Final Results from Zambia National HIV Survey Demonstrate Notable Progress Toward Epidemic Control

On February 28, 2019, representatives from the Government of Zambia, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. Centers for Disease Control and Prevention (CDC), and ICAP at Columbia University gathered in Lusaka to announce the final results of the Zambia Population-based HIV Impact Assessment (ZAMPHIA) survey. The extensive data provided in the ZAMPHIA final report show that Zambia has made notable progress toward controlling the nation’s HIV epidemic.

ZAMPHIA, a household-based, national survey was conducted between March and August 2016, and included more than 27,000 children and adults from nearly 11,000 randomly selected households across Zambia. Funded by the U.S. government through PEPFAR, it is the first national survey in Zambia to provide comprehensive information on key HIV/AIDS indicators at the national and regional level, and to measure progress toward the globally recognized UNAIDS 90-90-90 targets for the year 2020.

Final ZAMPHIA data show that in 2016, Zambia was close to achieving the UNAIDS 2020 targets, with 71 percent of people living with HIV in Zambia aware of their HIV diagnosis, 87 percent of all people diagnosed with HIV receiving antiretroviral therapy (ART), and 89 percent of people receiving ART virally suppressed. As noted in other countries, however, the data reveal that women in Zambia are disproportionately impacted by the HIV epidemic. HIV incidence (new HIV infections) was three times higher among women than men (ages 15–59), and HIV prevalence (current HIV infection) was four times higher among young women than men (ages 20–24).

“With my ministry taking the lead, there is a need for more intensive primary prevention among HIV-negative women, as well as targeting of secondary prevention, including safer sexual behaviors, HIV diagnosis, and treatment among HIV-positive individuals,” said Ministry of Health Permanent Secretary Kennedy Malama, MD, MPH. “The disparity in HIV prevalence between males and females, particularly in [young women], suggests more effort is needed to focus on early testing and ART initiation for adolescent girls and young women, as well as the need for preventative services.”

While the ZAMPHIA final report provides the most extensive data available on the HIV epidemic in Zambia to date, it builds on previously released, preliminary ZAMPHIA data that have already begun to shape the HIV response.

“The findings from ZAMPHIA provide a basis to target HIV interventions smartly,” said CDC Country Director Simon Agolory, MD. “Both the Ministry of Health and the U.S. government have used these data extensively to focus Government of Zambia and PEPFAR investments in HIV prevention and treatment.”

“We are privileged that Zambia was one of the first countries in Africa to implement the PHIA surveys,” said Prisca Kasonde, MD, MMed, MPH, ICAP’s country director in Zambia. “We know that the data from the first ZAMPHIA report have helped the government of Zambia and the different funding agencies and implementing partners to understand the impact that HIV programming has had on the HIV response in the country, as well as the gaps that still exist as Zambia strives to reach epidemic control.”

Recognizing the importance of publicly accessible data, full data sets from the ZAMPHIA survey are also now available on the PHIA website, along with data visualization tools that allow health researchers, policymakers, and program planners to explore the full range of survey results and to build tailored charts, graphs, and maps.


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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:

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.

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.