90-90-90 progress in southern Africa: HIV testing gap needs to be closed in young people and men

Three African countries with high burdens of HIV infection are achieving very high levels of HIV treatment initiation and viral suppression but need to make better progress on HIV testing in order to achieve the 90-90-90 targets, according to results from large studies presented on Tuesday at the 9th International AIDS Society Conference on HIV Science (IAS 2017) in Paris.

Population-based HIV Impact Assessments (PHIAs) measure national progress towards the 90-90-90 goals by carrying out household HIV counselling and testing and interviewing people about HIV treatment. The surveys are being co-ordinated by ICAP at Columbia University, New York, in partnership with the US Centers for Disease Control and Prevention (CDC) and Ministries of Health in PEPFAR-funded countries.

The surveys are designed to monitor progress and identify areas for new investment and service development.

In particular, the PHIAs provide up-to-date information on HIV incidence and prevalence, and information on engagement in care and viral suppression that is independent of facility-based record keeping.

Three PHIA studies, of Malawi, Zambia and Zimbabwe were presented. Each showed that lack of awareness of HIV-positive status is higher in younger people, and that men are more likely to be unaware of their HIV status than women.

Zambia

The Zambia Population-based HIV Impact Assessment (ZAMPHIA) was carried out in 2016. It offered HIV counselling and testing to 12,310 households in 511 areas selected to provide a national representative sample. A total of 19,029 adults and 7959 children consented to take part. Women were more likely to participate in testing than men (71 vs 63%, p < 0.0001).

The study found an adult HIV prevalence of 12.3% in adults and 0.9% in children. 67.3% already knew that they were HIV positive; women more likely to know their status than men (70 vs 62.8%).

HIV incidence was 0.32% in men and 1.02% in women – an overall total of 0.67% (0.70% in 15-49 year olds). This compares with a UNAIDS estimate of incidence in 2015, of 0.85%.

Of those who knew that they were HIV positive, 85.4% were on antiretroviral therapy (ART), and of those people, 89.2% were virally suppressed. Viral suppression ranged from 73% in the 45-59 age group (both men and women) to 33.6% in women and 36.7% in men aged 15-24.

Zambia’s overall progress towards the second and third 90-90-90 goals is very strong: 85% of diagnosed people are on treatment and 89.3% of those on treatment are virally suppressed, with no substantive difference between women and men. Awareness of HIV status is lagging behind: 67.3% of people with HIV in Zambia knew their HIV status in 2016.

Zimbabwe

The Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) was carried out in 2015 and 2016.

Testing was offered to 15,009 households and 20,572 people agreed to testing. The survey found a national HIV prevalence of 14.1% prevalence in 15-64 year olds.

72.9% were aware of their HIV status, 86.8% of those were on treatment and 86.5% of people on treatment were virally suppressed.

Lack of awareness of HIV status was much more likely in people under 35. Half of 15-24 year olds were unaware of their HIV status compared with less than one in five of 45-55 and 55-64 year olds. Younger age was also strongly correlated with not being on treatment after HIV diagnosis and not being virally suppressed on treatment.

Men were more likely to be unaware of their HIV status (adjusted hazard ratio 1.9, 95% CI 1.5-2.3), as were never married, divorced or separated people. Lack of condom use at the last occasion of sex in the previous 12 months was strongly associated with a lack of awareness of HIV status (aHR 3.5, 95% CI 2.3 -5.5), and with not being on treatment despite awareness of HIV status.

Malawi

The Malawi Population-based HIV Impact Assessment (MPHIA) was carried out from November 2015 to August 2016. Nellie Wadondo-Kabondo of CDC Malawi presented the survey’s findings on progress towards the 90-90-90 targets in women with HIV.

Malawi began moving towards a treat-all approach for women in 2013 when it introduced Option B+, the immediate initiation of lifelong antiretroviral treatment in pregnant and breastfeeding women. Since 2013, there has been concern that women are becoming lost to follow-up after delivery.

A total of 9979 women were tested (87.8% of eligible women). The survey found an overall HIV prevalence of 12.8% in women aged 15-64, but prevalence was 22.1% in women aged 35-39 and 24.6% in women aged 40-44.

Overall, 76.3% of women were aware of their HIV status, but there was a big variation in awareness by age. Whereas over 80% of women aged 35-49 and aged over 55 were aware of their HIV status, only 41.7% of women aged 15-19 and 61.4% aged 20-24 were aware that they were HIV positive.

There were similar disparities by age in treatment uptake and viral suppression. Overall, 69.5% of all women with HIV – diagnosed and undiagnosed – were on ART, but in the 15-19 age group only 37.4% were taking ART and all age groups below 35 had below-average levels of treatment uptake. This pattern was replicated for viral suppression; although 73.1% of all women with HIV in the population were virally suppressed, just 35.6% of 15-19 year olds and 56.2% of 20-24 year olds were virally suppressed.

The findings from Malawi reflect a pattern being seen across eastern and southern Africa: younger women are less likely to have tested or started treatment, and the same is being seen in young men. Greater focus on diagnosing HIV in younger and offering treatment services will be needed to bridge the gap, conference participants agreed.