While Zambia has made major strides over the last decade addressing the HIV epidemic, key populations continue to face new HIV infections, among other health challenges.

In collaboration with the Zambia National HIV/AIDS/STI/TB Council (NAC) and the Tropical Diseases Research Centre (TDRC), and with support from the U.S. President’s Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention (CDC), ICAP at Columbia University conducted a biobehavioral survey among men who have sex with men, assessing the status of HIV, syphilis, Hepatitis B, and Hepatitis C prevalence in the country. A critical step in addressing the spread of such diseases is measuring where and among whom the spread is most rampant. The study was the first ever biobehavioral survey of men who have sex with men in the country.

Consenting participants of the survey received rapid testing with immediate return of results, and those who tested positive received referrals for care at key population-friendly clinics. The survey demonstrated that across the four major urban towns assessed, nearly all men who have sex with men who were aware of their HIV-positive status were on antiretroviral treatment (ART), which significantly reduces one’s risk of infecting another person with the virus. In Lusaka, the capital and largest city in Zambia, 95.5 percent of men who have sex with men on ART had achieved viral suppression. In the districts of Kitwe, Livingstone, and Solwezi, all men who have sex with men living with HIV who were on ART had achieved viral suppression.

The percentage of men who have sex with men who had ever tested for HIV was highest (95.9%) in Lusaka, and lowest in Kitwe (78.8%). Among those who had never tested for HIV, the two most common reasons were not feeling at risk for HIV and fear of receiving a positive result.

Pre-exposure prophylaxis, or PrEP, significantly reduces risk for acquiring HIV. Across all towns and among men who have sex with men who were HIV-negative and had heard of PrEP, 17.2 percent to 26.4 percent had ever taken the preventative medication. Among HIV-negative survey participants who had never taken PrEP, the main reasons were not feeling at risk for HIV and not knowing where to access the medication. HIV-negative individuals who participated in the survey were referred for PrEP services at local clinics.

“PrEP is an important component of reducing new HIV infections and plays a vital role in the trajectory of achieving HIV epidemic control by 2030,” said Lazarus Chelu, co-investigator of the study. “The survey tells us that PrEP awareness and uptake is low among HIV-negative men who have sex with men – there is need to promote messages that increase awareness of PrEP, so that no one who is at risk of HIV is left behind.”

The biobehavioral survey also assessed that HIV prevalence among men who have sex with men was highest in Lusaka (22.9%), lowest in Solwezi (5.9%), and similar in Kitwe (9.4%) and Livingstone (10.9%). Awareness of one’s HIV-positive status differed across towns and was highest in Kitwe (90.9%), followed by Livingstone (79.8%), Lusaka (61.1%), and Solwezi (51.5%). Population viral load suppression (VLS) prevalence among men who have sex with men living with HIV also varied, ranging from 90.9 percent in Kitwe to 49.8 percent in Solwezi.

“While ART retention is high among men who have sex with men with a prior HIV diagnosis, awareness of one’s HIV status is low across most surveyed towns,” said Neena Philip, PhD, MPH, principal investigator of the study. “This results in low viral load suppression prevalence among all men who have sex with men living with HIV. Increasing HIV testing access through index testing and social network strategies is essential to remedy this gap.”

In sub-Saharan Africa, rates of opportunistic co-infections – in this instance, testing HIV-positive and testing positive for either hepatitis B infection or active syphilis at the same time – are disproportionately high. As with any virus, the introduction of more than one into the body can cause additional or exacerbated health complications. The prevalence of HIV co-infection with either hepatitis B or active syphilis was highest in Lusaka (4.2%). When assessing for a single infection, the prevalence of hepatitis B among men who have sex with men was highest in Kitwe (7.3%) and lowest in Lusaka (3.4%), while the prevalence of active syphilis was highest in Lusaka (7.9%) and lowest in Solwezi (3.4%). Across the four towns, the prevalence of hepatitis C among men who have sex with men was zero.

“This study will be incredibly helpful to Zambia,” said Job Mwanza, MD, PgDLM, MPH, acting country director of ICAP in Zambia. “We can use the findings to inform HIV infection and co-infection programming among key populations across the country.”

ICAP presented the Zambia biobehavioral survey findings at the National HIV conference in December 2022, at both the opening plenary and the session focused on key populations.

About ICAP

A major global health organization that has been improving public health in countries around the world for two decades, ICAP works to transform the health of populations through innovation, science, and global collaboration. Based at Columbia Mailman School of Public Health, ICAP has projects in more than 40 countries, working side-by-side with ministries of health and local governmental, non-governmental, academic, and community partners to confront some of the world’s greatest health challenges. Through evidence-informed programs, meaningful research, tailored technical assistance, effective training and education programs, and rigorous surveillance to measure and evaluate the impact of public health interventions, ICAP aims to realize a global vision of healthy people, empowered communities, and thriving societies. Online at icap.columbia.edu