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.

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.