Zimbabwe’s HIV prevalence rate has declined remarkably in recent years, dropping from as high as 24 to 14 percent according to the recently conducted Zimbabwe Population-based HIV Impact Assessment (Zimphia).
Having been launched in the country in September 2015, Zimphia was conducted by the Biomedical Research and Training Institute in collaboration with Zimstat, National Aids Council, ICAP at Columbia University, US Centre for Disease Control and PEPFAR.
The first of its kind, the door-to-door HIV and Aids assessment was carried out between 2015 and 2016 to ascertain the burden of HIV in the country and evaluate the impact of interventions rolled out so far.
During the survey, officials offered HIV testing and counselling services.
Besides seeing the reduction in both HIV incidence and prevalence, the survey also articulated a number of positives in the fight against HIV and Aids being recorded in the country.
Reduced incidence and
In 2011, the prevalence rate stood at an estimated 15,7 percent and in 2013 it declined to an estimated 15 percent. And now according to Zimphia, the prevalence rate is 14 percent.
Though still on the high side, Zimbabwe is faring well as compared to other countries such as Swaziland (28 percent), Botswana (22 percent) and South Africa (17 percent).
Countries such as Malawi (10,8 percent), Tanzania (5,1 percent), Nigeria (3,1 percent) and Liberia (0,9 percent) seem to be doing better than Zimbabwe (UNAids, 2016).
Even though Zimbabwe accounts for three percent of all new HIV infections globally, there has been a nearly 50 percent decline in the number of new infections in Zimbabwe since 2015.
Annual incidence of HIV among adults (15-64 years) in Zimbabwe declined from 0,85 percent in 2015 to 0,45 percent which corresponds to approximately 32 000 new cases annually.
Trends show people living with HIV increasing. The numbers for Zimbabwe rose to 1,4 million from 1,3 million in 2011.
Community Working Group on Health director, Mr Itai Rusike, praised the decline in prevalence. “Decline is a welcome move. It demonstrates that the efforts led by the Government and its stakeholders to reduce the HIV burden in our country are on track,” he said.
Political commitment in the national response has contributed to the decline such as achievements of the early adoption and implementation of the 2013 WHO guidelines on treatment and prevention-of-mother-to-child-treatment (PMTCT), male circumcision and other behavioural change programmes. A high TB/HIV collaboration treatment coverage has also significantly contributed to this impact.
Health and Child Care ministry’s Aids and TB unit director, Dr Owen Mugurungi, also commended the development.
“It is commendable that Zimbabwe’s HIV prevalence rate is declining and the rate of new infections has been reduced by nearly 50 percent,” noted Dr Mugurungi.
“However, the HIV prevalence has remained stable since 2012 and estimated number of HIV-related deaths is decreasing among adults and children and people on treatment are living longer.”
Dr Mugurungi, however, said that in Zimbabwe’s case, the HIV prevalence rate is no longer a good indicator of measuring the disease burden because a lot of people are on treatment and are living longer.
“We have realised that people living with HIV are living longer because of anti-retroviral drugs and this translates to the fact that we have more people with HIV but at the same time we are saying our prevalence rate is declining,” he said.
Zimbabwe is one of the 15 countries that account for 75 percent of new HIV infections globally.
It cannot be disputed, however, that even if the report shows that Zimbabwe has a major Aids burden, it is among the countries that have made the strongest response in Sub-Saharan region through the Aids Levy programme.
Viral load suppression
Zimphia also indicated that the viral load suppression is improving with a 78,7 percent and 71,1 percent among females and males living with HIV respectively (45-54 years). The development is attributed to the introduction of one tablet a day anti-retroviral treatment (ART) for people living with HIV as a measure to combat defaulting on the medication.
The one tablet a day ART therapy is a combination of three drugs —Tenofovir, Lamivudine and Efavirenz (TLE).
This is a departure from the previous three-pronged tablets — Tenofovir, Lamivudine and Nevirapine (TLN) — which were taken separately for two times a day.
Dr Mugurungi said the move tackles both treatment and prevention.
“The goal with the one tablet a day is for the country to realise maximum viral load suppression where one becomes less infectious, hence we will be undertaking prevention and treatment at the same time,” he said.
Transitioning to the one tablet a day therapy is one of the 2013 World Health Organisation guidelines. The country began rolling out one tablet a day from June 2014. The move also gave room for maximum viral suppression as those taking the tablets become less infectious.
However, viral load suppression remains a challenge in adolescents and younger adults.
For the said age-group, viral load suppression is 48,6 percent among adolescent females and 40,2 percent among adolescent males living with HIV.
Africaid-Zvandiri director, Ms Nicola Willis, decries the development.
“We’re not at all surprised by the data as it certainly matches our programmatic experience and early research data,” she said.
Dr Mugurungi feels that more needs to be done to address the many challenges faced by adolescents with regards to HIV.
“We have always faced problems in making sure that adolescents adhere to HIV treatment, hence more effort needs to be put by all stakeholders involved so that our adolescents living with HIV lead better and healthy lives,” said Dr Mugurungi.
Government estimates that 1,4 million people are living with HIV, of which 86 percent are on the ART programme.
As Zimbabwe scales up life-saving ART for people living with HIV, concerns are rife that the absence of mass routine viral load testing will hamper extending treatment to those who need it.
People living with HIV bemoan the lack of viral load testing machines at hospitals to enable them to measure the amount of virus in their blood.
However, due to limited funds, Zimbabwe is presently providing repeat CD4 count checks which are considerably cheaper than viral load testing.
Viral load testing, the gold standard in ART monitoring, is used to measure HIV levels in the blood, an indicator of the drugs’ success.
In 2013, World Health Organisation (WHO) recommended viral load testing at six months, and every 12 months thereafter as the preferred monitoring tool for diagnosing and confirming ART failure.
But a viral load test, although routine in wealthy countries, is scarce and expensive in Zimbabwe.
Viral load testing helps keep people on first line ARVs, which cost a fraction of second and third line.
While having people living with HIV on second line treatment is proving to be expensive for Zimbabwe, quite a sizeable number are failing and these have to be put on third line treatment.
Many low and middle income countries conduct viral load tests in only a small number of central laboratories.
In Zimbabwe, viral load testing is done in Harare, Bulawayo and Mutare.
Despite showing how effective the ART is in suppressing the virus, viral load testing gives room for the treatment to be modified to suit one’s genetic make-up.
Dr Mugurungi said due to financial constraints, Government strives to strike a balance between initiating people on ART and providing viral load machines.
“As a country we are being forced to rely on CD4 counts for HIV treatment monitoring due to the financial constraints that we are facing,” Dr Mugurungi said.
“We require at least $50 million to procure viral load machines that will cover the whole country adequately. However, we have to strike a balance because the average viral load check costs between $20 and $30 and that’s the amount needed for a month’s supply of ARVs. And if ever funds are availed to us, treating people remains a higher priority for Zimbabwe.”
Zimbabwe is yet to achieve the Abuja Declaration which recommends 15 percent national budget allocation to health. Some resource limited countries have drastically reduced CD4 monitoring in favour of increased viral load testing.
For instance, South Africa, Cameroon, Kenya, Malawi, Namibia, Swaziland, Thailand and Uganda also no longer recommend routine CD4 testing, unless viral load testing is unavailable.
To help address the problem, the Government has allowed non-governmental organisations with the capacity to scale up viral load testing in the country.
Nevertheless, Dr Mugurungi is of the view that viral load point-of-care machines will solve Zimbabwe’s looming challenge.
“The way forward will be that of having at least viral load point-of-care machines at initiating sites just like we did with CD4 count machines,” he explained.
The 2015 WHO guidelines remove all limitations on eligibility for ART and recommend that anyone infected with HIV should begin ART soon after diagnosis.
Zimphia also tackled the ambitious 90-90-90 target to help end the HIV pandemic. UNAids predicts 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 sustained ART and 90 percent of all people receiving ART will have viral suppression.
In Zimbabwe, 74 percent of people living with HIV (15-64 years) report knowing their HIV status. And among people living with HIV (15-64 years), 86 percent are currently on ART. Among people living with HIV (15-64 years) who self-report current use of ART; 78,7 percent are virally suppressed.
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