Lusaka's HIV Treatment Surge: 100,000 New Patients, and the Retention Gap It Exposed

In 18 months, Zambia's Lusaka Province started about 100,000 people with HIV on antiretroviral therapy (ART). Yet the number receiving treatment rose by only 43,911. The Lusaka Province HIV Treatment Surge improved on the measures it tracked, and in doing so it showed where the next problem lies: keeping people in care.

Where it started

Lusaka Province, home to 3.2 million people, has the highest HIV prevalence in Zambia, with about 340,000 people estimated to be infected. The 2016 Zambia Population-based HIV Impact Assessment (ZAMPHIA) put adult prevalence there at 15.7 percent, with 62.7 percent of people achieving viral load suppression (HIV-1 RNA below 1,000 copies/mL). Nationally, treatment coverage among people aged 15–24 was lower than among adults 25 and older — a gap against the UNAIDS 90/90/90 targets (90 percent of people with HIV knowing their status, 90 percent of those on ART, 90 percent of those virally suppressed).

The United States, through the President's Emergency Plan for AIDS Relief (PEPFAR), has worked with Zambia's government since 2004. By January 2018, PEPFAR was supporting about 750,000 Zambians on ART, and HIV incidence had fallen by about 40 percent since 2004.

What the Surge did

The Ministry of Health, PEPFAR-Zambia, CDC-Zambia and partners launched the Surge in January 2018, coordinating it through monthly reviews, quarterly leadership meetings and joint site visits.

• Focus. Of 201 ART facilities in the province, 11 high-volume ones — serving 43 percent of people who tested positive — got annual, monthly and weekly targets for testing, treatment and viral load.
• Spreading what worked to the other 190 facilities, through ad hoc trainings and staff exchanges, clinical mentors, and Project ECHO, which links HIV experts with distant staff by video teleconference.
• Four tracked practices: finding cases through risk screening and asking newly diagnosed clients to name sexual partners; bringing back clients who missed appointments and enrolling eligible clients in differentiated service delivery; using electronic medical record queries to find clients due for viral load testing; and enhanced adherence counseling for those not yet suppressed.

Eighteen months later

About 100,000 people (103,236) started ART, and young people were over-represented among them:

The definition of "currently receiving ART" tightened in late 2018, from a visit within 90 days to one within 30. In 34 public facilities supported by the Centre for Infectious Disease Research in Zambia — 17 percent of the province's HIV facilities, treating 57 percent of its patients — electronic records allowed the 30-day definition to be applied throughout; there the number on ART rose steadily from 119,239 to 141,164.

People starting ART each quarter, before and during the Surge. Credit: CDC.

What the numbers exposed

• Retention. The gap between about 100,000 new starts and a net rise of 43,911 suggests that keeping people on treatment is a notable challenge.
• Retesting. Some "new" patients may already be on treatment and testing again. In December 2018 and January 2019, among 612 newly diagnosed patients at 12 of the largest facilities, 24 percent were already virally suppressed at diagnosis.
• Young people. Despite the surge in young starters, the age profile of people on ART in June 2019 had barely changed — suggesting retention is especially hard at 15–24, as in global HIV programs, for reasons including stigma and discrimination, mobility and self-perceived risk.

Wider viral load testing also gives a truer picture of suppression, and helps clinics sort patients: suppressed clients can get decentralized care and several months of medicine at once, while unsuppressed clients can get adherence counseling, regimen changes, support, and testing for partners at risk.

Limits, and what came next

Program data vary in quality, though a 2017 province-wide check found facility records and reports closely matched. The data cannot give population-level coverage, and private facilities treat an unknown number of people. Prevalence estimates shift with migration and risk behavior; a second ZAMPHIA was planned for 2020. Building on the Lusaka experience, Zambia launched similar surges in other high-prevalence provinces, aiming to meet the 90/90/90 targets nationwide by 2020.

Sources

Based on "Increase in Antiretroviral Therapy Enrollment Among Persons with HIV Infection During the Lusaka HIV Treatment Surge — Lusaka Province, Zambia, January 2018–June 2019," by Mary Adetinuke Boyd and colleagues (CDC, Zambia Ministry of Health, Centre for Infectious Disease Research in Zambia), Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; a work of the United States government in the public domain.