National surveys in Zimbabwe, Malawi, and Zambia reveal exceptional progress against HIV, with decreasing rates of new infection, stable numbers of people living with HIV, and more than half of all those living with HIV showing viral suppression through use of antiretroviral medication. For those on antiretroviral medication, viral suppression is close to 90 percent. Thirty-five years into the global HIV epidemic, these findings are a clear sign of progress and source of hope for the rest of the world.
These data are the first to emerge from the Population HIV Impact Assessment (PHIA) Project, a unique, multi-country initiative funded by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). The Project deploys household surveys, which measure the reach and impact of HIV prevention, care and treatment programs in select countries. ICAP at Columbia University is implementing the PHIA Project in close collaboration with the U.S. Centers for Disease Control and Prevention (CDC) and in partnership with ministries of health.
Importantly, the data positively demonstrate that the 90-90-90 global targets set forth by UNAIDS in 2014 are attainable, even in some of the poorest countries in the world. According to these ambitious targets for 2020, the goal is for 90 percent of people with HIV to be diagnosed, 90 percent of those diagnosed to receive HIV treatment, and 90 percent of those on treatment to be effectively treated and achieve suppression of their infection. This would translate to 73 percent of all HIV-positive people being virally suppressed. The data show that once diagnosed, individuals are accessing treatment, staying on treatment, and their viral load levels are suppressed to levels that maintain their health and dramatically decrease transmission to others.
"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, including excellent durability of first line treatment regimens with high adherence to medications," said Ambassador Deborah Birx, U.S. Global AIDS Coordinator.
The PHIA Project surveys describe national HIV epidemics by looking at HIV incidence (the rate of new infections), HIV prevalence (the percent of the population living with HIV), and the prevalence of viral load suppression (a measure of a well-controlled HIV infection), all through a nationally-representative sample of the population. Additional measures in the surveys look at the proportion of those with HIV who have been tested and who are on treatment.
The household surveys of approximately 80,000 adults and children in Zimbabwe, Malawi, and Zambia were conducted in 2016. Results show that the rate of new infections is less than one percent per year. HIV prevalence, at 10 to 14 percent, is similar to 2010 estimates, and more than half of all adults living with HIV have viral load suppression. Compared to 2003 incidence estimates for the same three countries of between 1.3 and 1.5 percent per year, 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.
"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."
Preliminary data analyses show that, as of 2016:
- In Zimbabwe, among adults ages 15 to 64, HIV incidence is 0.45 percent; HIV prevalence is 14.6 percent (16.7 percent among females and 12.4 percent among males); 60.4 percent of all HIV-positive people are virally suppressed, and 86 percent of those on treatment are virally suppressed.
- In Malawi, among adults ages 15 to 64, HIV incidence is 0.37 percent; HIV prevalence is 10.6 percent (12.8 percent among females and 8.2 percent among males); 67.6 percent of all HIV-positive people are virally suppressed, and 91 percent of those on treatment are virally suppressed.
- In Zambia, among adults ages 15 to 59 years, HIV incidence is 0.66 percent; HIV prevalence is 12.3 percent (14.9 percent among females and 9.5 percent among males); 59.8 percent of all HIV-positive people are virally suppressed, and 89 percent of those on treatment are virally suppressed.
"The partnership with the ministries of health has been fundamental to the success of the surveys," said Dr. Shannon Hader, director of the Division of Global HIV and Tuberculosis at CDC. "This kind of information has not been available before and the ministries are eager to use the survey results to inform their policies and programs."
With high HIV prevalence estimates of 10 to14 percent, these three countries continue to bear a substantial HIV burden. Nonetheless, with prevalence stabilizing and incidence falling, the PHIA survey results suggest that people living with HIV are living longer thanks to effective and accessible treatment.
"It is heartening to see the impressive viral suppression noted in the three countries among those on treatment," said Dr. Wafaa El-Sadr, global director of ICAP. "Viral suppression is critical for the well-being of people living with HIV and for preventing HIV transmission to others."
The results from the first three PHIA surveys compel the global community to strengthen its efforts to reach those who have yet to receive an HIV test and to engage, support, and enable those who test HIV-positive to start and stay on effective treatment in order to achieve long-term viral suppression.
"Importantly, the PHIA surveys 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."
Affordability and supply remain critical to the success of long-lasting HIV drug