24 4.6 (2.0-10.9) 25-34 4.2 (2.2-7.8) 35-44 2.9 (1.5-5.5) 45-54 1.2 (0.6-2.5) 55-64 ref

2. Correlates of being aware but not on treatment Condom use last sex in last 12 months aOR (95% CI) Used condom 1.3 (0.8-2.3) Did not use condom 3.1 (1.9-5.1) Did not have sex ref

2. Correlates of being aware but not on treatment Number sex partners last 12 months aOR (95% CI) 1 ref 2+ 1.8 (1.1-2.8) Not significant in multivariate analysis: Education Marital status

3. Correlates of being on treatment but not virally suppressed Age aOR (95% CI) 15-24 3.0 (1.2-7.6) 25-34 3.7 (2.0-6.8) 35-44 3.3 (1.8-6.2) 45-54 1.4 (0.7-2.7) 55+ Ref

3. Correlates of being on treatment but not virally suppressed Gender aOR (95% CI) Female Ref Male 1.6 (1.2-2.2) Not significant in multivariate analysis: Condom use at last sex in last 12 months

Number of people aged 15-64 years not reached 311,000 people not aware of their HIV status 422,000 people not on treatment 465,000 people not virally suppressed

Limitations and next steps Relies on self-reported awareness and treatment status Proportion not virally suppressed includes people who may have just started treatment and would not be suppressed yet Next steps: Test specimens for presence of antiretroviral medications Explore interactions between key variables Examine reasons for being in the 10-10-10 cascade Estimate population attributable risks

Conclusions Males, people <45 years of age, the never married or divorced/separated, those not using condoms at last sex in 12 months, and those with 2+ sex partners in last 12 months were most likely not to be reaching UNAIDS goals Factors should be carefully considered when developing policies and services Results provide a valuable baseline for impact of treat all

Acknowledgements and Thanks Participants Field workers Zimbabwe Ministry of Health and Child Care U.S. Centers for Disease Control and Prevention ICAP at Columbia University Zimbabwe National AIDS Council Zimbabwe National Statistics Agency Biomedical Research & Training Institute in Zimbabwe Lancet Laboratories Statistical Center for HIV/AIDS Research and Prevention Westat This survey was supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through CDC under the terms of cooperative agreement #U2GGH001226. The contents of this presentation do not necessarily reflect the views of the United States Government. 27

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