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Title
ZAMPHIA 2021 showed reduction in advanced HIV disease (AHD) prevalence but further scale up of AHD screening and management needed
Presenter
Megumi Itoh
Authors
M. Itoh1, S. Sivile2, A. Mwila1, K. Mweebo1, L. Mwiinga1, D. Chanda2, K. Stafford3, K. Dzekedzeke3, M. Charurat3, M. Bronson4, S. Birhanu4, H. Patel4, J.Z. Hines1, L.B. Mulenga2
Institutions
1Centers for Disease Control and Prevention, Lusaka, Zambia, 2Zambia Ministry of Health, Lusaka, Zambia, 3University of Maryland, Baltimore, Baltimore, United States, 4Centers for Disease Control and Prevention, Atlanta, United States

BACKGROUND: Reducing HIV-related mortality from advanced HIV disease (AHD) through timely diagnosis and management is a critical aspect of a successful HIV program. We analyzed the nationally representative Zambia Population-based HIV Impact Assessment (ZAMPHIA) 2021 data to assess the population-level AHD prevalence.
METHODS: We determined AHD prevalence among people living with HIV (PLHIV) aged 15-59 years by their awareness and ART status and calculated the arithmetic mean difference with ZAMPHIA 2016 using z-scores. Participants completed a questionnaire and whole blood was collected. Awareness of HIV-positive status and treatment status were based on self-report or having detectable ART in one’s blood. CD4+ testing was done for all who tested HIV positive, with AHD defined as a CD4 count of <200 cell/mm3. Analyses were weighted and accounted for survey design.
RESULTS: AHD prevalence was 7.0% in 2021, compared to 13.9% in 2016 (Table 1). Among PLHIV who were unaware of their status, AHD prevalence was 18.8% in 2021. Among those aware of their status and on ART, AHD prevalence was 4.8% compared to 37.9% among those aware but not on ART. While those who were aware but not on ART only comprised 1.8% (CI: 1.2-2.3%) of PLHIV, they represented 9.7% (CI: 4.5-14.9%) of those with AHD; among them, 74.3% were female, average diagnosis was 3.9 years ago and 37.1% had ever taken ART (Table 2).

Table 1: Weighted proportion PLHIV aged 15-59 years with advanced HIV disease (CD4+ count <200) by awareness status in Zambia – 2016 (N = 2,446) versus 2021, (N = 2,045)
YearOverall,
% (95% CI)*		Unaware HIV,
% (95% CI)		Aware, on ART,
% (95% CI)*		Aware, not on ART,
% (95% CI)
20217.0 (5.7-8.5)18.8 (13.5-25.1)4.8 (3.5-6.3)37.9 (20.6-57.7)
201613.9 (12.5-15.3)17.7 (15.0-20.6)10.9 (8.3-11.8)22.8 (17.4-29.1)
p-value for mean difference
<0.01
0.74
<0.01
0.13

Table 2: Characteristics of PLHIV aged 15-59 years with advanced HIV disease (CD4+ count <200) by awareness status in Zambia, 2021
(*Analyses with sample size <50 participants should be interpreted with caution)
CharacteristicOverall
(n=148)		Unaware of HIV
(n= 46*)		Aware, currently on ART
(n=88)		Aware, currently not on ART
(n=14*)

Time since HIV diagnosis, mean years ( 95% CI)6.1 (4.7-7.6)n/a6.4 (4.8-8.1)4.1 (2.0-6.1)
Mean age, years ( 95% CI)40.3 (38.7-41.9)41.2 (38.9-43.5)40.1 (37.8-42.5)38.8 (35.1-42.5)
Female sex, % (95% CI)51.6 (41.6-61.5)51.1 (34.4-67.6)48.1 (35.1-61.4)74.3 (45.5-92.9)

CONCLUSIONS: The population-level burden of AHD has decreased in Zambia since 2016, likely reflecting achievements of Zambia’s universal test-and-treat strategy (started in 2016). Approximately one-third of PLHIV aware of their HIV status but not on ART had AHD but they only represent ~10% of the total AHD burden. Addressing AHD in Zambia will involve identifying the remaining undiagnosed PLHIV in addition to screening for AHD among those aware of their status, especially if they have disengaged from care.

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