A comparison of self-reported antiretroviral therapy use and detection of antiretrovirals in the blood: the Zimbabwe Population-based HIV Impact Assessments (ZIMPHIA 2016 and 2020)


BACKGROUND: Identifying people receiving antiretrovirals (ARVs) is essential to accurate estimation of UNAIDS 90-90-90 targets. We compared self-reported antiretroviral therapy (ART) use with detection of ARVs in blood among adults (15-64 years) living with HIV (ALWH) in two population-based surveys in Zimbabwe (2016 and 2020).
METHODS: We used participants' data from randomly selected households. Viral load (VL) suppression defined as <1000 copies/ml, and non-adherence as missed ARV doses for > one day in the past month. Most prescribed first- and second-line ARVs, efavirenz, nevirapine, and lopinavir in 2016, and additionally dolutegravir in the 2020 survey, were assayed.
RESULTS: Of all participants (20,577 in 2016 and 17,728 in 2020), 3,385 ALWH were identified in 2016 and 2,820 in 2020. In 2016, 63.4% (95% CI: 61.3-65.4%) and in 2020, 79.2% (95% CI: 77.1-81.1%) of ALWH self-reported ART use, however no ARVs were detected in 6.7% (95% CI: 5.4%-8.3%) in 2016 and in 2.9% (95% CI: 2.2%-3.8%) in 2020. Of those who reported ART use but no detectable ARVs, 6.0% (95% 3.2%-10.1%) in 2016 and 15.1% (95% CI: 8.3%-25.9%) in 2020 reported non-adherence. In 2016, 3.9% (95% CI: 3.2%-4.8%) and in 2020, 4.2% (95% CI: 3.4%-5.1%) of ALWH reported no prior HIV diagnosis, but ARVs were detected in their blood. Controlling for demographic covariates, ALWH were significantly less likely to have VL suppression if reported ART use but had no detectable ARVs (adjusted odds ratio [aOR]: 0.07, 95% CI: 0.05-0.10, P<0.001) and if they reported non-adherence (aOR: 0.66, 95% CI: 0.52-086, p=0.003). Including ARV detection improved the 90-90-90 estimations (Figure 1).
CONCLUSIONS: The findings indicate consistency between self-reported ART use and ARV detection, evidence of high ART adherence, but some level of unwillingness to disclose HIV+ status and ART use. Inclusion of ARV detection enhanced estimates of ART coverage and VL suppression for 90-90-90 target calculations.