New PHIA Data Announced as World Leaders Gather in New York to Mark Progress toward Ending AIDS

With world leaders gathered in New York for the UN General Assembly, ICAP at Columbia University—in partnership with PEPFAR and CDC— announced new data on the state of HIV epidemics in Lesotho and Uganda. The data, derived from Population-based HIVImpact Assessment surveys, show remarkable progress in Lesotho and a stabilization of Uganda’s previously expanding epidemic.

In Lesotho, where ICAP conducted LePHIA from November 2016 to May 2017, results show HIV viral load suppression—a key marker of the body successfully controlling the virus—has reached over 67 percent among all HIV-positive adults ages 15-59. This finding suggests that Lesotho is on track to achieve epidemic control by 2020, through reaching the UNAIDS 90-90-90 targets and expanding HIV prevention. Full achievement of 90-90-90 is equal to viral load suppression among 73 percent of all people living with HIV.

In a press conference to announce the results, Deputy Prime Minister Monyane Moleleki confirmed the Lesotho government’s commitment to build on the achievements made and to keep addressing gaps shown in the survey data.

With the announcement of the LePHIA results, five African countries are now approaching control of their HIV epidemics: Lesotho, Malawi, Swaziland, Zambia, and Zimbabwe. In addition, Uganda’s epidemic has likely stabilized due to increases in coverage of voluntary medical male circumcision for HIV prevention, as well as expansion of HIV treatment, including for pregnant women living with HIV.

“With five African countries approaching control of their HIV epidemics, we have the extraordinary opportunity to change the very course of the HIV pandemic over the next three years,” said Ambassador Deborah L. Birx, U.S. global AIDS coordinator and special representative for global health diplomacy.

ICAP’s global director, Dr. Wafaa El-Sadr concurred that the results are cause for optimism, but also note that there is much work still to be done. “These findings show marked progress against HIV in Lesotho and Uganda, but also highlight the need for focused attention as we move forward,” she said. “It is evident that young people, particularly young men under 35 years of age, are reluctant to get tested for HIV, which hinders efforts to stem the spread of this infection. Reaching them is critically important to achieving the ultimate goal of ending this epidemic.”

To mark the progress countries have made toward the 90-90-90 targets and rally momentum around ending AIDS, Ugandan President Yoweri Museveni co-hosted a high-level event with UNAIDS in New York on Thursday, September 21. The event featured heads of state from Guinea, Malawi, Seychelles, Swaziland, Uganda, and Zambia, as well as Ambassador Birx and other distinguished guests.

The immense showing of world leaders spotlighted the energy and resources governments and the international community are focusing on HIV/AIDS. UNAIDS Executive Director Michel Sidibé noted, “Leadership, partnership, and innovation will transform the epidemic.” President Museveni added, “I am confident that working together with you all, we shall attain an AIDS-free Africa. It is possible to end AIDS in our generation!”

Header image: UNAIDS

Press Release: Five African countries approach control of their HIV epidemics as U.S. government launches bold strategy to accelerate progress

Press Release

 

Latest survey results show Lesotho’s significant success with HIV viral load suppression and stabilization of Uganda’s previously expanding epidemic.

Washington, D.C./New York, September 19, 2017— Data released today from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) show that the HIV epidemic is coming under control in Lesotho. These results add to prior PEPFAR-supported Population-based HIV Impact Assessments (PHIAs) announced in the last nine months for Malawi, Swaziland, Zambia, and Zimbabwe.

Together, these data demonstrate impressive progress toward controlling the HIV epidemics in the five countries. The latest data also indicate that the previously expanding epidemic in Uganda has now stabilized. None of these achievements would be possible without the political will and leadership to focus resources for maximum impact in each of these countries.

According to the new Lesotho PHIA results, HIV viral load suppression – a key marker of the body successfully controlling the virus – has reached over 67 percent among all HIV-positive adults ages 15-59. This finding suggests that Lesotho is on track to achieve epidemic control by 2020, through reaching the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets and expanding HIV prevention. Uganda’s epidemic has likely stabilized due to increases in coverage of voluntary medical male circumcision for HIV prevention and expansion of HIV treatment, including for HIV-positive pregnant women.

Building on this progress, U.S. Secretary of State Rex Tillerson today released the new PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020). The Strategy reaffirms the U.S. government’s leadership and commitment, through PEPFAR, to support HIV/AIDS efforts in more than 50 countries, ensuring access to services by all populations, including the most vulnerable and at-risk groups.

The Strategy outlines plans to accelerate implementation in a subset of 13 high-burden countries that have the potential to achieve epidemic control by 2020, working in collaboration with host governments, the Global Fund to Fight AIDS, Tuberculosis and Malaria, UNAIDS, and other partners. Through this international effort, we expect not only to control the epidemic, but also to reduce the future costs required to sustain the HIV/AIDS response.

“With five African countries approaching control of their HIV epidemics, we have the extraordinary opportunity to change the very course of the HIV pandemic over the next three years,” said Ambassador Deborah L. Birx, M.D., U.S. Global AIDS Coordinator and Special Representative for Global Health Diplomacy. “We are deeply grateful for Secretary Tillerson’s bold leadership and clear vision in launching this landmark Strategy. PEPFAR is poised to deliver on it, showing that what once seemed impossible is now possible.”

Data from these six countries were gathered through national surveys (PHIAs), which are funded by the U.S. government through PEPFAR, and conducted by the U.S. Centers for Disease Control and Prevention (CDC), ICAP at Columbia University’s Mailman School of Public Health, and local governmental and non-governmental partners. With PEPFAR support, seven additional countries will complete PHIAs on a rolling basis through 2017-2019, providing an ability to chart and validate their respective progress toward reaching epidemic control by 2020.

“CDC is so pleased to contribute to the global HIV response, working with ministries of health and other partners on science-based solutions that are transforming some of the world’s most severe HIV epidemics,” said CDC Director Brenda Fitzgerald, M.D. “National surveys are critical to show the impact of efforts and to chart the path to fully achieve HIV epidemic control.”

While the PHIA results demonstrate tremendous progress, they also reveal key gaps in HIV prevention and treatment programming for younger men and women that require urgent attention and action. In all six surveys, young women and men under age 35 were less likely to know their HIV status, be on HIV treatment, or be virally suppressed than older adults. These gaps are all areas in which PEPFAR will continue to invest and innovate under its new strategy. In particular, PEPFAR will continue to advance efforts to reduce HIV incidence among adolescent girls and young women through the DREAMS Partnership and reach and link more young men to HIV services.

“The findings from the six countries provide a report card on the global and local efforts in confronting the HIV epidemics while at the same time help in shaping a blueprint for their future course as they continue their quest to stem this epidemic,” said Wafaa El-Sadr, M.D., M.P.H., M.P.A., global director of ICAP. “The gaps identified in reaching young women and men are relevant to many other countries around the world, and addressing them is critically important to achieving the ultimate goal of ending this epidemic.”

###

About the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)
PEPFAR is the U.S. government’s response to the global HIV/AIDS epidemic, which represents the largest commitment by any nation to address a single disease in history. Through the compassion and generosity of the American people, PEPFAR has saved and improved millions of lives, accelerating progress toward controlling and ultimately ending the AIDS epidemic as a public health threat. For more information, please visit www.pepfar.gov, and follow PEPFAR on Twitter, Facebook, and Instagram.

About the U.S. Centers for Disease Control and Prevention (CDC)
CDC works 24/7 saving lives and protecting people from health threats to have a more secure nation. HIV and tuberculosis (TB) are the world’s two most deadly infectious diseases, and CDC’s Division of Global HIV & TB works with partners to tackle these two epidemics and produce the greatest global health impact. More information can be found at www.CDC.gov/globalhivtb.

About ICAP at Columbia University
ICAP was founded in 2003 at Columbia University’s Mailman School of Public Health. A global leader in HIV, tuberculosis, other health threats, and health systems strengthening, ICAP provides technical assistance and implementation support to governments and non-governmental organizations. More than 2.2 million people have received HIV care through ICAP-supported programs, and over 1.3 million have received antiretroviral therapy through such support.

Media Contact
David Haroz, PEPFAR
+1 202 445 3269

Curran Kennedy, ICAP
+1 212 342 3789

Major Progress in Confronting HIV in Swaziland Announced at IAS 2017

The Population-based HIV Impact Assessment (PHIA) Project announced major findings from the Swaziland survey at the 9th IAS Conference on HIV Science (July 23-26). Key findings from the second Swaziland HIV Incidence Measurement Survey, SHIMS2, the Swaziland PHIA, revealed impressive progress in confronting the HIV epidemic. Previously released survey results showed similar progress in three high-burden countries: Malawi, Zambia, and Zimbabwe.

The Kingdom of Swaziland has long had a severe HIV epidemic with the world’s highest national HIV prevalence and incidence (rate of new infections). The country has demonstrated a commitment to turning the tide of the epidemic by dramatically scaling up HIV testing and treatment as well as other prevention efforts. Between 2011, when SHIMS1 was conducted, and SHIMS2 in 2016, HIV incidence among adults fell by nearly half (2.5% to 1.4%) and the percentage of HIV-positive adults with viral load suppression (VLS), as a measure of control of the virus, doubled (35% to 71%). HIV prevalence among adults was stable at 30%, similar to the 2011 HIV prevalence of 32%.

“Because of the severe HIV epidemic in Swaziland, it was critical for us to implement a combination HIV prevention package, scale up HIV care and treatment services, and engage in ongoing measurement of HIV incidence in order to assess the impact of these efforts,” said Senator Sibongile Ndlela-Simelane, the honorable Minister of Health, Swaziland. “The results of the SHIMS2 survey reveal a dramatic improvement in the state of the epidemic in Swaziland and we are very encouraged by this progress. We understand that the battle is not over, and therefore we must maintain the momentum.”

Leaders from across global health field expressed enthusiasm over the data. Wafaa El-Sadr, Director of ICAP at Columbia University, called the findings a “cause for celebration,” and Michele Sidibé, Executive Director of UNAIDS, said, “The best news of this conference will be the Swaziland results… The result should drive all our efforts.”

The Swaziland findings echo other PHIA results – released in December 2016 and expanded on through oral abstracts and posters presented at the IAS Conference.

Despite this substantial progress, significant work remains in order to further reach and engage men and young women, particularly around raising awareness of individual’s HIV-positive status and ensuring their access to effective treatment with high adherence.

The nationally representative PHIA surveys, implemented by ICAP in partnership with the US Centers for Disease Control and Prevention (CDC) and the ministries of health with funding from the President’s Emergency Plan for AIDS Relief (PEPFAR), provide valuable information on the state of HIV epidemics across Africa and help demonstrate measurable progress toward the UNAIDS 90-90-90 targets. In addition, the results provide further proof of how treatment works for prevention of HIV transmission.

“The partnership with the Swazi Ministry of Health was fundamental to the success of the survey,” said Shannon Hader, MD, MPH, director of the CDC’s Division of Global HIV & TB. “As we’ve seen in other countries, the PHIA findings will help the Ministry of Health and its partners to focus resources on urgent program priorities to achieve epidemic control.”

“We now have clear evidence that four African countries are approaching control of their HIV epidemics,” said Ambassador Deborah L. Birx, M.D., U.S. Global AIDS Coordinator and Special Representative for Global Health Diplomacy. “These unprecedented findings demonstrate the remarkable impact of the U.S. government’s efforts, through PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria, in partnership with African countries. We now have a historic opportunity to change the very course of the HIV pandemic.”

SHIMS2 Summary Sheet: Preliminary Findings, July 2017

Swaziland HIV Incidence Measurement Survey 2: A Population-Based HIV Impact Assessment

The Swaziland HIV Incidence Measurement Survey 2 (SHIMS2) was a household-based national survey conducted between August 2016 and March 2017 to measure the impact of Swaziland’s national HIV response on HIV incidence and viral load suppression. SHIMS2 offered household-based HIV counseling and testing with return of results and collected information about uptake of HIV care and treatment services. This is the second survey to estimate national HIV incidence and viral load suppression. Previous measurements were conducted in SHIMS1 in 2011.

Click the link below to view the results summary sheet.

SHIMS2 Summary Sheet: Preliminary Findings (Updated in October 2017 with revised total number of HIV infections)

Press Release: Swaziland Survey Shows Impressive Progress in Confronting the HIV Epidemic

PRESS RELEASE

 

CONTACTS:
Stephanie Berger
Columbia University Mailman School of Public Health
212-305-4372
sb2247@columbia.edu

Hugh Siegel
ICAP at Columbia University
212-305-6533
hs3000@columbia.edu

PARIS, July 24, 2017                                 

Key findings from the second Swaziland HIV Incidence Measurement Survey, SHIMS2, reveal impressive progress in confronting the HIV epidemic in the country. Results show a doubling in population viral load suppression since 2011 and a decrease by nearly half in the rate of new HIV infections. The findings were released today at a press conference held by the Prime Minister’s office in Mbabane, Swaziland and at the International Aids Society (IAS) 2017 Conference in Paris, France.

“Because of the severe HIV epidemic in Swaziland, it was critical for us to implement a combination HIV prevention package, scale up HIV care and treatment services, and engage in ongoing measurement of HIV incidence in order to assess the impact of these efforts,” said Senator Sibongile Ndlela-Simelane, the honorable Minister of Health, Swaziland. “The results of the SHIMS2 survey reveal a dramatic improvement in the state of the epidemic in Swaziland and we are very encouraged by this progress. We understand that the battle is not over, and therefore we must maintain the momentum.”

The data come from one of the population-based HIV impact assessment (PHIA) surveys led by the Government of the Kingdom of Swaziland (GKoS) through the Ministry of Health (MOH) and Central Statistical Office (CSO). The survey (SHIMS2) was implemented by ICAP at Columbia University and the US Centers for Disease Control and Prevention (CDC), with funding from the President’s Emergency Plan for AIDS Relief (PEPFAR).

SHIMS2 is the second national incidence survey to be conducted in Swaziland, following the 2011 survey (SHIMS1) among adults 18-49 years of age.

In SHIMS2, over 14,000 children and adults participated in this nationally representative survey by agreeing to be interviewed and providing a blood sample for HIV testing.

Key SHIMS2 survey results include:

  • The annual rate of new HIV infections (“HIV incidence”) among adults ages 15 years and older was 1.36 percent: 1.70 percent among females and 1.02 percent among males. Among adults 18-49 years, HIV incidence was 1.39 percent, nearly half of the prior HIV incidence rate in 2011 2.48 percent.
  • The percentage of the adult population living with HIV (“HIV prevalence”) was 27.0 percent: 32.5 percent among females and 20.4 percent among males. The HIV prevalence among adults 18-49 years was 30.5 percent, similar to the 2011 HIV prevalence of 32.1 percent.
  • The percentage of all HIV-positive adults with viral load suppression (VLS), an indication that the infection is under control, was 73.1 percent: 76.0 percent among females and 67.6 percent among males. VLS was estimated using all people living with HIV (PLHIV) as a denominator, regardless of knowing their HIV status or use of antiretroviral drugs. Among all HIV+ adults aged 18-49 years, twice as many had VLS in SHIMS2 as compared to SHIMS1 (71.3 percent compared to 34.8 percent in 2011).
  • The percentage of all HIV-positive adults who knew their HIV status was 84.7%; of these individuals, 87.4% reported current use of antiretroviral treatment and, among those reporting treatment, 91.9 percent had VLS. These results indicate Swaziland has made substantial progress toward achieving all three of the “90-90-90’ targets set by UNAIDS to help end the HIV epidemic.

The progress represented by the findings is attributed to the expansion of HIV testing in the country as well as a substantial increase in the number of HIV-positive individuals on antiretroviral drugs from 2011 to 2016. This is combined with other HIV control interventions expanded in the country.

“These remarkable findings from Swaziland add to the evidence base that we are beginning to control the HIV epidemic in several high-burden countries,” said Ambassador Deborah L. Birx, M.D., U.S. Global AIDS Coordinator and Special Representative for Global Health Diplomacy. “They both demonstrate our extraordinary progress in ensuring that older HIV-positive adults are on life-saving treatment and virally suppressed as well as reveal key gaps that remain in reaching younger men and women with HIV services.”

“An amazing array of partnerships lasting over a decade – from collaboration within and between governments to coordination across international organizations and implementers – have brought us to an incredible level of success in the work on HIV and AIDS in Swaziland,” said Lisa J. Peterson, US Ambassador to Swaziland. “These partnerships are about people bringing their time and talents together to effect change. Thanks to these joint efforts, the SHIMS 2 data show that many more people will have the opportunity to share their own time and talents with their families and communities. It is especially important that we sustain and strengthen our collective engagement with Swaziland’s youth to ensure that we achieve an AIDS-free generation.”

“The partnership with the Swazi Ministry of Health was fundamental to the success of the survey,” said Shannon Hader, MD, MPH, director of the CDC’s Division of Global HIV & TB. “As we’ve seen in other countries, the PHIA findings will help the Ministry of Health and its partners to focus resources on urgent program priorities to achieve epidemic control.”

“The findings from SHIMS2 are a testimony to the remarkable commitment by the Government of Swaziland in confronting the HIV epidemic,” said Wafaa El-Sadr, MD, MPH, MPA, director of ICAP. “It is a demonstration that all the efforts put into the scale-up of HIV prevention, care and treatment services have borne fruit. ICAP is honored to have played a role in helping to support this successful scale-up.”

“Each Population-based HIV Impact Assessment – PHIA – survey provides a ‘report card’ on how each country is doing in responding to its epidemic as well as a blueprint for future response,” said Jessica Justman, MD, ICAP’s senior technical director and principal investigator of all of ICAP’s PHIA projects, including SHIMS1 and SHIMS2. “Swaziland has made notable progress and is poised to continue making great strides forward with the implementation of test and start and ongoing scale-up of routine viral load monitoring. The SHIMS2 results will help focus efforts and prioritize specific populations in need of urgent attention and innovative approaches.”

Other collaborating governmental entities in Swaziland included the Health Research Unit, Swaziland Health Laboratory Services (SHLS), Swaziland National AIDS Program (SNAP), Health Promotion Unit, Health Management Information System, Environmental Health Department, and National Emergency Response Council on HIV/AIDS (NERCHA).

Additional details on SHIMS2 are available in the summary sheet released by the Swaziland Ministry of Health and the websites for the Ministry of Health www.gov.sz , CDC/PEPFAR www.cdc.gov and www.pepfar.gov, and ICAPs PHIA Project: phia.icap.columbia.edu.

About ICAP at Columbia University

ICAP was founded in 2003 at Columbia University’s Mailman School of Public Health. A global leader in HIV, tuberculosis, other health threats and health systems strengthening, ICAP provides technical assistance and implementation support to governments and non-governmental organizations. More than 2.2 million people have received HIV care through ICAP-supported programs and over 1.3 million have received antiretroviral therapy through such support.

New Population-Based HIV Impact Assessments (PHIA) Show Global Efforts are Helping to Control the HIV Epidemic

Findings from surveys in Swaziland, Zambia, Malawi, and Zimbabwe show remarkable progress toward HIV epidemic control, and confirm that global efforts are helping to curb the HIV epidemic and save lives. These Population-based HIV Impact Assessments (PHIA) are complex, national surveys, supported by CDC through the President’s Emergency Plan for AIDS Relief (PEPFAR), that provide critical information on the state of the HIV epidemic and response in countries affected by the disease. See more in the link below.

New Population-Based HIV Impact Assessments (PHIA) Show Global Efforts are Helping to Control the HIV Epidemic

And learn more at www.CDC.gov.

PHIA at IAS 2017: The Latest on Satellite Sessions, Oral Abstracts, and Poster Exhibitions

Join us to learn what the Population-based HIV Impact Assessment (PHIA) surveys data are telling us about the evolving HIV epidemic. (Full details can be found here)

Featured satellite session speakers:

  • Ambassador-at-Large Deborah Birx, U.S. global AIDS coordinator
  • Shannon Hader, CDC  director of the Division of Global HIV and TB
  • Jessica Justman, ICAP technical director
  • Peter Ghys, UNAIDS director of strategic information and evaluation
  • Harriet Nuwagaba-Biribinwoha, Research director, ICAP in Swaziland

Additional PHIA activities at IAS 2017:

Monday, July 24

Oral abstracts
11:00 a.m.–12:30 p.m.
Late Breaker Oral Abstract Session (Blue Amphitheater)

Tuesday, July 25 

Oral abstracts
11:00 a.m.–12:30 p.m.
Hitting the First 90 Target: Lessons from Population-based Surveys
Oral Abstract Session Track C, Prevention Science (Maillot Room)

  • Findings from the 2016 Zambia Population-based HIV Impact Assessment (ZAMPHIA): HIV prevalence, incidence and progress towards the 90-90-90 goals. D.T. Barradas (# TUAC0301)
  • Correlates of being outside the 90-90-90 cascade among adults ages 15-64 years in Zimbabwe. A. Hakim (# TUAC0302)
  • 90-90-90 targets in HIV-positive women using results from MPHIA: a Malawi success story. N. Wadonda-Kabondo (# TUAC0303)
  • Children living with HIV in Malawi: first survey-based measurement of national pediatric HIV prevalence and viral suppression. S. Jonnalagadda (# TUAC0304)

Poster Exhibition
12:30–14:30 p.m. (Level 3)

  • Estimation of HIV incidence and the profile of incident cases in Zimbabwe Population Based Impact Assessment (ZIMPHIA) 2015- 2016 (# TUPEC0832)
  • Evidence from the Zimbabwe population HIV impact assessment on 90-90-90: a national and provincial call to action for the first 90 (# TUPEC0743)
  • Undiagnosed HIV is higher among urban residents, young adults and men: first findings from Malawi Population-based HIV Impact Assessment (MPHIA) (# TUPEC0841)
  • Is MPHIA survey a validation method for HIV spectrum estimates in Malawi? (# TUPEC0741) Closing the 90-90-90 Gap: ZAMPHIA, 2016 (# TUPEC0875)
  • Geographical distribution of HIV burden in Malawi: where is the gap in achieving the 3rd 90? (# TUPEC0877)
  • Unmet 90-90-90 targets among adolescent girls and young women living with HIV in Malawi (# TUPEC0876)

The PHIA Project is led by ICAP at Columbia University in partnership with the U.S. Centers for Disease Control and Prevention (CDC) and the Ministry of Health in each country. The project is funded through the U.S. President’s Emergency Plan for AIDS Relief (PEFPAR).

Turning the Corner on the HIV Epidemic: New PHIA Survey Results Announced at CROI 2017 Show Progress in Zimbabwe, Malawi, and Zambia

Newly released findings from national HIV surveys in Zimbabwe, Malawi, and Zambia reveal extraordinary progress in confronting the HIV epidemic. These three countries in Southern Africa have been heavily affected by HIV and now there are encouraging signs that the epidemics are going in the right direction.

The findings, presented on February 16 at the 2017 Conference on Retroviruses and Opportunistic Infections (CROI), are from the PEPFAR-supported Population-based HIV Impact Assessment (PHIA) Project surveys. The surveys are led by each Ministry of Health, with technical assistance from ICAP at Columbia in collaboration with the U.S. Centers for Disease Control and Prevention (CDC). Compared with previous estimates, the PHIA data show that the rate of new infections (incidence) is stabilizing or declining. In addition, more than half of all adults living with HIV, regardless of use of antiretroviral medication, have a suppressed viral load and for those on antiretroviral medication, viral suppression is close to 90 percent. “Taken together, these findings tell a coherent and remarkable story of progress,” said Dr. Jessica Justman, principal investigator. “We can see that Zimbabwe, Malawi, and Zambia are on track to hit the UNAIDS 90-90-90 targets by 2020.”

Understanding the true status of an HIV epidemic rests on accurate measures of HIV prevalence, HIV incidence, and viral load suppression. These critical estimates provide a “report card” on the control of the epidemic and indicate where resources should be channeled to enable continued progress toward the 90-90-90 targets. The PHIA Project provides such information by directly assessing all of these measures through household surveys.

“These results are gratifying evidence that the investment by PEPFAR and other donors, and the efforts of national HIV programs, are paying off. The data from the PHIA surveys provide greater insights on where to focus our collective efforts and resources going forward,” said Dr. Shannon Hader, director of the Division of Global HIV and Tuberculosis at CDC.

In Malawi, Zambia, and Zimbabwe, nationally representative groups of adults and children were recruited in each country in 2015-16. Across the three countries, a total of 76,000 adults and children from 34,000 selected households took part in interviews and provided blood samples for testing. Participants received their HIV test result from a trained counselor during the same visit.

Combined HIV prevalence across the three countries was 12.2 percent among adults ages 15-59 years and 1.4 percent among children ages 0-14 years. Combined HIV incidence among adults was 0.51 percent. The combined prevalence of viral suppression (HIV RNA <1000 c/ml) among all HIV-positive adults, irrespective of knowledge of their HIV status, was 61.8 percent. Achievement of the “first 90 target” across the three countries—i.e., prior knowledge of status among those found to be HIV-positive during the survey—was 70 percent; the “second 90 target”—i.e., the percentage of those aware of their HIV-positive status who report current use of antiretroviral therapy (ART)—was 87 percent; and the “third 90 target”—i.e., the percentage among those who report current ART who had HIV viral suppression—was 89 percent. Less progress has been made toward the 90-90-90 targets among adolescents and young adults compared to older adults.

“These results reflect successful HIV care and treatment programs in each country,” said Dr. Wafaa El-Sadr, Director of ICAP. “Now more than ever, we have to keep our foot on the pedal and push even harder. Targeted testing, especially for adolescents and young adults, and continued expansion of HIV treatment programs and other prevention interventions for all will be critical to achieve ultimate epidemic control.”

A webcast of Dr. Justman’s CROI presentation is available on the CROI website: http://www.croiwebcasts.org/p/2017croi/croi33590

New Findings from the PHIA Project Show Significant Progress Against HIV in Africa

Preliminary results from the PHIA Project are now available for Zimbabwe, Malawi, and Zambia, and the news is excellent. The new data show exceptional progress against the HIV epidemic: rates of new infection are down, the number of people living with HIV is stable, and over half of all people living with HIV are on antiretroviral treatment and virally suppressed.

“The effects of HIV have been far-reaching. But these outcomes affirm that global, country and U.S.-supported HIV efforts have been successful to date, and that strong progress is being made across the entire HIV continuum of care,” said Ambassador Deborah Birx, U.S. Global AIDS Coordinator.

A five-year, multi-country initiative funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through U.S. Centers for Disease Control and Prevention (CDC), and led by ICAP at Columbia University, the PHIA surveys are implemented in collaboration with CDC and the Ministry of Health and other partners in each country. The Project deploys nationally representative household surveys to collect information related to HIV and offer in-home HIV counseling and testing by trained survey staff, with immediate return of results. It also conducts laboratory tests to characterize the HIV epidemic in adults and children and to measure reach and access to prevention, care and treatment services in each country.

The PHIA surveys are also measuring progress toward the UNAIDS 90-90-90 targets: that by 2020, 90 percent of all people living with HIV will know their HIV status, 90 percent of all people diagnosed with HIV will receive treatment, and 90 percent of all people on treatment achieve viral load suppression. This would translate to 73 percent of all HIV-positive people being virally suppressed.

“The Population-based HIV Impact Assessments are a powerful new tool in that they paint the clearest picture to date of the HIV epidemic in several sub-Saharan countries. New findings from Malawi, Zambia, and Zimbabwe validate what we have only been able to previously predict in models – that our global efforts are having a measurable impact in countries with some of the most severe HIV epidemics,” said Dr. Shannon Hader, director of the CDC Division of Global HIV and Tuberculosis.

PHIA and HIV Incidence

PHIA is the first effort to measure the national rate of new HIV infections, or HIV incidence, in the three countries. “The survey was designed to identify the rate of new infections at the national level, as well as to estimate the number of people living with HIV,” said Dr. Jessica Justman, PHIA principal investigator and senior technical director at ICAP. “This information is critically important to determining future resource needs.”

Conducted between October 2015 and August 2016, the first three surveys found that HIV incidence is lower than previously estimated and well below 1 percent in each country. The PHIA data estimate HIV incidence

  • In Zimbabwe as 0.45 percent (ages 15 to 64)
  • In Malawi as 0.37 percent (ages 15 to 64)
  • In Zambia as 0.66 percent (ages 15 to 59)

Compared to the 2003 incidence estimates between 1.3 and 1.5 percent per year for the same three countries, the current rate of new HIV infections has been cut in half during the past 13 years, when effective HIV treatment became available in sub-Saharan Africa, largely through support from PEPFAR.

PHIA and HIV Prevalence

HIV prevalence, or the percentage of people living with HIV, was measured for adults and children, and is similar to 2010 estimates. In addition to validating what has only been predicted previously in models, the surveys also provide new information, including the first measurements of pediatric HIV prevalence in Malawi and Zambia.

  • In Zimbabwe, prevalence among adults ages 15 to 64 is 14.6 percent, and is 1.6 percent among children ages 0 to 14.
  • In Malawi, prevalence among adults ages 15 to 64 is 10.6 percent, and is 1.6 percent among children ages 0 to 14.
  • In Zambia, prevalence among adults ages 15 to 59 is 12.3 percent, and is 1.3 percent among children ages 0 to 14.

These three countries continue to bear a substantial HIV burden, however, with prevalence stabilizing, the PHIA survey results suggest that people living with HIV are living longer thanks to effective and accessible treatment.

PHIA and Viral Load Suppression

The survey also conducted viral load testing for HIV-positive participants, which measures the number of HIV particles in a milliliter of blood to assess the effectiveness of antiretroviral therapy (ART). Viral load suppression (VLS) is a measure of well-controlled HIV infection. Among HIV-positive adults in the first three PHIA countries, prevalence of VLS was:

  • 60.4 percent for those ages 15 to 64 in Zimbabwe
  • 67.6 percent among those ages 15 to 64 in Malawi
  • 59.8 percent among those ages 15 to 59 in Zambia

“It is heartening to see the impressive viral suppression noted in the three countries among those on treatment,” said Dr. Wafaa El-Sadr, director of ICAP. “ Viral suppression is critical for the well-being of people living with HIV and for preventing HIV transmission to others.”

PHIA and 90-90-90

Preliminary PHIA data show that Zimbabwe, Malawi, and Zambia have made great strides in responding to their HIV epidemics. While increases in testing are needed to ensure that all people living with HIV know their status, the PHIA results show that Zimbabwe, Malawi, and Zambia are close to achieving the global targets for, treatment, and VLS.

  • 74.2 percent of PLHIV ages 15 to 64 in Zimbabwe report knowing their status, 86.8 percent of those individuals self-report being on ART, and 86.5 percent of that group are virally suppressed
  • 72.7 percent of PLHIV ages 15 to 64 in Malawi report knowing their status, 88.6 percent of those individuals self-report being on ART, and 90.8 percent of that group are virally suppressed
  • 67.3 percent of PLHIV ages 15 to 59 in Zambia report knowing their status, 85.4 percent of those individuals self-report being on ART, and 89.2 percent of that group are virally suppressed

“These data suggest that, in the areas surveyed, we are making encouraging progress towards global targets for people on HIV treatment and virally suppressed. And although we’ve made great strides, these findings indicate we still need to do more to help ensure people living with HIV are reached with life-saving services,” said Dr. Hader of the CDC.

Looking Forward

The PHIA data offer critical evidence to inform global and national HIV programs and investments in order for progress to be sustained and built upon. However, achieving this will require continued expansion of HIV treatment programs and increased testing for all people, especially men and young women.

“Importantly, the PHIA surveys clearly point to what still needs to be done, who we need to reach, and where we must focus our efforts, in order to build on these achievements,” Ambassador Birx added. “The findings will guide an effective response to the epidemic.”

From Arm to Freezer: PHIA Project Laboratory Network Supports Ambitious HIV Testing Targets

How can a large public health survey in sub-Saharan Africa collect blood samples efficiently? Is it possible to perform sophisticated lab tests in people’s homes? What is the best way to transport samples collected from remote locations? The Population-based HIV Impact Assessment (PHIA) Project, which relies on laboratory testing of blood samples as a core component, is providing answers to these questions. Led by ICAP at Columbia University, the PHIA surveys will assess the HIV epidemic in 13 select countries located primarily in sub-Saharan Africa. Fieldwork is nearly complete in three countries, with ten more national surveys to follow over the next two to three years. The surveys depend on well-trained staff and sufficient laboratory infrastructure to collect, test, and transport blood from individuals in approximately 15,000 households in each country.

Conducted in partnership with ministries of health and the Centers for Disease Control and Prevention (CDC), with support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the PHIA Project draws on the expertise of ICAP and its partners for all aspects of its laboratory activities, from facility selection to staff training, laboratory setup, and quality assurance. Critical support in these areas has come from the CDC’s International Laboratory Branch, which builds sustainable laboratory capacity in PEPFAR-supported countries.

Currently, throughout Zimbabwe, Malawi, and Zambia, PHIA survey teams are visiting thousands of households to collect blood samples and perform rapid HIV tests, point-of-care CD4 tests, and in some countries, hepatitis B and syphilis rapid tests. While many other population-based surveys have collected a few drops of blood through a finger prick, the PHIA surveys collect two test tubes of blood from a vein in order to have both whole blood and plasma for testing. Participants receive test results within minutes, in the privacy of their homes. But that is not the final stop for each blood sample.

Quality assurance testing is performed in nearby satellite laboratories to ensure that the initial field test results are accurate. “All HIV-positive samples are retested using the Geenius HIV-1/HIV-2 test in the satellite lab to confirm the results,” says Dr. Herbert Longwe, one of ICAP’s regional lab advisors for the PHIA Project. “We also retest the first 50 of each field worker’s samples and 5 percent of all HIV-negative samples with the same rapid test kits to ensure accurate and trustworthy results.” Dried blood spots are prepared and then plasma and blood cells are separated, steps necessary for further testing. With a targeted “arm-to-freezer” time of less than 24 hours, the samples are then placed in a freezer and sent to a central lab for HIV incidence and HIV viral load testing, as well as for long-term storage.

The last steps in the testing process consist of specialized tests such as viral load testing to measure the quantity of HIV RNA in plasma, HIV incidence assays, DNA-PCR for HIV diagnosis in HIV-exposed infants, assays to detect antiretroviral agents, and HIV drug resistance testing. The two latter tests will be performed after survey completion at labs in several locations, including South Africa and Zimbabwe. The detailed data these additional tests provide can help improve HIV programming at local and national levels by indicating what percentage of people on treatment have achieved viral load suppression, a measure of whether they are on treatment and if treatment is working well.

To handle samples collected in remote locations in Zambia and Tanzania, PHIA teams are using mobile labs to ensure specimen quality. The mobile labs are fully equipped with a centrifuge, refrigerator, a -20⁰ C freezer, and basic supplies. “Mobile labs are an innovative way to handle samples when other labs are not close enough,” says Dr. Yen Pottinger, ICAP’s PHIA senior technical advisor for laboratory.

As part of the focus on high-quality testing and processing of PHIA samples, the PHIA team conducts instrument verification and assay validation to ensure tests are accurate and reliable. Working together, CDC’s International Lab Branch and ICAP monitor the accuracy of the HIV testing in the field and provide ongoing reviews to ensure each and every staff member’s proficiency with the techniques they learned in lab training.

“It was a challenge to create, but the PHIA Project now has a simple, workable quality assurance system in place, and this is one of the most exciting things I’ve seen in my career,” Longwe observes.

HIV viral load results are returned to a health facility of the participant’s choice, where they can consult with a health care provider to interpret the results and gain a greater understanding of their health status. Providing these results to participants is another innovative aspect of the PHIA survey. “Viral load testing is not yet routinely available in many of the survey countries. By returning the results within about eight weeks, the PHIA Project is making it possible for HIV-positive individuals and their doctors to have access to important clinical data to help manage their treatment,” says Pottinger.

PHIA’s complex network of satellite labs is helping the survey teams perform a high volume of HIV tests at the community level—more than 30,000 in Zimbabwe since October, more than 23,000 in Malawi since November, and more than 27,000 in Zambia since March—with accuracy. The systems established by CDC and ICAP also demonstrate the benefits of strong partnerships for a large, complex project, and allow the PHIA Project to pave the way for future surveys to handle blood samples.

Behind the Numbers: a Biostatistician in the Field

AAfter graduation, biostatisticians with advanced degrees usually end up in an office or lab to work with abstract numbers and equations. For Joshua Kriger, MS ’14, the experience has been more tangible. As the statistical program manager for ICAP’s Population-based HIV Impact Assessment (PHIA) Project, he spent 17 days doing fieldwork in Zambia where he trained local staff on survey methods to measure progress in the fight against HIV.

Josh Kriger
Josh Kriger
Implemented in partnership with the U.S. Centers for Disease Control and Prevention, PHIA will assess the state of the HIV epidemic in more than a dozen countries in sub-Saharan Africa where the epidemic has claimed millions of lives. Providing the latest data on the number of people infected, the rate of new infections, and how many people are getting effective treatment, the PEPFAR-funded survey will arm policymakers with the best information to direct resources to the fight against HIV.

Kriger and Seamus Thompson, director of Mailman’s Statistical Analysis Center, work closely with the PHIA team to analyze data from these household surveys and generate reliable reports. Before they could start crunching the numbers, they needed a firmer understanding of the data collection process, necessitating Kriger’s 7,400-mile trip to Zambia.

In collaboration with the national ministry of health and central statistical office (similar to the U.S. Census Bureau), the PHIA survey teams will visit around 15,000 households in each country to administer questionnaires and offer onsite HIV testing and counseling. When someone tests positive for HIV, survey staff will refer them to care and treatment services.

Building Trust

During his time in Zambia, Kriger trained survey workers to collect data using mobile tablets. At the same time, he took home important lessons on the context of how the survey will be implemented.

HIV is a sensitive topic for many people, and researchers and others working to respond to the epidemic must often ask intimate questions to gather accurate information. Among other things, the PHIA survey asks respondents about their sexual behavior, including anal sex, multiple partners, and sex work, to help identify risk factors and areas where interventions may be most effective.

“We are coming into peoples’ homes and offering HIV testing and asking them very personal questions about their health and behaviors,” says Kriger. “A big part of the survey is establishing trust.”

By learning about potential issues, Kriger and his team of 10 biostatisticians are much better prepared to identify and account for any gaps in the data later on. “Interpreting the data requires an intimate knowledge of how the data were collected in the field,” says Kriger.

Done right, biostatistics is about much more than crunching the numbers. As Kriger attests, it takes a healthy dose of cultural literacy and empathy for the experience of those living in countries affected by HIV.

Supplies on Demand: Logistics Coordination for the Multi-Country PHIA Survey

Today, survey teams for the PHIA Project are at work in three countries and have tested more than 53,000 people for HIV. Funded by PEPFAR through the CDC, this multi-year project to conduct population-based HIV-impact assessments (PHIAs) will provide critical information on the state of the HIV epidemic in these countries and help shape policies and programs to confront the epidemic.

Currently, PHIA survey teams are conducting thousands of interviews and HIV tests as they travel throughout Zimbabwe, Malawi, and Zambia in 4×4 trucks loaded with supplies. Every single item the teams use, from butterfly needles and vacutainer tubes to clipboards and pens, has arrived in their hands through months of meticulously planned procurement, transport, and inventory management. As the project prepares to start new surveys in Uganda, Tanzania, Swaziland, and Lesotho, logistics are a central focus of activities. “The project requires a unique combination of team talent, as well as supplies, and that must be available for consumption at remote locations,” says Charles Wentzel, ICAP’s PHIA regional procurement and logistics advisor.

Nearly every aspect of the survey fieldwork, including transportation of teams, laboratory testing, and training, relies on well-functioning equipment and adequate supplies to meet the survey targets. Given the scale of the project, which will survey between 20,000 and 30,000 people in each country, precise coordination is essential to delivering everything when and where it is needed. “There is a lot of information needed well ahead of time,” says Wentzel. Since most items are procured internationally, orders must be placed far in advance. The team factors in three months for shipping by sea, as well as customs clearances.

For each PHIA country, the ministry of health, the CDC, and ICAP work together to complete a planning worksheet. The team enters information onto the worksheet such as the number of households, expected HIV prevalence, specific lab tests, survey team composition, number of satellite labs, number of vehicles, and other parameters, and the worksheet then calculates the quantity needed for each item. David Hoos, PHIA project director, recalls that “ICAP first implemented a complex procurement tool during the implementation of the MTCT-Plus Initiative in 2002, for antiretroviral medication quantification.”

In some cases, mobile laboratories must be procured. This is necessary when blood samples will be collected from participants who are too far from any existing lab to meet the cold-chain or “arm-to-freezer” time requirements. In Zambia ICAP is using mobile laboratories which can process specimens and are equipped with refrigerators to ensure the samples and supplies are kept cold.

A customized logistics plan is necessary for each country and it reflects geography, weather, cultural, and political factors. Each factor may affect the specific equipment and supplies needed, the timing of the survey and transport of samples back to the lab, and time needed for customs clearance of imported supplies. Wentzel adds that, “addressing urgent or unforeseen challenges like delays, really comes down to the capacity of our team and the capacity of our system. Our team is experienced and can handle emergencies because they know what needs to be done.”

At the country level, the local logisticians are often lab technicians who understand the unique properties of PHIA supplies, particularly cold-chain items that may spoil. These technicians are trained in logistics functions and warehouse procedures. Some products have long production lead times, yet short expiry dates, further complicating the efforts to avoid ruptures in stock. Distribution of supplies is planned at multiple levels, with the warehouse providing stock to labs, and labs ensuring the field teams are fully equipped.

Tracking inventory is an essential function for the logisticians. The tracking mechanism itself is a user-friendly online system through which the in-country warehouse officer makes updates. Multiple people can access this in real time, so it allows simultaneous updating and tracking. The real-time aspect of the system is crucial for ensuring the field teams can work and move efficiently.

As the PHIA Project expands operations further, with four more countries starting data collection in 2016, the logistics teams are constantly implementing lessons learned. “We’re strengthening systems and enhancing ease of use for the upcoming surveys,” says Wentzel. “The system is changeable and we can make adjustments according to need.”

The PHIA Project is a multi-country initiative to measure the reach and impact of HIV programs in PEPFAR-supported countries and guide policy and funding priorities.

ZAMPHIA: Educating a Community about HIV

As the headmaster and only teacher at the Ndondo Community School in the rural Mongu District of Zambia in Western Province, Mr. Lambi Chingumbe educates the children of his community on math, English, and science. In addition, he is educating his community as a community mobilizer for the Zambia Population-based HIV Impact Assessment (ZAMPHIA) survey, showing his commitment to improving people’s health through knowledge.

“It is important to know your HIV status. Then you can start taking medicine early and live longer,” says Mr. Chingumbe.

Through in-home interviews and HIV counseling and testing, the ZAMPHIA survey is yielding essential national data on HIV in Zambia. The survey has a direct benefit for participants, and also serves a wider public health purpose. It will enable the Ministry of Health to better understand the impact of HIV at this stage of the global epidemic and target its treatment and prevention efforts at the national and community levels. In 2014, HIV prevalence among adults in Zambia was estimated at 12.4 percent. The country has made important strides in its response to HIV, reducing the rate of maternal HIV transmission from 24 percent to less than nine percent in the last five years. It has also increased the number of people tested for HIV by 20 percent between 2013 and 2014.

The survey began on March 1 and since then, 32 ZAMPHIA survey teams across Zambia’s Northern and Western provinces have been visiting selected households and providing HIV testing to adults and children who agree to participate. Before the teams arrive, community mobilizers like Mr. Chingumbe play a critical role in raising awareness of the survey and its importance. These local residents distribute brochures, talk to neighbors and organize community events. They are trained to address key project challenges and community concerns, including questions about HIV testing, how blood samples will be collected, and how participants’ personal information will be used. With a goal of reaching 16,000 households throughout the country, the community mobilizers are vital to the success of the survey.

Since December, 275 community mobilizers have been preparing for the arrival of ZAMPHIA in three provinces, under the direction of community mobilization coordinators. ”The coordinators are an essential link among the communities, the survey teams, and the broader ZAMPHIA team. Throughout the survey period they support the mobilizers in planning activities, monitoring community feedback, and responding to questions and issues that emerge,” says Kumbutso Dzekedzeke, ICAP’s ZAMPHIA project director.

Mr. Chingumbe says the most frequent question that arises from the community members is what kind of support is available if someone tests positive for HIV. The ZAMPHIA survey teams, who are trained in confidentiality procedures, provide HIV test results on the spot as well as pre- and post-test counseling, and they refer individuals who test positive to a local health center for care and support.

To Mr. Chingumbe, the work is an extension of his role as an educator in the community. “ZAMPHIA is here to help people know their status and help them see their children grow as well as to provide counseling and give lessons on how people can care for themselves.”

In this rural community, “most people work in the morning, so [we] go to the village around 2 PM when people are back from work.” This approach allows Mr. Chingumbe and the data collection team to maximize the number of survey participants. Community mobilization activities began in Mongu District in late December, and a few weeks into the effort, Mr. Chingumbe reported that the community response has been positive, and that people were eager for the survey to start.

“Tapping into the community mobilizers’ local knowledge is critical for securing high rates of participation,” says Mr. Dzekedzeke.

Zambia’s ZAMPHIA survey, the third PHIA survey to launch, is part of the PHIA Project, led by ICAP in partnership with the U.S. Centers for Disease Control and Prevention. The project is measuring the reach and impact of HIV programs in selected countries receiving support from the President’s Emergency Plan for AIDS Relief by estimating HIV prevalence, incidence, and viral load suppression among a nationally representative sample of adults and children in each country. The results of these surveys will guide national and global HIV programs, as well as policy and funding priorities.

Knock Knock Knock: Zimbabwe’s Soundtrack to Understanding HIV

IN NINE LANGUAGES, ICAP’S HIT POP SONG INSPIRES ZIMBABWEANS TO TAKE PART IN A NATIONAL HIV SURVEY

There’s something new spreading through Zimbabwe—and it’s a good thing.

“Knock Knock Knock” is a catchy and up-tempo song, with sunny Afro-jazz beats and a hard-to-forget jingle. More than a hit song on the airwaves of Zimbabwe, it is also an essential tool for public health promotion. (Watch the video, below.)

In Zimbabwe and most African countries, creative arts and music play an important role in promoting public health programs, according to Rosemary Muchengeti, ICAP Communications Officer for the Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) survey. Zimbabwe is the first country to roll out surveys for the PHIA Project, a five-year, multi-country initiative led by ICAP at Columbia University and supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention.

The PHIA Project is measuring the reach and impact of HIV programs in PEPFAR-supported countries by estimating HIV prevalence, incidence, and population viral load in each country. Conducted in close collaboration with ministries of health, the CDC, and local stakeholders, each national survey of about 30,000 adults and children offers household-based HIV counseling and testing with return of results, and asks household members questions about access to preventive care and treatment services. The results of these surveys will guide policy and funding priorities.

Participation in the survey is voluntary, so getting public buy-in is vital for data collection—and “Knock Knock Knock” is one way ZIMPHIA hopes to spread the word.

“We saw the song as tool to communicate about ZIMPHIA through national and community radio stations,” said Muchengeti, who proposed the idea of the song after past success using interactive arts and music for health promotion.

The first step of any health communications campaign is to gauge community interests and preferences, Muchengeti said, to get a sense of public attitudes and beliefs about a particular issue before coming up with a strategy to achieve desired outcomes.

The ICAP team in Zimbabwe worked with project partners including the Ministry of Health and the CDC, as well as community members to develop the lyrics of “Knock Knock Knock,” which conveys its message in English and eight of Zimbabwe’s languages, with the goal of spreading the word far and wide, among old and young.

To lead musical production, ICAP approached Albert Nyathi, a leading Zimbabwean poet, musician and activist. Nyathi then recruited fellow artists who are all well-known in Zimbabwe for their performances in support of various human rights campaigns. Together, these musicians are the voices and faces of “Knock Knock Knock,” communicating the importance of the ZIMPHIA survey to communities. In the dramatic introduction to the song, Nyathi says:

“After a decade of successful scaling up of HIV prevention and treatment efforts in Zimbabwe

Now is the time to assess the effects of HIV in our nation

Now is the right moment to take stock of what has been achieved in confronting the HIV epidemic

In Zimbabwe and define the way forward…”

Played almost daily on the radio in Zimbabwe, the song reaches rural areas as easily as it does city centers. The “Knock Knock Knock” music video is broadcast as a public service announcement on television, and a one-minute jingle version of the song was adapted to be played on ZTV, the country’s one and only national TV channel.

“The ZIMPHIA song is a great example of the creative, collaborative approaches to public health promotion that CDC likes to support,” said Beth Tippett Barr, CDC Country Director, Zimbabwe. “It reflects a strong engagement with our national partners.”

“Knock Knock Knock” has been key to letting the Zimbabwean public know that surveyors would soon come knocking on their doors for the ZIMPHIA survey, according to Muchengeti. But beyond awareness, the song also helps to dispel discomfort and change negative perceptions.

“Many people are understandably reluctant to allow someone to come into their home and draw their blood,” said Jessica Justman, principal investigator for the PHIA Project and ICAP’s senior technical director. “The song makes it easier for people to understand why it’s important for them to take part in ZIMPHIA.”

Unlike other hit songs, the success of “Knock Knock Knock” is not measured by record sales, number of downloads, or YouTube views. In this case, its success is reflected in the nearly 12,000 people who have participated in the ZIMPHIA survey since its launch in October 2015.

“The response has been overwhelming. All age groups are singing along and they love the artists,” Muchengeti said. “The way the song is framed with creativity and with an emphasis on the community is very appealing to the public.”

Zimbabwe’s history of success in responding to the HIV epidemic over the past decade makes it a role model for the other sub-Saharan African countries included in the PHIA Project. Wide participation in the survey will enhance the ability to measure the status of the HIV epidemic and inform the next phase of the global HIV response. And that’s something to sing about.

Watch the video:

BY Michelle Truong,
MPH 2016

Leap of Faith: ZIMPHIA Partners with Religious Leaders in Zimbabwe

Before the PHIA survey teams begin to knock on household doors, community workers visit selected communities, known as enumeration areas, to help community leaders and members understand some of the sensitivities that surround HIV and to strengthen support for the survey. In Zimbabwe, community workers held a recent workshop with members of the Apostolic religious community to make them aware of the project’s potential to improve national health.

Approximately 85 percent of Zimbabweans are Christians, and of those, over one-third are members of the Apostolic Church, a denomination which follows the teachings of Christ’s apostles. In Manicaland Province, where ZIMPHIA survey teams are visiting 1,620 households, about one-quarter of the population is Apostolic. To help encourage full participation of this group, the ZIMPHIA team reached out to the Secretary General of the Union for the Development of Apostolic Churches in Zimbabwe Africa (UDACIZA), the churches’ governing body. As Godfrey Musuka, ICAP’s country representative in Zimbabwe and project director for ZIMPHIA noted, “It’s important for ZIMPHIA to survey a nationally representative ‘slice’ of Zimbabwe, and we asked the Apostolic Church to work together with us on this goal.”

More than 50 Apostolic leaders and bishops attended the workshop, as well as representatives from the Ministry of Health and Child Care and its ZIMPHIA partners: ICAP, the National AIDS Committee, and the Biomedical Research & Training Institute. At the meeting, Dr. Mutsa Mhangara from the Ministry of Health acknowledged the religious leaders’ support, noting that the Ministry of Health “provides health services to all groups in the country and ZIMPHIA provides a unique opportunity to get information to guide service provision and we thank you for accepting this project.”

Ministry of Health representatives gave presentations on the methodology and goals of the survey and explained how the data will be used to improve HIV services throughout Zimbabwe. The presenters also emphasized that the survey is a government program that will inform future health interventions so they can best serve all citizens, including the Apostolic community.

“The Apostolic representatives said that they felt honored to be invited to the meeting because it showed the ZIMPHIA team recognized them as active, important community leaders and provided an opportunity for their voice to be heard,” said Musuka.

The bishops acknowledged HIV as a major health problem in Zimbabwe, and indicated that they were open to any intervention that allowed the government to better understand and respond to the epidemic. The workshop was well-received and included strong statements of support for the survey from church leaders. Rev. Edison Tsvakai, secretary general of UDACIZA, said, “We assure you that we will work together to make this survey a success and we are glad because we will now be able to answer questions when asked about ZIMPHIA by our members.” The UDACIZA endorsed ZIMPHIA, saying “The ZIMPHIA survey is a good project for Zimbabwe and the Apostolic group of churches welcomes it and will participate and support the survey in every way possible.”

Their endorsement and support went beyond the workshop. Shortly after the meeting, the group formed a committee of bishops to assist with community mobilization in Manicaland. The bishops made themselves available to consult with the ZIMPHIA community mobilizers and advise them in case they need help in working with Apostolic Church members.

The ZIMPHIA team’s successful engagement with this religious community will inform community mobilization in other countries as additional PHIA surveys roll out.

There’s an App for That: Using Tablets for PHIA Data Collection

After weeks of training and preparation, PHIA survey teams are on the ground in Zimbabwe and Malawi, equipped with tablet computers and wearing brightly colored t-shirts emblazoned with survey logos. Over the next six months, they will interview adults and children from approximately 15,000 randomly selected households in each country using pre-programmed tablets and portable blood testing equipment.

Tablet technology is a critical part of the PHIA Project, a multi-country initiative to assess the impact of scaled-up national HIV programs on the HIV epidemic in PEPFAR-supported countries. Funded by PEPFAR through the CDC, and implemented in partnership with CDC and key national stakeholders, ICAP plans to launch PHIA surveys in approximately 15 countries in Africa and the Caribbean over the next five years. ICAP, in collaboration with Westat, Inc., a PHIA Project partner with extensive experience collecting data on tablets, developed PHIA-specific apps using Open Data Kit, an open-source software, to collect high-quality data.

To date, teams have used tablets for household listing, a key planning step needed for survey implementation, in Malawi and Zambia. The teams found that it took much less time, only one month, to clean the electronic household listing data in Malawi compared to the six months needed for the paper-based household listing data in Zimbabwe. In addition to a faster time to clean data, the state-of-the-art tablets provide many advantages over paper-based methods, including portability, built-in checks to help reduce errors, and the ability to store all necessary forms in multiple languages.

In Zimbabwe, data collection started with 12 survey teams in October and scaled up to 20 teams in November; they are using 160 tablets programmed with questionnaires and consent forms in three languages created using Open Data Kit. Data collection started in Malawi (160 tablets, three languages) in November and will start in Zambia (260 tablets, eight languages) in December. All team members are trained to conduct interviews using the tablets.

The tablet has pre-programmed skip patterns in the survey questionnaire—meaning the program automatically moves to the most appropriate next question based on participants’ responses to earlier questions—to guide interviewers, and all data collected are uploaded to a central database server. Internet access is not required to complete the forms on the tablets, but only for uploading finalized forms. Portable routers, used to transmit data via Wi-Fi hotspots, maximize connectivity.

In addition, since there are approximately 15 different consents, assents, and permissions for each survey, each tablet includes custom applications that assign the correct consent and permission forms for each participant, based primarily on the age of the individual. Electronic signatures are collected for each form in the tablet, and a scanning app is used to link participant identification numbers with point-of-care testing results from pre-printed barcode labels for blood specimens.

The biomarker testing portion of the survey may include tests for syphilis and hepatitis B in addition to HIV. Survey staff collect blood samples and are guided by a built-in testing algorithm on the tablet that prompts when move on to the next appropriate step after the first HIV rapid test. For example, if the initial HIV test finds the blood sample is reactive, the tablet will instruct the tester to perform a confirmatory HIV test. If the first two HIV test results are discordant, the tablet will prompt the survey staff to conduct a third tie-breaker test.

To be sure, there have been a few technical challenges, such as occasional bugs in the application when revising or correcting forms and the need to hone the survey application within a short testing and review period. However, as the household listing exercises have already demonstrated, the tablets will improve efficiency and quickly provide clean data.

How Close Are We to Beating HIV in Africa?

Harare, Zimbabwe—Due to global efforts to respond to the epidemic, millions of people are receiving HIV treatment and services. But many more still lack access to the care they need. To improve the response, donors and governments require detailed information about the epidemic so they can assess progress and identify future needs. As part of a broader effort to understand the national epidemic in Zimbabwe, the groundbreaking Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) survey enrolled its first participants in October, with 12 field teams traveling to the northern region of Zimbabwe to start collecting data. It is the first of more than 15 such household-based surveys to be conducted in Africa as part of the PHIA project, which aims to provide a snapshot of the HIV epidemic in each country, representing an important step toward bringing even the most severely affected countries closer to the goal of treating all of those living with HIV and eliminating new infections.

A member of the ZIMPHIA survey team prepares to begin data collection.

Funded by the U.S. Centers for Disease Control and Prevention (CDC) through the President’s Emergency Plan for AIDS Relief (PEPFAR), the PHIA project is led by ICAP at Columbia University. Survey teams will collect information and conduct laboratory tests to estimate the magnitude of the HIV epidemic in adults and children and to measure access to prevention, care and treatment services.

“After more than ten years of global effort to expand access to treatment, there is a great deal of interest in understanding where things stand with the HIV epidemic. ZIMPHIA will allow Zimbabwe to gain a deeper understanding of what has been accomplished and what still needs to be done in the future,” said Jessica Justman, principal investigator and senior technical director at ICAP.

Owen Mugurungi, Director of the AIDS and TB Unit in the Government of Zimbabwe’s Ministry of Health and Child Care, announced the survey’s launch in the Mbire District of Mashonaland Central Province, saying, “ZIMPHIA survey data collection has started, marking a very important milestone in our HIV response efforts as a country.” Mugurungi noted that this survey will be the first of its kind to be conducted in the country. “We are expecting a smooth survey and look forward to high rates of participation by the population,” added Dr. Mugurungi.

ZIMPHIA teams will visit 15,000 randomly selected households across Zimbabwe and administer tablet-based questionnaires to consenting household members. Survey participants receive HIV and syphilis testing and counseling, with immediate return of results, all provided with privacy in each participant’s home. Participants who test positive are referred to their preferred health care facility for treatment.

Zimbabwe’s success in responding to the HIV epidemic has been the result of well-coordinated efforts at the national level. Both the Zimbabwe and U.S. governments are enthusiastic about the ZIMPHIA survey and their continued collaboration supporting the country’s HIV response. Additional resources for the survey are provided by the Government of Zimbabwe and the Global Fund.

“ZIMPHIA, and the PHIA project as a whole, will provide critical evidence that will guide HIV programs over the next decade. This is historic and timely effort will inform the next phase of the global response to the HIV epidemic,” added Wafaa El-Sadr, ICAP director.

ZIMPHIA, a Government of Zimbabwe initiative, is being implemented in partnership with the Biomedical Research and Training Institute of Zimbabwe and Lancet Laboratories. In addition to ICAP, the PHIA project partners include, the African Society for Laboratory Medicine, ICF International, Statistical Center for HIV/AIDS Research and Prevention at the Fred Hutchinson Cancer Center, University of California San Francisco’s Global Health Sciences and Westat, Inc.

Founded in 2003, ICAP at Columbia University supports programs and research that address major health issues such as HIV, malaria, tuberculosis, maternal and child health and non-communicable diseases. ICAP works in collaboration with partners around the world to support high-performing health system strengthening initiatives and implements innovative and sustainable health solutions. ICAP, situated at the Columbia Mailman School of Public Health, works in partnership with governmental and non-governmental organizations across 21 countries.

Data Collection Begins for First PHIA Survey

The groundbreaking Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) survey enrolled its first participants on October 18th, with 12 ZIMPHIA field teams kicking off data collection in the northern region of Zimbabwe.

ZIMPHIA is part of the PHIA Project, a five-year, multi-country initiative funded by the U.S. Centers for Disease Control and Prevention (CDC) through the President’s Emergency Plan for AIDS Relief (PEPFAR) and led by ICAP at Columbia. The PHIA Project consists of household-based, population surveys that will collect information related to HIV in approximately 15 to 20 African countries. Each survey, beginning with ZIMPHIA, will collect information and conduct laboratory tests in order to estimate the magnitude of the HIV epidemic in adults and children and to measure access to prevention, care and treatment services in each country.

“ZIMPHIA will allow Zimbabwe to gain a deeper understanding of what has been accomplished and what still needs to be done in the future,” said Dr. Jessica Justman, principal investigator and senior technical director at ICAP. “ZIMPHIA, and the PHIA Project as a whole, will provide critical evidence that will guide HIV programs over the next decade.”

Dr. Owen Mugurungi, Director of the AIDS and TB Unit in the Government of Zimbabwe’s Ministry of Health and Child Care, announced the survey’s launch in the Mbire District of Mashonaland Central Province, saying, “ZIMPHIA survey data collection has started, marking a very important milestone in our HIV response efforts as a country.” Dr. Mugurungi noted that this survey will be the first of its kind to be conducted in the country. “We are expecting a smooth survey and look forward to high rates of participation by the population,” added Dr. Mugurungi.

ZIMPHIA teams will visit 15,000 randomly selected households across Zimbabwe and administer tablet-based questionnaires to consenting household members. Survey participants receive HIV and syphilis testing and counseling, with immediate return of results, all provided with privacy in each participant’s home. Participants who test positive are referred to their preferred health care facility for treatment.

Zimbabwe’s success in responding to the HIV epidemic has been the result of well-coordinated efforts at the national level. Both the Zimbabwe and U.S. governments are enthusiastic about the ZIMPHIA survey and their continued collaboration supporting the country’s HIV response. The survey is supported by substantial resources provided by PEPFAR with additional resources provided by the Government of Zimbabwe and the Global Fund.

“This is a historic and timely effort. It will provide critical information to inform the next phase of the global response to the HIV epidemic,” added Wafaa El-Sadr, ICAP director.

ZIMPHIA, a Government of Zimbabwe initiative, is being implemented in partnership the Biomedical Research and Training Institute of Zimbabwe and Lancet Laboratories. The PHIA Project partners include, in addition to ICAP, the African Society for Laboratory Medicine, ICF International, Statistical Center for HIV/AIDS Research and Prevention at the Fred Hutchinson Cancer Center, University of California San Francisco’s Global Health Sciences and Westat, Inc.

Founded in 2003, ICAP at Columbia University supports programs and research that address major health issues such as HIV, malaria, tuberculosis, maternal and child health and non-communicable diseases. ICAP works in collaboration with partners around the world to support high-performing health system strengthening initiatives and implements innovative and sustainable health solutions. ICAP, situated at the Columbia Mailman School of Public Health, works in partnership with governmental and non-governmental organizations across 21 countries.

Major HIV Assessment Launches in Zimbabwe

On September 18th, the Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) was formally launched in Harare by Zimbabwe’s Ministry of Health and Child Care, the National AIDS Council, the Ambassador of the Government of the United States of America, and representatives of PEPFAR, CDC, ICAP at Columbia University, and other project partners.

This major initiative will describe the current status of the HIV epidemic in Zimbabwe, with survey teams set to visit approximately 15,000 randomly selected households in order to estimate national HIV incidence, prevalence, and viral load suppression among adults and children. The results of the ZIMPHIA survey will help guide policy and set funding priorities in Zimbabwe in the years to come.

ZIMPHIA teams will offer free and voluntary HIV, CD4, viral load, and syphilis testing to approximately 30,000 adults and children. ZIMPHIA participants will be provided with their HIV test results and post-test counseling, and anyone who tests HIV-positive will be referred to the nearest health facility for care.

As high participation rates are essential, ZIMPHIA project partners are dedicating significant efforts to sensitize communities around Zimbabwe. The Ministry of Health and partners are working with traditional leaders, religious leaders, and local organizations to engage the community through educational brochures, advertising, radio spots, and even a song specially produced in collaboration with local Zimbabwean artists: Knock, Knock, Knock.

To prepare local teams to carry out the large-scale, very technical survey and to conduct the various blood tests, ICAP led the training of over 100 nurses, 15 medical laboratory scientists, and 40 interviewers. The ZIMPHIA team is also working with 12 district-level laboratories to ensure the medical tests are conducted correctly.

Over the past 30 years, Zimbabwe has made important strides in responding to the HIV epidemic. Through targeted HIV prevention efforts from voluntary medical male circumcision to the prevention of mother-to-child transmission of HIV, Zimbabwe has lowered its national HIV prevalence rate from 30 percent to less than 15 percent.

“Zimbabwe is at a turning point where an AIDS-free generation and an end to AIDS deaths is not only possible, but is in sight,” said Robert Scott, deputy chief of mission for the U.S. Embassy in Zimbabwe. “Not only will ZIMPHIA advance HIV insights, programming and policy in Zimbabwe, it will also serve as a template and example for other African countries that will conduct similar surveys in the coming years.”

ZIMPHIA is a Ministry of Health and Child Care initiative being implemented in partnership with National AIDS Council, ZIMSTAT, the U.S. Centers for Disease Control and Prevention (CDC), with support from the United States President’s Emergency Plan forAIDS Relief (PEPFAR). ICAP at Columbia University is the implementing agency for ZIMPHIA. Other ZIMPHIA partners include: Biomedical Research and Training Institute (BRTI), Lancet Laboratories, and Westat.

ICAP to lead large population-based HIV surveys in 20 African countries

ICAP at Columbia University has received $25 million in the first year of a $125 million, five-year award from the U.S. Centers for Disease Control and Prevention to conduct national, population-based HIV impact assessments (PHIAs) in 20 countries in sub-Saharan Africa. These surveys will provide critical information on the state of the HIV epidemic in these countries and help shape policies and programs to confront the epidemic. The findings may also help inform global funding priorities.

After a decade of successful scale-up of HIV prevention and treatment efforts in sub-Saharan Africa, there is a great deal of interest in looking at what has been accomplished to date, understanding the effect HIV programs have had on the trajectory of the epidemic and how such information may be used to modify the response to the epidemic in the coming years. Household-based, population-level surveys will address these key areas by using biologic markers to measure HIV prevalence, incidence and to estimate access to prevention, care and treatment services. The findings from these surveys will provide a deeper understanding of the impact of the HIV response at a national level and will guide future investments and help target programs and resources for priority populations at greatest risk and in most need of services.

“We have an important opportunity to gather and use population-based data, much like a census focused on HIV, to get a better picture of the HIV epidemic in Africa,” said Dr. Jessica Justman, principal investigator and senior technical director at ICAP. “This project will yield a body of evidence and lessons learned to inform HIV programs over the next decade.”

The PHIA Project, led by ICAP, includes other key partners: the African Society for Laboratory Medicine, ICF International, Statistical Center for HIV/AIDS Research and Prevention at the Fred Hutchinson Cancer Center, University of California San Francisco’s Global Health Sciences and Westat. The team has presence in each of the 20 countries and will work in collaboration with local and regional governments in the survey planning and implementation, as well as analysis and dissemination of results.

ICAP will provide technical support to strengthen data collection systems and enhance laboratory infrastructure in the countries where the surveys will be conducted. An additional and important aspect of this project is enhancing capacity within countries to design, conduct, and analyze PHIAs and to use findings in policy development and program design.

“This is an opportune moment to take stock of what has been achieved in confronting theHIV epidemic in Africa and to use rigorous methods to collect the type of information we need to guide the way forward,” added Wafaa El-Sadr, ICAP director. An External Advisory Group of distinguished academic, policy and organizational leaders from the global north and south will provide guidance to the project and help generate and disseminate global and local HIV programmatic and policy recommendations.

The PHIA Project builds on ICAP’s previous experience in designing and implementing similar HIV surveys in Tanzania, Zambia and in the conduct of a large-scale population survey in Swaziland that included over 13,000 participating households. ICAP launched theSwaziland HIV Incidence Measurement Survey website earlier this year, making select data and survey findings available online to researchers.

Founded in 2004, ICAP at Columbia University supports programs and research that address major health issues such as HIV, malaria, tuberculosis, maternal and child health and non-communicable diseases. ICAP works in collaboration with partners around the world to support high-performing health system strengthening initiatives and implements innovative and sustainable health solutions. ICAP, situated at the Columbia Mailman School of Public Health, works in partnership with governmental and non-governmental organizations and is currently working in more than 3,300 health facilities across 21 countries.