1. 9th IAS Conference on HIV Science
targets in HIV positive women using results from MPHIA: a Malawi success story
Wadonda-Kabondo N1, West C1, Nyirenda R2, Chimbwandira F2, Nkoka S3, Voetsch A4, Dobbs T4, Chipungu G2, Chirwa I5, Matatiyo B6, Gupta S2, Radin E7, MPHIA Study Team
1. CDC Malawi, 2. Malawi Ministry of Health, 3. ICAP Malawi 4.CDC Atlanta 5. National Statistical Office of Malawi 6. Malawi National AIDS Commission 7. ICAP at Columbia University
25 July 2017
9th IAS Conference on HIV Science
Center for Global Health
Division of Global HIV & TB

2. Background
In 2015 UNAIDS estimated HIV prevalence for Malawi to be 9.1% among year olds
ART and PMTC program started in 2004 and option B+ in 2011
Malawi monitors its program through active and quarterly facility-based supervision system
Malawi population based Impact Assessment (MPHIA) was conducted between November 2015 and August 2016
MPHIA provided opportunity to assess Prevalence, incidence and progress towards achieving targets

3. Primary Objectives of MPHIA
To estimate national rate of new HIV infections (incidence) among adults 15 to 64
To estimate national and subnational prevalence of viral load suppression [HIV RNA <1000 c/ml] among adults age 15 to 64 years

4. Methods Design Laboratory Data analysis
Two-stage cluster sample design – selected 500 EAs
Targeted 24,000–29,000 participants providing blood samples
Laboratory
HIV testing was done in the field using rapid tests national algorithm (serial testing of Determine and Unigold) and results returned immediately
Confirmed HIV Positive with Geenius at satellite lab
VL tests were done at central lab and VLS was defined as <1000 copies per ml
Data analysis
Descriptive analysis was performed in Stata and SAS
Data was weighted for design and non-response (Jackknife replication method)

5. Objectives of current analysis
Assess progress towards achieving targets in women
Assess age and geographical gaps in achieving targets in women

6. Results

7. MPHIA Women’s Response Rates 15-64

8. Women HIV prevalence, by age – 15-64
Overall, HIV prevalence in women was 12.8% (12.4% in 15-49)
HIV prevalence was 12.8 % in those age and 12.4 % in those aged HIV prevalence varied by age, 2% prevalence in the year olds and 24.6% in those aged 40-44

9. Population level Progress to 1st 90 in Women
Overall, 73% of all PLHIV, knew their HIV+ status (76% in females)
Prevalence & Aware of status in women
by zone
Overall, 72.7 of all PLHIV in Malawi ages outhwest zone and lowest CE.
Blantyre has lower awareness and yet highest HIV prevalence
None of the age groups had achieved the 1st 90 target though those above 35 seem to be on the right tracjectory but the young women are lagging behind

10. Population level Progress to 2nd 90 in Women 15-64
Overall, 65.1% of PLHIV reported to be on ART ( 69.5% in females )
Overall xx % of PLHIV reported to be on ART (69.5 females, 58.2% men)
Self report ART to use was higher in regions with higher prevalence except for Blantyre
Like with 1st 90 ART use was lower in young women particularly again those above 35 seem to be on the right trajectory although none of the age groups have achieved the 2nd 90 by self report ART

11. Viral Load Suppression (3rd 90) among HIV Positive Women, 15-64, by age
Overall, 68.7 % of all PLHIV , were virally suppressed (73.1% in females )
Overall, 68.7 % of all PLHIV in Malawi, years, were virally suppressed (73.1% females, 60.9% in men)
Older women 30 years and above had surpassed the 3rd 90 target. Younger women particularly year olds, were lagging behind

12. Population level Status of 90-90-90 by gender 15-64, MPHIA 2015-16
Comparing with progress in men, we see that women are clearly doing be
According to MPHIA data Women have already achieved the 3rd 90 in Malawi though the self report ART use do not reflect tter than men in all three 90sthis achievement

13. Progress to 90-90-90 in adults 15-64, by gender, MPHIA 2015-16
Once Diagnosed, treatment uptake and viral load suppression remain high particularly for women
Using self report ART (multiplying three 90s); 59% of PLHIV have achieved viral suppression, 64 % women compared to 52 % men
But at population level we see that 73% suppression has already been achieved for women. Metabolite data is still being analyzed and will shed more light in these differences between self report and actual biological data, so stay tuned
*The number within each bar represents the conditional percentage

14. Implications for HIV programing

15. Malawi in 2016: Persons Living with HIV and NOT Virally Suppressed (n=354,000)
In 2004 more women than men had un suppressed viral load
viral load is now lower among females 25+ (32%) than males 25+
The largest group of PLHIV with non-suppressed viral load are males 25+ (39%)
Looking at the gap to third 90, we see larger proportion of unsuppressed population are men above 25 (39% than females)
This picture was different in 2004 where largest proportion with unsuppressed viral load were women
Source: Malawi Department of HIV & AIDS (DHA)

16. Conclusion
Malawi is on track to achieving targets by 2020; women above the age of 30 have already achieved the 3rd 90
Mature Option B+ program in Malawi may explain success observed in women
More work still need to be done in younger women particularly on first 90 and in Blantyre city.
Women in Blantyre has highest prevalence and lowest suppression
Malawi program needs to also focus in men in addition to young women

17. Acknowledgement MPHIA study participants MPHIA field teams
Malawi Ministry of Health
CDC Atlanta and CDC Malawi
ICAP at Columbia University, NY and ICAP Malawi
Centre for Social Research (CSR)
National Statistical Office (NSO)
Johns Hopkins Project – College of Medicine
WESTAT
This project is 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 document do not necessarily reflect the views of the United States Government.

18. ThaNK you

19. HIV Testing
Used National Algorithm for field testing. Confirmed HIV positives with Geenius at the laboratory, incidence used Limited antigen Lag avidity assay

20. HIV Incidence in Women
MPHIA sample size was designed to measure incidence in
Incidence in was 0.36% (95% CI: 0.19%-0.53%).
HIV incidence for year-olds was 0.39% (95% CI: 0.22%-0.57%).
Incidence among women 0.52% and 0.26% in men ages 15 to 64 years.
Among females, annual incidence peaked in year-olds (0.87%).
Among males, annual incidence peaked in year-olds (0.49%),
Results should be interpreted with caution

21. Overall Progress to 3rd 90 in Women
VLS among women was highest in south west and lowest in Blantyre city

22. HIV Prevalence in women
The Malawi national HIV prevalence in women was was 12.8%, similar to that of women Prevalence varied by zone, from 6.2 in CE to 21.8 in Blantyre city
Among all HIV positive children, 41% were virally suppressed.

23. These 5 Districts Account for 70% of the National Gap to achieving 90-90-90
Blantyre
Chikwawa
Machinga
Looking at overall numbers by district, Blantyre has the largest gap to saturation (32%)
70% of the gap is in 5 districts and this is where PEPFAR is currently focusing efforts
Mangochi
Zomba

24. Progress to in Women
Among persons ages 15 to 64 years who were aware of their HIV-positive status, 91.6 percent of females and 86.1 percent of males reported being on ART
Though