1. Correlates of being outside the cascade among adults aged years in Zimbabwe: Results from the 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

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

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

4. METHODS

5. 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

6. 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

7. 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

8. 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

9. Results

10. 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%)

11. 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%)

12. 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%

13. ZIMPHIA National HIV Prevalence: 14.1%

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

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

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

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

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

19. 2. Correlates of being aware but not on treatment
Age
aOR (95% CI)
15-24
4.6 ( )
25-34
4.2 ( )
35-44
2.9 ( )
45-54
1.2 ( )
55-64
ref

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

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

22. 3. Correlates of being on treatment but not virally suppressed
Age
aOR (95% CI)
15-24
3.0 ( )
25-34
3.7 ( )
35-44
3.3 ( )
45-54
1.4 ( )
55+
Ref

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

24. 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

25. 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 cascade
Estimate population attributable risks

26. 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

27. 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 #U2GGH The contents of this presentation do not necessarily reflect the views of the United States Government. 27

28. Thank you