1. Gaps in the cascade of care in two high prevalence settings in Zimbabwe and Malawi
Nolwenn Conan1, Cyrus Paye2, Erica Simons2, Abraham Mapfumo3, Tsitsi Apollo4, Alexander Chijuwa5, Daniela Belen Garone3, Reinaldo Ortuno6, Eric Goemaere7, Ousseni Tiemtore7, Menard Chihana1, David Maman1
. On behalf of the co investigators,
1Epicentre, Cape Town, South Africa; 2Epicentre, Paris, France; 3Médecins Sans Frontières (MSF), Harare, Zimbabwe; 4Ministry of Health and Child Care, Harare, Zimbabwe; 5Ministry of Health, Nsanje, Malawi; 6MSF, Blantyre, Malawi; 7Southern Africa Medical Unit, Cape Town, South Africa

2. Background Cascade of HIV care
Proportion of people living with HIV who are diagnosed
Proportion of diagnosed who are enrolled on ART
Proportion of people in treatment have a full suppressed Viral Load
UNAIDS
Increasing ART coverage and increasing the number of HIV positive individuals with an undetectable Viral Load lead to a reduction of HIV transmission.

3. Background
Since 2011 MSF activities in Gutu (Zimbabwe) and Nsanje (Malawi)
Mentoring approach to increase access to quality HIV care through decentralization of ART diagnosis and treatment from hospital to clinics
Decision to implement HIV population surveys:
To estimate the impact of the mentoring approach after 5 years of implementation in both settings and to define plans and priority interventions
To give information on HIV prevalence, cascade of care and data coverage in both districts
To compare the HIV population based survey findings with the National survey outcomes-Zimbabwe Population-Based HIV Impact Assessment (ZIMPHIA) and Malawi Population-Based HIV Impact Assessment (MPHIA)

4. Study locations
Malawi- Nsanje District
Zimbabwe- Gutu District

5. Study objectives Primary Objective
To estimate population viral load suppression (Viral load <1,000cp/ml) among adults, stratified by gender
Secondary Objectives
To estimate HIV cascade of care
- To estimate HIV diagnosed
- To estimate ART coverage
- To estimate Viral Load suppression
To estimate the HIV prevalence
All estimates stratified by age and gender

6. Methodology Design: cross- sectional two stage cluster sampling
Study population: all individuals ≥ 15 years old in Gutu District (pop= 203,533 ) and Nsanje District (pop=241,107)
Survey duration: 13 weeks of data collection on each site
We obtained ethics approvals from the MSF ERB, MRCZ and NHSRC

7. Methodology:Study procedures (adults)
Interview head of household
Interview eligible individuals
Household questionnaire
Adults questionnaire
HIV test on spot in series
Negative
Positive
Interview HIV positive
Laboratory tests
Laboratory testing: VL; Genotyping; ART blood level; Incidence; 10% HIV confirmatory QC; + CD4 in Gutu
Questionnaire HIV & ART
HIV rapid test (RDT)
Pre counselling
Discordant*
Post counselling
*HIV confirmatory testing

8. Participation and inclusion rate
Results
Participation and inclusion rate
Households
completed
Individuals
eligible
% Individuals
included
% Individuals tested
Gutu
2,400
5,440
91.5%
89.0%
Nsanje
2,443
5,322
91.1%
87.8%
Primary education in Nsanje= 2,808 (57.9%)

9. Table: Participants’ socio-demographic characteristics
Results
Table: Participants’ socio-demographic characteristics
Gutu Nsanje
Women, n (%)
3,122 (57.4)
2,893 (54.4)
Age, median years [IQR]
36 [20-56]
33 [22-47]
Married, n (%)
2,850 (52.3)
3,137 (64.7)
Secondary education, n (%)
2,866 (57.6)
894 (18.4%)
Farming, n (%)
2,789 (56.0)
3,083 (63.6)
Living continuously in the District n(%)
3,826 (76.8)
3,891 (83.3)
Primary education in Nsanje= 2,808 (57.9%)

10. Results HIV Prevalence
Gutu
Nsanje
MSF Overall*: 13.6 % (95%CI: )
(*5 HIV indeterminate tests on spot)
MSF Women vs. Men: 14.5 % vs. 12.3% (p=0.03)
MSF Overall*: 12.1% (95%CI: )
(* 1 HIV indeterminate tests on spot)
MSF Women vs. Men: 14.0% vs. 9.5% (p<0.01)
HIV prevalence stratified by gender and age group
Gutu : Median age HIV-positive women = 41y. [IQR: 34-49] - Median age HIV-positive men: 44y. [IQR: 36-54]
Nsanje: Median age HIV-positive women = 36 y. [IQR: Median age HIV-positive men: 41 y. [IQR: 33-50]

11. Results Gutu: MSF vs. National 15-64 years old
Prevalence = 15.4% vs. 14.6%
Viral Load < 1,000cp/ml
coverage
Cascade of care
Diagnosed coverage
ART coverage
Overall*
* 1 missing value
Women*
* 1 missing value
Men*
* 5 missing values
Male: 79.6 % (95CI: )/ 90.3 (95%CI: )/ 86.1% (95%CI: )
Female: 91.2% (95%CI: )/ 96.4% (95%CI: )/ 85.5% (95%CI: )
Overall: 87.0 % (95%CI: )/ 94.4% (95%CI: )/ 85.7% (95%CI: )
Overlap of CI for the two second 90- no difference.
Difference between gender for the first 90 (p<0.001)
MSF results: 25.8% of adults previously diagnosed
MSF results: 41.7% of men undiagnosed

12. Results Nsanje:MSF vs. National 15-64 years old
Prevalence= 13.1% vs. 10.6%
Viral Load < 1,000cp/ml
coverage
Cascade of care
Diagnosed coverage
ART coverage
Overall*
* 4 missing values
Women*
* 1 missing value
Men*
* 9 missing values
Male: 70.1( )/93.0( )/ 87.9( )
Female: 81.3( )/ 93.1( )/ 89.4( )
Overall: 77.5( )/ 93.1( )/ 89.0( )
MSF results: 35.5% of adults undiagnosed
MSF results: 57.7% of men undiagnosed

13. Discussion
General
An ageing HIV positive population; 25% of all HIV positive participants above 50 year old
Coverage
Good results in coverage outcomes in both settings
Gender and age group imbalance specifically in the diagnosed coverage
Youths less aware of their HIV status than older adults
Males less aware of their HIV status than females
Among HIV positive males< 30 years old STILL > 40% in Gutu and > 55% in Nsanje not aware of their HIV status

14. Discussion Operational decision Two first 90s:
Higher results in Gutu than national level
No difference in Nsanje
Third 90: in both settings similar results than national level
=> Discussion at operational level is still ongoing

15. Discussion High acceptability of the studies
High participation rate even among men
Comparability of results between District level with Country wide coverage
Survey design allowed identification of gaps in the cascade of care

16. Acknowledgements
All the study participants and Gutu & Nsanje Community
Survey teams
Gutu & Nsanje team
MSF Zim & Malawi
MoH Zim & Malawi
MSF OCB
Epicentre
SAMU
NICD, UCT