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Population-based HIV Impact Assessments
(PHIA): An Introduction Focusing on
Malawi and Zimbabwe
Elizabeth Radin, PhD
Technical Specialist – Population-based SurveysProject Director, Malawi & Zimbabwe PHIAs
November 6, 2014
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Presentation Objectives
1. Explain what ICAP’s PHIAs are2. Explain why ICAP is doing PHIAs from both a
SCIENTIFIC and POLICY perspective 3. Present how we are approaching the first two
PHIAs in Malawi and Zimbabwe4. Share information on the future of PHIAs at
ICAP
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What are ICAP’s PHIAs
Population-based HIV Impact AssessmentA survey that is:• Nationally-led (MOH, NSO) • In collaboration with CDC• Cross-sectional• Household-based• Nationally and Sub-nationally Representative• Focused on impact-level indicators of the HIV
epidemic through biomarkers and self report
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What we mean by ‘Impact Assessment’
IMPACTS
OUTCOMES
OUTPUTS
A Description of Impacts . . .
OUTPUT: product of activities(# of health staff trained)
IMPACT: long term, high-level result (reduced transmission, reduced mortality)
OUTCOME: medium-term result (# tested, # on ART)
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What does a PHIA Assess?
• The currents status of the epidemic in a country
• The access to and uptake of HIV care and treatment services
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Scientific Rationale for PHIAs
Health facilities, and health facility access exists in a spectrum . . .
ART Site VCT/ANC Health Center
Pharmacy Limited/No Access
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Current data is largely facility-based
Facility-based data describes a subset of the population
It is difficult to infer population measures– such as prevalence or incidence – from facility based data
Population-based surveys are the gold standard for these indicators
Summary: Scientific Rationale
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Policy Rationale for PHIAs
4 million
Num
ber o
n AR
T
El-Sadr WM et al 2012
Adults and children with HIV infection receiving ART with PEPFAR support, 2004-2011
2004 2011
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Policy Rationale for PHIAs
After more than a decade of PEPFAR what is that status of the epidemic? For Example:• What is the rate of new infection following
prevention efforts?
• What is the proportion of Viral Load Suppression following expanded ART coverage?
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Sampling for the PHIAsA Two-stage Cluster-based Sampling Strategy:
An example: What is the prevalence of coffee drinking at ICAP? Background: ICAP has 1000 staff, 20 Offices, 50 Staff/Office
A Census: Ask all 1000 ICAP staff if they drink coffee
A Simple Random Sample: Select 10, 100 or 500 ICAP staff and ask if they drink coffee
A Cluster-based Sample: Select 5 ICAP country offices, ask all staff in those offices if they drink coffee
A Two-stage Cluster-based Sample: Select 10 ICAP country offices, randomly select 25 people from each country office
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Sampling for the PHIAsSampling Strategy:
• Using two-stage cluster-based sampling strategy– Sample ~500 Enumeration Areas (EA),stratified by health zone – Sample ~30 Households per EA
• Sample size includes ~15,000 HH; ~30,000 individuals
• Adults from every HH ~20,000, all children every other HH ~10,000
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The DHS: A Pop Survey Celebrity
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Similarities between DHS/PHIA
• Population-based household survey• Cross-sectional, nationally representative• Household and individual questionnaires• National and subnational HIV prevalence
estimates• Household and individual sample size similar
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Differences between DHS & PHIA
• Biomarkers for CD4 counts, viral load, recency, drug resistance, ARV metabolites, peds
• Point-of-Care HIV testing and CD4 testing with return of results
• Opportunity to assess global HIV outcomes of interest that are outside domain of DHS– PMTCT – Potential for Treatment as Prevention
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ICAP Experience with Pop Surveys• Swaziland HIV Incidence Measurement Survey • Sinazongwe Combination Prevention Evaluation
[SCOPE], in partnership with the Zambia MOH• Bukoba without New Infections, “Bukoba Bila
Maambukizi Mapya,” [BBM2] in Tanzania
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Presentation Objective
MOH, CDC & ICAP’s Approach to Two PHIAs: Malawi and Zimbabwe
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First Two PHIAs: Malawi and Zimbabwe
• In collaboration with CDC • Work with Ministries of Health to develop,
implement and disseminate findings from PHIA Pilots in Malawi in Zimbabwe
• From April 2014-March 2016• Currently in protocol development and pre-
implementation stage
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Malawi• 16. 3 Million People
• Life expectancy: 54 Years
• Causes of Premature Mortality (YLL): HIV/AIDS (23.7%), Malaria (10%), Lower Respiratory Infection (9.7%)1
• HIV Prevalence (age 15-49)
• National: 10.3% 2
• HIV Care and Treatment:
• 675 ART sites, 470,000 patients on ART (83% of need)3
Malawi 2010 DHS.
1 Malawi Global Burden of Disease Study 2010; Institute for Health Metrics and Evaluation (IHME); 2 UNAIDS HIV and AIDS Estimates
3 UNGASS 2013 Malawi Country Progress Report
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Zimbabwe• 13 Million People
• Life expectancy: 58 Years
• Causes of Premature Mortality (YLL): HIV/AIDS (29.0%), Lower respiratory infection (11.7%), Diarrheal disease (6.0%)1
• HIV Care and Treatment: 665,000 patients on ART (77% of need)2
Duri Kerina et al. HIV/AIDS: The Zimbabwean Situation and Trends. American Journal of Clinical Medicine Research, 2013, Vol. 1, No. 1.
1 Zimbabwe Global Burden of Disease Study 2010; Institute for Health Metrics and Evaluation (IHME); 2 UNGASS 2013 Zimbabwe Country Progress Report
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Objectives for Malawi & Zimbabwe PHIAs
Primary Objectives:
• To estimate HIV incidence (i.e., prevalence of recent HIV infection) in a household-based, nationally representative sample of HIV-infected adults
• To estimate the sub-national prevalence of suppressed HIV viral load (<1000 cells/ml3) in a household-based, nationally representative sample of HIV-infected adults
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Measuring Incidence LongitudinallyIncidence: new infections in a population
- --
---+-
January 1, 2014
= .25 cases per person year
January 1, 2015
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Measuring Incidence Cross-Sectionally
2
1
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Objective 1: IncidenceRecent infection (4-6 months) is identified by:
1) Low avidity - weak bonding strength between host antibody and virus.
2) An elevated level of HIV virus in the body
. . . And converted into an annualized rate
US HIV Incidence (06-09) = .02% Expected Zimbabwe/Malawi Incidence= ~1%
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Objective 2: Viral Load Suppression (VLS)
0
10
20
30
40
50
60
70
80
90
100 HIV Treatment Cascade
% o
f all
peop
le w
ith H
IV
Adapted from: aids.gov/federal-resources/policies/care-continuum/
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Objectives for Malawi & Zimbabwe PHIAs
• To estimate HIV incidence (i.e., prevalence of recent HIV infection) in a household-based, nationally representative sample of HIV-infected adults
• To estimate the sub-national prevalence of suppressed HIV viral load (<1000 cells/ml3) in a household-based, nationally representative sample of HIV-infected adults
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Objectives for Malawi & Zimbabwe PHIAs
Secondary Objectives:
• HIV prevalence in adults and children• CD4 T-Cell counts• Transmitted drug resistance • ARV metabolites• Nutrition in HIV positive children• HIV-related risk behaviors • Use of HIV-related services• HIV knowledge and attitudes
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Similarities in Malawi and Zimbabwe PHIAs
Objectives:• Incidence (national), Viral Load Suppression (zonal)
Eligibility Criteria:• Must be a HH member
– resides or slept night before in HH• Must give informed consent• All adults in every household• All children (ages 0-14) in every other household
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Similarities in Malawi and Zimbabwe PHIAs
Survey Procedures: • Collect questionnaire data and blood samples • Carry out POC HIV and CD4 testing• Provide counseling and return results• Refer HIV positives to care• Transport blood samples to central lab for
additional testing
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Similarities in Malawi and Zimbabwe PHIAs
Questionnaires:• Household Questionnaire • Adult Individual Questionnaire
– Demographics including marriage– HIV knowledge and attitudes– Reproduction– Sexual history– HIV testing, care and treatment history
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Similarities in Malawi and Zimbabwe PHIAs
Data Management: • Tablets Cloud server in-country server
Laboratory Management:• Central level testing at a national lab (VL, EID, recency)
Country Oversight Mechanism:• TWG chaired by MOH • Sub-committees on Management, Protocol, Data,
Communications
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Unique to Malawi PHIA
• Oversampling of high prevalence health zones – for greater precision around cascade analysis– interest in making programmatic
assessments/comparisons in future rounds
• Sample will include adults aged 15-64
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Unique to ZIMPHIASecondary Objectives:• Prevalence of Syphilis• Describing the extent of stigma
Sampling:• Sample will include all adults over 15
Questionnaire:• Module for adolescents aged 10-14
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Presentation Objective
The Future of PHIAs:The PHIA Project
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On the Horizon: ‘the next 20’In collaboration with CDC and MOHs , ICAP will
conduct PHIAs in ~20 sub-Saharan African countries over the next 5 years
• No country list yet
Focus on building capacity for population-based surveys • Strengthen capacity in epidemiology, surveillance, statistics
and national reference laboratory services to collect, analyze, and use morbidity and mortality data
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On the Horizon: ‘the next 20’• Partnerships with experienced groups:
– UCSF (KAIS), ICF (DHS), Westat (NHANES), SCHARP (e.g., HPTN/MTN/VTN and SHIMS) and ASLM
• Approach for high prevalence countries may differ for low prevalence countries
• Use results to assess impact of PEPFAR and guide policies and future programs
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Key Messages• ICAP’s PHIAs are Population-based HIV Impact
Assessments
• Rigorously measure key indicators of the epidemic such as• Incidence• Viral Load Suppression
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Key Messages• They will provide information on HIV program
effectiveness that can be used to inform future programs and policies
• The first two PHIAs will be in Malawi and Zimbabwe
• ICAP will work on ~20 PHIAs over the next 5 years
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Acknowledgements
• The Governments of Malawi & Zimbabwe• United States Centers for Disease Control and
Prevention• The U.S. President’s Emergency Plan for AIDS
Relief (PEPFAR)• Padmaja Patnaik, Suzue Saito, Jessica Justman• The PHIA Team
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Zikomo, Tatenda, Thank you!