Zambia Population-based HIV Impact Assessment (ZAMPHIA) 2016 ZAMPHIA 2016 COLLABORATING INSTITUTIONS Ministry of Health, Zambia Zambia National Public Health Institute National HIV/AIDS/STI/TB Council, Zambia University of Zambia Central Statistical Office, Zambia Tropical Diseases Research Centre University Teaching Hospital, Zambia The United States President’s Emergency Plan for AIDS Relief (PEPFAR) The United States Centers for Disease Control and Prevention (CDC) WESTAT ICAP at Columbia University DONOR SUPPORT AND DISCLAIMER This project is supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through CDC under the terms of cooperative agreement #U2GGH001226. The findings and conclusions are those of the authors and do not necessarily represent the official position of the funding agencies. SUGGESTED CITATION Ministry of Health, Zambia. Zambia Population-based HIV Impact Assessment (ZAMPHIA) 2016: Final Report. Lusaka, Ministry of Health. February 2019. ACCESS THIS REPORT ONLINE The PHIA Project: http://phia.icap.columbia.edu CONTACT INFORMATION The Ministry of Health Ndeke House, Haile Selassie Avenue P.O. Box 30205 Lusaka Zambia 1 CONTENTS Glossary of Terms 6 List of Abbreviations 8 List of Tables and Figures 9 Summary of Key Findings 12 Chapter 1 Introduction 16 1.1 Background 16 1.2 Overview of ZAMPHIA 2016 16 1.3 Specific Objectives 16 Chapter 2 Survey Design, Methods, and Response Rates 18 2.1 Sample Frame and Design 18 2.2 Eligibility Criteria, Recruitment, and Consent Procedures 19 2.3 Survey Implementation 19 2.4 Field-Based Biomarker Testing 22 2.5 Laboratory-Based Biomarker Testing 24 2.6 Data Processing and Analysis 27 2.7 Response Rates 28 2.8 References 29 Chapter 3 Survey Household Characteristics 30 3.1 Key Findings 30 3.2 Background 30 3.3 Household Composition 30 3.4 Prevalence of HIV-Affected Households 34 Chapter 4 Survey Respondent Characteristics 37 4.1 Key Findings 37 4.2 Background 37 4.3 Demographic Characteristics of the Adult Population 37 4.4 Demographic Characteristics of the Adolescent Population 38 4.5 Demographic Characteristics of the Pediatric Population 39 Chapter 5 HIV Incidence 41 5.1 Key Findings 41 5.2 Background 41 5.3 HIV Incidence Among Adults 42 5.4 Gaps and Unmet Needs 43 5.5 References 43 Chapter 6 HIV Prevalence 44 6.1 Key Findings 44 6.2 Background 44 6.3 Adult HIV Prevalence by Demographic Characteristics 44 2 6.4 Adult HIV Prevalence by Age and Sex 47 6.5 Adult HIV Prevalence by Province 49 6.6 Gaps and Unmet Needs 50 Chapter 7 HIV Testing 51 7.1 Key Findings 51 7.2 Background 51 7.3 Self-Reported HIV Testing Among Adults 51 7.4 Gaps and Unmet Needs 56 Chapter 8 HIV Diagnosis and Treatment 57 8.1 Key Findings 57 8.2 Background 57 8.3 Self-Reported Diagnosis and Treatment Status Among HIV-Positive Adults 57 8.4 Reliability of Self-Reported Treatment Status versus Laboratory ARV Data 61 8.5 Gaps and Unmet Needs 63 8.6 References 63 Chapter 9 Viral Load Suppression 64 9.1 Key Findings 64 9.2 Background 64 9.3 Adult Viral Load Suppression by Demographic Characteristics 64 9.4 Adult Viral Load Suppression by Age and Sex 65 9.5 Adult Viral Load Suppression by Provence 67 9.6 Gaps and Unmet Needs 69 Chapter 10 UNAIDS 90-90-90 Targets 70 10.1 Key Findings 70 10.2 Background 70 10.3 Status of the 90-90-90 UNAIDS Targets 71 10.4 Gaps and Unmet Needs 74 10.5 References 74 Chapter 11 Clinical Perspectives on People Living with HIV 75 11.1 Key Findings 75 11.2 Background 75 11.3 CD4 Counts and Immunosuppression 75 11.4 Late HIV Diagnosis 74 11.5 Retention on Antiretroviral Therapy 78 11.6 Transmitted Resistance to Antiretroviral Therapy 78 11.7 Viral load Suppression and Severe Immunosuppression 81 11.8 Gaps and Unmet Needs 82 11.9 References 84 Chapter 12 Prevention of Mother-to-Child Transmission 85 12.1 Key Findings 85 12.2 Background 85 12.3 Antenatal Care Attendance 85 12.4 Breastfeeding 86 12.5 Awareness of Mother’s HIV Status 87 3 12.6 Antiretroviral Therapy Among HIV-Positive Pregnant Women 86 12.7 Early Infant Diagnosis 89 12.8 Mother-to-Child Transmission 90 12.9 Gaps and Unmet Needs 91 12.10 References 91 Chapter 13 Adolescents and Young Adults 92 13.1 Key Findings 92 13.2 Background 92 13.3 Sex Before the Age of 15 Years 92 13.4 Knowledge About HIV Prevention 93 13.5 HIV Incidence and Prevalence 98 13.6 HIV Testing, Treatment, and Viral Load Suppression 98 13.7 Status of the 90-90-90 UNAIDS Targets 98 13.8 Gaps and Unmet Needs 99 13.9 References 99 Chapter 14 Children 100 14.1 Key Findings 100 14.2 Background 100 14.3 HIV Prevalence 101 14.4 Viral Load Suppression 101 14.5 Status of the 90-90-90 UNAIDS Targets 101 14.6 Nutrition Status 104 14.7 Gaps and Unmet Needs 105 Chapter 15 HIV Risk Factors 106 15.1 Key Findings 106 15.2 Background 106 15.3 HIV Prevalence by Sexual Behavior 106 15.4 Condom Use at Last Sex with a Non-marital, Non-Cohabitating Partner 107 15.5 Male Circumcision 112 15.6 Gaps and Unmet Needs 113 Chapter 16 Intimate Partner Violence 114 16.1 Background 114 16.2 Prevalence of Recent Intimate Partner Violence 114 16.3 Gaps and Unmet Needs 116 16.4 References 116 Chapter 17 Discriminatory Attitudes Toward People Living with HIV 117 17.1 Key Findings 117 17.2 Background 117 17.3 Discriminatory Attitudes Toward People Living with HIV 117 17.4 Gaps and Unmet Needs 119 17.5 References 119 Chapter 18 Tuberculosis, Syphilis, HBV, STI Symptoms, and Cervical Cancer Screening 120 18.1 Key Findings 120 18.2 Background 120 4 18.3 Tuberculosis 121 18.4 Syphilis 122 18.5 Hepatitis B 124 18.6 Self-Reported Symptoms and Diagnosis of Sexually Transmitted Infection 124 18.7 Cervical Cancer Screening Among HIV-Positive Women 127 18.8 Gaps and Unmet Needs 128 18.9 References 128 Discussion and Conclusions 129 Appendix A Sample Design and Implementation 130 Appendix B HIV Testing Methodology 136 Appendix C Estimates of Sampling Errors 147 Appendix D Survey Personnel 158 Appendix E Household Questionnaire 169 Appendix F Adult Questionnaire 191 Appendix G Adolescent Questionnaire 251 Appendix H Survey Consent Forms 269 5 GLOSSARY OF TERMS 90-90-90: An ambitious treatment target to help end the AIDS epidemic. By 2020, 90% of all people living with HIV (PLHIV) will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART); and 90% of all people receiving ART will have viral load (VL) suppression (VLS). Acquired Immunodeficiency Syndrome (AIDS): AIDS is a disease caused by infection with HIV. AIDS is the result of severe damage to the immune system that leaves the body vulnerable to life-threatening conditions such as infections and cancers. Antiretroviral Therapy (ART): Treatment with antiretroviral drugs that inhibit the ability of HIV to multiply in the body, leading to improved health and survival among people living with HIV. CD4+ T-Cells: CD4+ T-cells (CD4) are white blood cells that are an essential part of the human immune system. These cells are often referred to as T-helper cells. HIV attacks and kills CD4 cells leaving the body vulnerable to a wide range of infections. The CD4 count is used to determine the degree of weakness of the immune system from HIV infection. De Facto Household Resident: A person who slept in the household the night prior to the survey. Enumeration Area (EA): A limited geographic area defined by the national statistical authority and the primary sampling unit for the Population-based HIV Impact Assessment (PHIA) surveys. Head of Household: The head of household is defined as the person who is recognized within the household as being the head and is 18 years of age or older or, in special cases, a person between the ages of 15 and 17 years who is either married, has one or more children or living alone. This person may be acknowledged as the head on the basis of age (older), sex (generally, but not necessarily, male), economic status (main provider), or some other reason. Human Immunodeficiency Virus (HIV): HIV is the virus that causes AIDS. The virus is passed from person to person through blood, semen, vaginal fluids and breast milk. HIV attacks CD4 cells in the body, leaving the infected person vulnerable to illnesses that would have otherwise been eliminated by a healthy immune system. HIV Incidence: A measure of the frequency with which new cases of HIV occur in a population over a period of time. The denominator is the population at risk; the numerator is the number of new cases that occur during a given time period. HIV Prevalence: The proportion of living persons in a population who are infected with HIV at a specific point in time. HIV Viral Load (VL): The concentration of HIV in the blood, usually expressed as copies/milliliter (mL). 6 HIV Viral Load Suppression (VLS) or Suppressed Viral Load: An HIV VL of less than 1,000 copies/mL. Household: A person or group of persons, related or unrelated to each other, who live in the same compound (fenced or unfenced), share the same cooking arrangements, and have one person whom they identify as head of that household.