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Gaps in the cascade of care in two high prevalence settings in Zimbabwe and Malawi Nolwenn Conan1, Cyrus Paye2, Erica Simons2, Abraham Mapfumo3, Tsitsi.

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Presentation on theme: "Gaps in the cascade of care in two high prevalence settings in Zimbabwe and Malawi Nolwenn Conan1, Cyrus Paye2, Erica Simons2, Abraham Mapfumo3, Tsitsi."— Presentation transcript:

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


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