Experiences and lessons learned from the real-world implementation of an HIV recent infection testing algorithm in three routine service-delivery settings in Kenya and Zimbabwe

INTRODUCTION

Testing for recent HIV infection can distinguish recently acquired infection from long-standing infections. Given current interest in the implementation of recent infection testing algorithms (RITA), we report our experiences in implementing a RITA in three pilot studies and highlight important issues to consider when conducting recency testing in routine settings.

METHODS

We applied a RITA, incorporating a limited antigen (LAg) avidity assay, in different routine HIV service-delivery settings in 2018: antenatal care clinics in Siaya County, Kenya, HIV testing and counselling facilities in Nairobi, Kenya, and female sex workers clinics in Zimbabwe. Discussions were conducted with study coordinators, laboratory leads, and facility-based stakeholders to evaluate experiences and lessons learned in relation to implementing recency testing.

RESULTS

In Siaya County 10/426 (2.3%) of women testing HIV positive were classified as recent, compared to 46/530 (8.7%) of women and men in Nairobi and 33/313 (10.5%) of female sex workers in Zimbabwe. Across the study setting, we observed differences in acceptance, transport and storage of dried blood spot (DBS) or venous blood samples. For example, the acceptance rate when testing venous blood was 11% lower than when using DBS. Integrating our study into existing services ensured a quick start of the study and kept the amount of additional resources required low. From a laboratory perspective, the LAg avidity assay was initially difficult to operationalise, but developing a network of laboratories and experts to work together helped to improve this. A challenge that was not overcome was the returning of RITA test results to clients. This was due to delays in laboratory testing, the need for multiple test results to satisfy the RITA, difficulties in aligning clinic visits, and participants opting not to return for test results.

CONCLUSION

We completed three pilot studies using HIV recency testing based on a RITA in Kenya and Zimbabwe. The main lessons we learned were related to sample collection and handling, LAg avidity assay performance, integration into existing services and returning of test results to participants. Our real-world experience could provide helpful guidance to people currently working on the implementation of HIV recency testing in sub-Saharan Africa.

Universal HIV testing and treatment and HIV stigma reduction: a comparative thematic analysis of qualitative data from the HPTN 071 (PopART) trial in South Africa and Zambia

Despite continued development of effective HIV treatment, expanded access to care and advances in prevention modalities, HIV-related stigma persists. We examine how, in the context of a universal HIV-testing and treatment trial in South Africa and Zambia, increased availability of HIV services influenced conceptualisations of HIV. Using qualitative data, we explore people's stigma-related experiences of living in 'intervention' and 'control' study communities. We conducted exploratory data analysis from a qualitative cohort of 150 households in 13 study communities, collected between 2016 and 2018. We found that increased availability of HIV-testing services influenced conceptualisations of HIV as normative (non-exceptional) and the visibility of people living with HIV (PLHIV) in household and community spaces impacted opportunities for stigma. There was a shift in community narratives towards individual responsibility to take up (assumingly) widely available service - for PLHIV to take care of their own health and to prevent onward transmission. Based on empirical data, we show that, despite a growing acceptance of HIV-related testing services, anticipated stigma persists through the mechanism of shifting responsibilisation. To mitigate the responsibilisation of PLHIV, heath implementers need to adapt anti-stigma messaging and especially focus on anticipated stigma.

HIV Stigma and Viral Suppression Among People Living With HIV in the Context of Universal Test and Treat: Analysis of Data From the HPTN 071 (PopART) Trial in Zambia and South Africa

BACKGROUND

The impact of HIV stigma on viral suppression among people living with HIV (PLHIV) is not well characterized.

SETTING

Twenty-one communities in Zambia and South Africa, nested within the HPTN 071 (PopART) trial.

METHODS

We analyzed data on viral suppression (<400 copies HIV RNA/mL) among 5662 laboratory-confirmed PLHIV aged 18-44 years who were randomly sampled within the PopART trial population cohort 24 months after enrolment (PC24). We collected data on experiences and internalization of stigma from those PLHIV who self-reported their HIV status (n = 3963/5662) and data on perceptions of stigma from a 20% random sample of all PLHIV (n = 1154/5662). We also measured stigma at the community-level among PLHIV, community members, and health workers. We analyzed the association between individual- and community-level measures of HIV stigma and viral suppression among PLHIV, adjusting for confounding.

RESULTS

Of all 5662 PLHIV, 69.1% were virally suppressed at PC24. Viral suppression was highest among those 3963 cohort participants who self-reported living with HIV and were on ART (88.3%), and lower among those not on treatment (37.5%). Self-identifying PLHIV who reported internalized stigma were less likely to be virally suppressed (75.0%) than those who did not (80.7%; adjusted risk ratio, 0.94 95% CI: 0.89 to 0.98). Experiences, perceptions, and community-level measures of stigma were not associated with viral suppression.

CONCLUSION

Internalized stigma among PLHIV was associated with a lower level of viral suppression; other dimensions of stigma were not. Stigma reduction approaches that address internalized stigma should be an integral component of efforts to control the HIV epidemic.

Stigma and HIV service access among transfeminine and gender diverse women in South Africa - a narrative analysis of longitudinal qualitative data from the HPTN 071 (PopART) trial

Background

Transgender women have a disproportionately high HIV prevalence compared to cisgender women and men who have sex with men, which puts them at risk of HIV-related stigma (Baral SD et al., Lancet Infect Dis, 13;3, 2013). People whose gender identities are in tension with dominant social norms (including transgender women) often also experience gender identity-related stigma. There has been increasing attention to transgender people in HIV research and interventions. However, very little research has been done in sub-Saharan African countries.

Methods

We conducted a qualitative cohort study which included eight transfeminine and/or gender diverse women (four living with HIV) in Western Cape, South Africa, for a follow-up period of 12–18 months. Using a narrative analysis approach, we set out to understand how transfeminine and gender diverse participants in the cohort anticipated, experienced and internalised HIV stigma and gender identity stigma, and how these stigmas affected HIV service access.

Result

We found that participants reported anticipated, experienced, and internalised stigma relating both to their gender identity and to living with HIV. Participants reported inconsistent uptake of antiretroviral therapy (ART) services (including ART initiation and adherence) that they linked to stigma. We also found that gender diverse women and transfeminine women are challenged with other stigmatising social identities, like being a sex worker, drug user and/or a man (or assigned male sex at birth) who have sex with men (MSM). We use the terms ‘transfeminine’ and ‘gender diverse’ as terms that are inclusive of gender variant people who were all assigned male sex at birth and identify as women in some or all aspects of their lives. The persons in our study also showed gender identifications that were fluid and sometimes varied in different contexts and situations, therefore gender identity and sexual identity were often conflated for these individuals. Participants managed high levels of reported stigma by drawing on social support networks like families, friends and peers.

Conclusion

Our study provides exploratory work on how stigma may affect HIV services uptake amongst gender diverse women and transfeminine women in South Africa. We recommend future studies to further explore the unique HIV risks of gender diverse individuals.

Trial registration

DOH-27-0513-4253.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09942-5.

Public target interventions to reduce the inappropriate use of medicines or medical procedures: a systematic review

Background

An epidemic of health disorders can be triggered by a collective manifestation of inappropriate behaviors, usually systematically fueled by non-medical factors at the individual and/or societal levels. This study aimed to (1) landscape and assess the evidence on interventions that reduce inappropriate demand of medical resources (medicines or procedures) by triggering behavioral change among healthcare consumers, (2) map out intervention components that have been tried and tested, and (3) identify the “active ingredients” of behavior change interventions that were proven to be effective in containing epidemics of inappropriate use of medical resources.

Methods

For this systematic review, we searched MEDLINE, EMBASE, the Cochrane Library, and PsychINFO from the databases’ inceptions to May 2019, without language restrictions, for behavioral intervention studies. Interventions had to be empirically evaluated with a control group that demonstrated whether the effects of the campaign extended beyond trends occurring in the absence of the intervention. Outcomes of interest were reductions in inappropriate or non-essential use of medicines and/or medical procedures for clinical conditions that do not require them. Two reviewers independently screened titles, abstracts, and full text for inclusion and extracted data on study characteristics (e.g., study design), intervention development, implementation strategies, and effect size. Data extraction sheets were based on the checklist from the Cochrane Handbook for Systematic Reviews.

Results

Forty-three studies were included. The behavior change technique taxonomy v1 (BCTTv1), which contains 93 behavioral change techniques (BCTs), was used to characterize components of the interventions reported in the included studies. Of the 93 BCTs, 15 (16%) were identified within the descriptions of the selected studies targeting healthcare consumers. Interventions consisting of education messages, recommended behavior alternatives, and a supporting environment that incentivizes or encourages the adoption of a new behavior were more likely to be successful.

Conclusions

There is a continued tendency in research reporting that mainly stresses the effectiveness of interventions rather than the process of identifying and developing key components and the parameters within which they operate. Reporting “negative results” is likely as critical as reporting “active ingredients” and positive findings for implementation science. This review calls for a standardized approach to report intervention studies.

Trial registration

PROSPERO registration number CRD42019139537

Lifting lockdown policies: A critical moment for COVID-19 stigma

COVID-19 'lockdown' policies may have unintended consequences for individuals, households and country economies. Hence lockdown may be unsustainable despite the risk of a resurgence of new COVID-19 infections. The repeal and alteration of lockdown policies mark a symbolic transfer of responsibility for epidemic control from state to individual. This has the potential to catalyse fear, blame and judgement within and between populations. We draw on experience from the HIV pandemic to show that this will worsen during later phases of the pandemic if COVID-19 stigma increases, as we fear it could. We suggest policy recommendations for 'lockdown lifting' to limit COVID-19 stigma. We suggest three policy priorities to minimise potential increases in COVID-19 stigma: limit fear by strengthening risk communication, engage communities to reduce the emergence of blaming, and emphasise social justice to reduce judgement. 'Lockdown' policies cannot continue uninterrupted. However, lifting lockdown without unintended consequences may prove harder than establishing it. This period has the potential to see the emergence of fear, blame and judgement, intersecting with existing inequalities, as governments seek to share responsibility for preventing further Sars-Cov-2 transmission. As we have learned from HIV, it is critical that a wave of COVID-19 stigma is prevented from flourishing.

Will it work here? A realist approach to local decisions about implementing interventions evaluated as effective elsewhere

There is increasing interest in what evidence is needed to inform decisions about transporting interventions evaluated as effective to new settings. There has been less attention to how local decision-makers decide whether to implement such interventions immediately or subject to further evaluation. Using the example of school-based social and emotional learning, we consider this drawing on realist methods. We suggest decisions need to assess existing evaluations not merely in terms of whether the intervention was effective but also: how the intervention was implemented and what contextual factors affected this (drawing on process evaluation); and for whom the intervention was effective and through what mechanisms (drawing on mediation, moderation and qualitative comparative analyses from primary studies and/or systematic reviews). We contribute new insights to local needs assessments, suggesting that these should assess: the potential, capability, contribution and capacity present in the new setting for implementation; and whether similar 'aetiological mechanisms' underlie adverse outcomes locally as in previous evaluations. We recommend that where there is uncertainty concerning whether an intervention can feasibly be implemented this indicates the need for piloting of implementation. Where there is uncertainty concerning whether implementation of the intervention will trigger intended mechanisms, this suggests the need for a new effectiveness trial. Where there is uncertainty concerning whether intervention mechanisms, even if triggered, will generate the intended outcomes, this suggests that decision-makers may need to look to other types of intervention as being needed for their setting instead.

Directed and target focused multi-sectoral adolescent HIV prevention: Insights from implementation of the 'DREAMS Partnership' in rural South Africa

INTRODUCTION

The "DREAMS Partnership" promotes a multi-sectoral approach to reduce adolescent girls and young women's (AGYW) vulnerability to HIV in sub-Saharan Africa. Despite widespread calls to combine structural, behavioural and biomedical HIV prevention interventions, this has not been delivered at scale. In this commentary, we reflect on the two-year rollout of DREAMS in a high HIV incidence, rural and poor community in northern KwaZulu-Natal, South Africa to critically appraise the capacity for a centrally co-ordinated and AGYW-focused approach to combination HIV prevention to support sustainable development for adolescents.

DISCUSSION

DREAMS employed a directed target-focused approach in which local implementing partners were resourced to deliver defined packages to AGYW in selected geographical areas over two years. We argue that this approach, with high-level oversight by government and funders, enabled the rapid roll-out of ambitious multi-sectoral HIV prevention for AGYW. It was most successful at delivering multiple interventions for AGYW when it built on existing infrastructure and competencies, and/or allocated resources to address existing youth development concerns of the community. The approach would have been strengthened if it had included a mechanism to solicit and then respond to the concerns of young women, for example gender-related norms and how young women experience their sexuality, and if this listening was supported by versatility to adapt to the social context. In a context of high HIV vulnerability across all adolescents and youth, an over-emphasis on targeting specific groups, whether geographically or by risk profile, may have hampered acceptability and reach of the intervention. Absence of meaningful engagement of AGYW in the development, delivery and leadership of the intervention was a lost opportunity to achieve sustainable development goals among young people and shift gender-norms.

CONCLUSIONS

Centrally directed and target-focused scale-up of defined packages of HIV prevention across sectors was largely successful in reaching AGYW in this rural South African setting rapidly. However, to achieve sustainable and successful long-term youth development and transformation of gender-norms there is a need for greater adaptability, economic empowerment and meaningful engagement of AGYW in the development and delivery of interventions. Achieving this will require sustained commitment from government and funders.

Association between HIV stigma and antiretroviral therapy adherence among adults living with HIV: baseline findings from the HPTN 071 (PopART) trial in Zambia and South Africa

OBJECTIVES

Adherence to antiretroviral therapy (ART) leads to viral suppression for people living with HIV (PLHIV) and is critical for both individual health and reducing onward HIV transmission. HIV stigma is a risk factor that can undermine adherence. We explored the association between HIV stigma and self-reported ART adherence among PLHIV in 21 communities in the HPTN 071 (PopART) trial in Zambia and the Western Cape of South Africa.

METHODS

We conducted a cross-sectional analysis of baseline data collected between 2013 and 2015, before the roll-out of trial interventions. Questionnaires were conducted, and consenting participants provided a blood sample for HIV testing. Poor adherence was defined as self-report of not currently taking ART, missing pills over the previous 7 days or stopping treatment in the previous 12 months. Stigma was categorised into three domains: community, health setting and internalised stigma. Multivariable logistic regression was used for analysis.

RESULTS

Among 2020 PLHIV self-reporting ever taking ART, 1888 (93%) were included in multivariable analysis. Poor ART adherence was reported by 15.8% (n = 320) of participants, and 25.7% (n = 519) reported experiencing community stigma, 21.5% (n = 434) internalised stigma, and 5.7% (n = 152) health setting stigma. PLHIV who self-reported previous experiences of community and internalised stigma more commonly reported poor ART adherence than those who did not (aOR 1.63, 95% CI 1.21 -2.19, P = 0.001 and aOR 1.31, 95% CI 0.96-1.79, P = 0.09).

CONCLUSIONS

HIV stigma was associated with poor ART adherence. Roll-out of universal treatment will see an increasingly high proportion of PLHIV initiated on ART. Addressing HIV stigma could make an important contribution to supporting lifelong ART adherence.

Decisions to use antibiotics for upper respiratory tract infections across China: a large-scale cross-sectional survey among university students

OBJECTIVES

To investigate the decision-making process of Chinese university students with respect to antibiotic use for upper respiratory tract infections (URTIs).

DESIGN

A cross-sectional questionnaire study.

SETTING

The participants recruited from six universities across all Chinese regions from September to November 2015.

PARTICIPANTS

A total of 2834 university students sampled across six Chinese regions who self-reported experiencing symptoms of URTI within the past month completed the survey.

OUTCOME MEASURES

The prevalence of decisions for treatment and antibiotic use for URTIs as well as knowledge about antibiotic use were measured by a self-administrated questionnaire. Using regular and multinomial logistic regression a nd adapted health belief model, we identified and measured a number of variables as potential risk factors for antibiotic misuse behaviours in order to explain and predict people's treatment decisions and antibiotic use including knowledge, perceptions, access to antibiotics and cues to action.

RESULTS

Of the 2834 university students who self-diagnosed a URTI, 947 (33.4%) self-reported having taken antibiotics; among them, 462 (48.8%) used non-prescription antibiotics, which came principally from left-over prescriptions (29.0%) and over-the-counter purchases at retail pharmacies (67.3%). One in four who sought care pressured their doctors for antibiotics; all received them. Those who perceived greater severity of the disease, had access to antibiotics, perceived benefits of using antibiotics (for the common cold: adjusted OR (aOR)=2.55, 95% CI 1.93 to 3.38 or as anti-inflammatory drugs: aOR=1.35, 95% CI 1.12 to 1.63), and were cued to action (eg, seeing presence of fever: aOR=2.05, 95% CI 1.62 to 2.60 or self-diagnosing their current infection as severe: aOR=1.86, 95% CI 1.41 to 2.45), keeping antibiotics at home (aOR=2.27, 95% CI 1.83 to 2.81) and access to over-the-counter antibiotics (aOR=2.00, 95% CI 1.63 to 2.45), were more likely to misuse antibiotics.

CONCLUSIONS

Misconceptions of antibiotic efficacy and easy access to antibiotics-with or without a prescription-were associated with antibiotic misuse among Chinese university students, which calls for context-appropriate multifaceted interventions in order to effectively reduce antibiotic misuse.

Strengthening the scale-up and uptake of effective interventions for sex workers for population impact in Zimbabwe

Introduction

UNAIDS’ goal of ending AIDS by 2030 is unreachable without better targeting of testing, prevention and care. Female sex workers (FSW) in Zimbabwe are at high risk of HIV acquisition and transmission. Here, we report on collated programme and research data from Zimbabwe's national sex work programme. We also assess the potential for wider population impact of FSW programmes by modelling the impact on HIV incidence of eliminating transmission through FSW (i.e. calculate the population attributable fraction of incidence attributable to sex work).

Methods

Descriptive analyses of individual‐level programme data collected from FSW between 2009 and June 2018 are triangulated with data collected through 37 respondent driven sampling surveys from 19 sites in Zimbabwe 2011 to 2017. We describe programme coverage, uptake, retention and patterns of sex work behaviour and gaps in service provision. An individual‐level stochastic simulation model is used to reconstruct the epidemic and then the incidence compared with the counter‐factual trend in incidence from 2010 had transmission through sex work been eliminated from that date.

Results

Sisters has reached >67,000 FSW since 2009, increasing attendance as number of sites, programme staff and peer educators were increased. Over 57% of all FSW estimated to be working in Zimbabwe in 2017 (n = 40,000) attended the programme at least once. The proportion of young FSW reached has increased with introduction of the “Young Sisters programme.” There are no clear differences in pattern of sex work across settings. Almost all women report condom use with clients at last sex (95%); however, consistent condom use with clients in the last month varies from 52% to 95% by site. Knowledge of HIV‐positive status has increased from 48 to 78% between 2011 and 2016, as has prevalence of ART use among diagnosed women (29 to 67%). Although subject to uncertainty, modelling suggests that 70% (90% range: 32%, 93%) of all new infections in Zimbabwe from 2010 are directly or indirectly attributable to transmission via sex work.

Conclusions

It is feasible to increase coverage and impact of sex work programming through community‐led scale‐up of evidence‐based interventions. Eliminating transmission through commercial sex would likely have a substantial impact on new infections occurring more widely across Zimbabwe.

Assessing Bias in Population Size Estimates Among Hidden Populations When Using the Service Multiplier Method Combined With Respondent-Driven Sampling Surveys: Survey Study

BACKGROUND

Population size estimates (PSEs) for hidden populations at increased risk of HIV, including female sex workers (FSWs), are important to inform public health policy and resource allocation. The service multiplier method (SMM) is commonly used to estimate the sizes of hidden populations. We used this method to obtain PSEs for FSWs at 9 sites in Zimbabwe and explored methods for assessing potential biases that could arise in using this approach.

OBJECTIVE

This study aimed to guide the assessment of biases that arise when estimating the population sizes of hidden populations using the SMM combined with respondent-driven sampling (RDS) surveys.

METHODS

We conducted RDS surveys at 9 sites in late 2013, where the Sisters with a Voice program (the program), which collects program visit data of FSWs, was also present. Using the SMM, we obtained PSEs for FSWs at each site by dividing the number of FSWs who attended the program, based on program records, by the RDS-II weighted proportion of FSWs who reported attending this program in the previous 6 months in the RDS surveys. Both the RDS weighting and SMM make a number of assumptions, potentially leading to biases if the assumptions are not met. To test these assumptions, we used convergence and bottleneck plots to assess seed dependence of RDS-II proportion estimates, chi-square tests to assess if there was an association between the characteristics of FSWs and their knowledge of program existence, and logistic regression to compare the characteristics of FSWs attending the program with those recruited to RDS surveys.

RESULTS

The PSEs ranged from 194 (95% CI 62-325) to 805 (95% CI 456-1142) across 9 sites from May to November 2013. The 95% CIs for the majority of sites were wide. In some sites, the RDS-II proportion of women who reported program use in the RDS surveys may have been influenced by the characteristics of selected seeds, and we also observed bottlenecks in some sites. There was no evidence of association between characteristics of FSWs and knowledge of program existence, and in the majority of sites, there was no evidence that the characteristics of the populations differed between RDS and program data.

CONCLUSIONS

We used a series of rigorous methods to explore potential biases in our PSEs. We were able to identify the biases and their potential direction, but we could not determine the ultimate direction of these biases in our PSEs. We have evidence that the PSEs in most sites may be biased and a suggestion that the bias is toward underestimation, and this should be considered if the PSEs are to be used. These tests for bias should be included when undertaking population size estimation using the SMM combined with RDS surveys.

Condom use among young women who sell sex in Zimbabwe: a prevention cascade analysis to identify gaps in HIV prevention programming

INTRODUCTION

Adolescent girls and young women (AGYW), including those who sell sex in sub-Saharan Africa, are especially vulnerable to HIV. Reaching them with effective prevention is a programmatic priority. The HIV prevention cascade can be used to track intervention coverage, and identify gaps and opportunities for programme strengthening. The aim of this study was to characterise gaps in condom use and identify reasons underlying these gaps among young women who sell sex (YWSS) in Zimbabwe using data from enrolment into an impact evaluation of the DREAMS programme. DREAMS provided a package of biomedical, social and economic interventions to AGYW aged 10 to 24 with the aim of reducing HIV incidence.

METHODS

In 2017, we recruited YWSS aged 18 to 24 using respondent-driven sampling in six sites across Zimbabwe. We measured knowledge about efficacy of, access to, and effective (consistent) use of condoms with the most recent three sexual partners, separately by whether YWSS self-identified as female sex workers (FSW) or not. Among YWSS without knowledge about efficacy of, not having access to, and not effectively using condoms, we described the potential reasons underlying the gaps in the condom cascade. To identify socio-demographic characteristics associated with effective condom use, we used logistic regression modelling. All analyses were RDS-II weighted and restricted to YWSS testing HIV-negative at enrolment.

RESULTS

We enrolled 2431 YWSS. Among 1842 (76%) YWSS testing HIV-negative, 66% (n = 1221) self-identified as FSW. 89% of HIV-negative YWSS demonstrated knowledge about efficacy of condoms, 80% reported access to condoms and 58% reported using condoms consistently with the three most recent sexual partners. Knowledge about efficacy of and effective use of condoms was similar regardless of whether or not YWSS self-identified as FSW, but YWSS self-identifying as FSW reported better access to condoms compared to those who did not (87% vs 68%; age- and site-adjusted (adjOR) = 2.69; 95% CI: 2.01 to 3.60; p < 0.001). Women who reported experiencing sexual violence in the past year and common mental disorder in the past week were less likely to use condoms consistently (43% vs. 60%; adjOR = 0.49; 95% CI: 0.35 to 0.68; p < 0.001) and (51% vs. 61%; adjOR = 0.76; 95% CI: 0.60 to 0.97; p = 0.029), respectively.

CONCLUSIONS

Despite high knowledge about efficacy of and access to condoms, there remain large gaps in self-reported consistent condom use among YWSS. Addressing the structural determinants of YWSS' inconsistent condom use, including violence, could reduce this gap. YWSS who do not self-identify as FSW have less access to condoms and may require additional programmatic intervention.

Enhancing national prevention and treatment services for sex workers in Zimbabwe: a process evaluation of the SAPPH-IRe trial

Targeted HIV interventions for female sex workers (FSW) combine biomedical technologies, behavioural change and community mobilization with the aim of empowering FSW and improving prevention and treatment. Understanding how to deliver combined interventions most effectively in sub-Saharan Africa is critical to the HIV response. The Sisters' Antiretroviral Programme for Prevention of HIV: an Integrated Response (SAPPH-Ire) randomized controlled trial in Zimbabwe tested an intervention to improve FSW engagement with HIV services. After 2 years, results of the trial showed no significant difference between study arms in proportion of FSW with HIV viral load ≥1000 copies/ml as steep declines occurred in both. We present the results of a process evaluation aiming to track the intervention's implementation, assess its feasibility and accessibility, and situate trial results within the national HIV policy context. We conducted a mixed methods study using data from routine programme statistics, qualitative interviews with participants and respondent driven surveys. The intervention proved feasible to deliver and was acceptable to FSW and providers. Intervention clinics saw more new FSW (4082 vs 2754), performed over twice as many HIV tests (2606 vs 1151) and nearly double the number of women were diagnosed with HIV (1042 vs 546). Community mobilization meetings in intervention sites also attracted higher numbers. We identified some gaps in programme fidelity: offering pre-exposure prophylaxis took time to engage FSW, viral load monitoring was not performed, and ratio of peer educators to FSW was lower than intended. During the trial, reaching FSW with HIV testing and treatment became a national priority, leading to increasing attendance at both intervention and control clinics. Throughout Zimbabwe, antiretroviral therapy coverage improved and HIV-stigma declined. Zimbabwe's changing HIV policy context appeared to contribute to positive improvements across the HIV care continuum for all FSW over the course of the trial. More intense community-based interventions for FSW may be needed to make further gains.

Exploring the Association Between Mobility and Access to HIV Services Among Female Sex Workers in Zimbabwe

Female sex workers (FSW) face structural barriers to HIV-service access, however the effect of their mobility is uncertain. Using cross-sectional data from 2839 FSW in 14 sites in Zimbabwe, we explored the association between mobility (number of trips, distance, duration) in the past 12 months and five HIV-service-access outcomes: exposure to community mobilisation, clinic attendance, HIV testing, antiretroviral treatment initiation, and viral suppression (< 1000 copies per mL). We used modified-Poisson regression, and natural-effects models to estimate how the effect of trip frequency was mediated by distance and duration away. Each additional trip in 12 months was associated with increased community-mobilisation-event attendance (adjusted RR 1.08, 95% CI 1.04-1.12) and attending clinic two-or-more times (adjusted RR 1.02, 95% CI 1.00-1.05). There was little evidence of any other associations, or of mediation. Our findings are consistent with literature that found the effects of mobility to vary by context and outcome. This is the first study to consider many FSW-mobility and HIV-service-access measures together. Future research on mobility and health-related behaviour should use a spectrum of measures.

Stigma and Judgment Toward People Living with HIV and Key Population Groups Among Three Cadres of Health Workers in South Africa and Zambia: Analysis of Data from the HPTN 071 (PopART) Trial

Stigma and judgment by health workers toward people living with HIV (PLHIV) and key populations can undermine the uptake of HIV services. In 2014, we recruited health workers delivering HIV services from 21 urban communities in South Africa and Zambia participating in the first year of the HPTN 071 (PopART) cluster-randomized trial. We analyzed self-reported levels of stigma and judgment toward (1) PLHIV, (2) women who sell sex, (3) men who have sex with men (MSM), and (4) young women who become pregnant before marriage. Using logistic regression, we compared responses between three health worker cadres and explored risk factors for stigmatizing attitudes. Highest levels of stigma and judgment were in relation to women who sell sex and MSM, especially in Zambia. Heath workers did not generally think that clients should be denied services, although this was reported slightly more commonly by community health workers. Higher education levels were associated with lower judgmental beliefs, whereas higher perceptions of coworker stigmatizing behaviors toward PLHIV and each key population were associated with holding judgmental beliefs. Training experience was not associated with judgmental attitudes for any of the key populations. Our findings confirm a high prevalence of judgmental attitudes toward key population groups but lower levels in relation to PLHIV, among all cadres of health workers in both countries. Planning and implementing targeted stigma reduction interventions within health settings are critical to meet the needs of vulnerable populations that face more stigmatizing attitudes from health workers.

Development of parallel measures to assess HIV stigma and discrimination among people living with HIV, community members and health workers in the HPTN 071 (PopART) trial in Zambia and South Africa

INTRODUCTION

Integrating standardized measures of HIV stigma and discrimination into research studies of emerging HIV prevention approaches could enhance uptake and retention of these approaches, and care and treatment for people living with HIV (PLHIV), by informing stigma mitigation strategies. We sought to develop a succinct set of measures to capture key domains of stigma for use in research on HIV prevention technologies.

METHODS

From 2013 to 2015, we collected baseline data on HIV stigma from three populations (PLHIV (N = 4053), community members (N = 5782) and health workers (N = 1560)) in 21 study communities in South Africa and Zambia participating in the HPTN 071 (PopART) cluster-randomized trial. Forty questions were adapted from a harmonized set of measures developed in a consultative, global process. Informed by theory and factor analysis, we developed seven scales, with values ranging from 0 to 3, based on a 4-point agreement Likert, and calculated means to assess different aspects of stigma. Higher means reflected more stigma. We developed two measures capturing percentages of PLHIV who reported experiencing any stigma in communities or healthcare settings in the past 12 months. We validated our measures by examining reliability using Cronbach's alpha and comparing the distribution of responses across characteristics previously associated with HIV stigma.

RESULTS

Thirty-five questions ultimately contributed to seven scales and two experience measures. All scales demonstrated acceptable to very good internal consistency. Among PLHIV, a scale captured internalized stigma, and experience measures demonstrated that 22.0% of PLHIV experienced stigma in the community and 7.1% in healthcare settings. Three scales for community members assessed fear and judgement, perceived stigma in the community and perceived stigma in healthcare settings. Similarly, health worker scales assessed fear and judgement, perceived stigma in the community and perceived co-worker stigma in healthcare settings. A higher proportion of community members and health workers reported perceived stigma than the proportion of PLHIV who reported experiences of stigma.

CONCLUSIONS

We developed novel, valid measures that allowed for triangulation of HIV stigma across three populations in a large-scale study. Such comparisons will illuminate how stigma influences and is influenced by programmatic changes to HIV service delivery over time.

HIV risk among young women who sell sex by whether they identify as sex workers: analysis of respondent-driven sampling surveys, Zimbabwe, 2017

INTRODUCTION

Across sub-Saharan Africa, selling sex puts young women at high risk of HIV. Some young women who sell sex (YWSS) may self-identify as sex workers, while others may not, having implications for how to reach them with HIV prevention. We describe characteristics, sexual behaviours and health service use of YWSS in Zimbabwe, comparing women who identified as female sex workers (FSW) and women who did not (non-identifying-YWSS), and explore factors associated with HIV infection.

METHODS

We analysed data from respondent-driven sampling (RDS) surveys among YWSS aged 18 to 24 implemented in six sites in Zimbabwe from April to July 2017. RDS was used to enrol YWSS into an impact evaluation of the multi-country DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) Partnership, which provides comprehensive HIV prevention programming to adolescent girls and young women. Women completed an interviewer-administered questionnaire and were offered HIV testing services. We used logistic regression (RDS-II-weighted, normalized by site) to identify factors associated with prevalent HIV infection.

RESULTS

Forty-four seeds recruited 2387 YWSS. RDS-adjusted HIV prevalence was 24%; 67% of women identified as FSW. FSW were older and had lower educational attainment than non-identifying-YWSS. While 40% of FSW reported 10+ clients in the previous month, 9% of non-identifying-YWSS did so. FSW were more likely to have accessed HIV-related services, including HIV testing in the last six months (FSW: 70%; non-identifying-YWSS: 60%). Over half of all YWSS described selling sex as their main financial support (FSW: 88%; non-identifying YWSS: 54%). Increasing age, lower educational attainment, younger age of first selling sex and higher number of clients in the previous month were associated with prevalent HIV.

CONCLUSIONS

YWSS in Zimbabwe have a high prevalence of HIV, reported high numbers of sexual partners and depend financially on selling sex. Non-identifying-YWSS differed socio-demographically to FSW, yet factors associated with HIV risk were similar for all women. Women not identifying as FSW were less likely to access services, suggesting they should be prioritized for HIV prevention. Network-based recruitment may enhance their inclusion in programmes, like DREAMS, which aim to reach young women at highest-risk with comprehensive health, HIV prevention and social protection services.

Outcomes of Patients Lost to Follow-up in African Antiretroviral Therapy Programs: Individual Patient Data Meta-analysis

Background

Low retention on combination antiretroviral therapy (cART) has emerged as a threat to the Joint United Nations Programme on human immunodeficiency virus (HIV)/AIDS (UNAIDS) 90-90-90 targets. We examined outcomes of patients who started cART but were subsequently lost to follow-up (LTFU) in African treatment programs.

Methods

This was a systematic review and individual patient data meta-analysis of studies that traced patients who were LTFU. Outcomes were analyzed using cumulative incidence functions and proportional hazards models for the competing risks of (i) death, (ii) alive but stopped cART, (iii) silent transfer to other clinics, and (iv) retention on cART.

Results

Nine studies contributed data on 7377 patients who started cART and were subsequently LTFU in sub-Saharan Africa. The median CD4 count at the start of cART was 129 cells/μL. At 4 years after the last clinic visit, 21.8% (95% confidence interval [CI], 20.8%-22.7%) were known to have died, 22.6% (95% CI, 21.6%-23.6%) were alive but had stopped cART, 14.8% (95% CI, 14.0%-15.6%) had transferred to another clinic, 9.2% (95% CI, 8.5%-9.8%) were retained on cART, and 31.6% (95% CI, 30.6%-32.7%) could not been found. Mortality was associated with male sex, more advanced disease, and shorter cART duration; stopping cART with less advanced disease andlonger cART duration; and silent transfer with female sex and less advanced disease.

Conclusions

Mortality in patients LTFU must be considered for unbiased assessments of program outcomes and UNAIDS targets in sub-Saharan Africa. Immediate start of cART and early tracing of patients LTFU should be priorities.

Challenges and opportunities in evaluating programmes incorporating human-centred design: lessons learnt from the evaluation of Adolescents 360

Adolescents 360 (A360) is a four-year initiative (2016-2020) to increase 15-19-year-old girls' use of modern contraception in Nigeria, Ethiopia and Tanzania. The innovative A360 approach is led by human-centred design (HCD), combined with social marketing, developmental neuroscience, public health, sociocultural anthropology and youth engagement 'lenses', and aims to create context-specific, youth-driven solutions that respond to the needs of adolescent girls. The A360 external evaluation includes a process evaluation, quasi-experimental outcome evaluation, and a cost-effectiveness study. We reflect on evaluation opportunities and challenges associated with measuring the application and impact of this novel HCD-led design approach. For the process evaluation, participant observations were key to capturing the depth of the fast-paced, highly-iterative HCD process, and to understand decision-making within the design process. The evaluation team had to be flexible and align closely with the work plan of the implementers. The HCD process meant that key information such as intervention components, settings, and eligible populations were unclear and changed over outcome evaluation and cost-effectiveness protocol development. This resulted in a more time-consuming and resource-intensive study design process. As much time and resources went into the creation of a new design approach, separating one-off "creation" costs versus those costs associated with actually implementing the programme was challenging. Opportunities included the potential to inform programmatic decision-making in real-time to ensure that interventions adequately met the contextualized needs in targeted areas. Robust evaluation of interventions designed using HCD, a promising and increasingly popular approach, is warranted yet challenging. Future HCD-based initiatives should consider a phased evaluation, focusing initially on programme theory refinement and process evaluation, and then, when the intervention program details are clearer, following with outcome evaluation and cost-effectiveness analysis. A phased approach would delay the availability of evaluation findings but would allow for a more appropriate and tailored evaluation design.

90-90-90 by 2020? Estimation and projection of the adult HIV epidemic and ART programme in Zimbabwe - 2017 to 2020

INTRODUCTION

The 90-90-90 targets set by the United Nations aspire to 73% of people living with HIV (PLHIV) being virally suppressed by 2020. Using the HIV Synthesis Model, we aim to mimic the epidemic in Zimbabwe and make projections to assess whether Zimbabwe is on track to meet the 90-90-90 targets and assess whether recently proposed UNAIDS HIV transition metrics are likely to be met.

METHODS

We used an approximate Bayesian computation approach to identify model parameter values which result in model outputs consistent with observed data, evaluated using a calibration score. These parameter values were then used to make projections to 2020 to compare with the 90-90-90 targets and other key indicators. We also calculated HIV transition metrics proposed by UNAIDS (percentage reduction in new HIV infections and AIDS-related mortality from 2010 to 2020, absolute rate of new infections and AIDS-related mortality, incidence-mortality ratio and incidence-prevalence ratios).

RESULTS

After calibration, there was general agreement between modelled and observed data. The median predicted outcomes in 2020 were: proportion of PLHIV (aged 15 to 65) diagnosed 0.91 (90% uncertainty range 0.87, 0.94) (0.84 men, 0.95 women); of those diagnosed, proportion on treatment 0.92 (0.90, 0.93); of those receiving treatment, proportion with viral suppression 0.86 (0.81, 0.91). This results in 72% of PLHIV having viral suppression in 2020. We estimated a percentage reduction of 36.5% (13.7% increase to 67.4% reduction) in new infections from 2010 to 2020, and of 30.4% (9.7% increase to 56.6% reduction) in AIDS-related mortality (UNAIDS target 75%). The modelled absolute rates of HIV incidence and AIDS-related mortality in 2020 were 5.48 (2.26, 9.24) and 1.93 (1.31, 2.71) per 1000 person-years respectively. The modelled incidence-mortality ratio and incidence-prevalence ratios in 2020 were 1.05 (0.46, 1.66) and 0.009 (0.004, 0.013) respectively.

CONCLUSIONS

Our model was able to produce outputs that are simultaneously consistent with an array of observed data and predicted that while the 90-90-90 targets are within reach in Zimbabwe, increased efforts are required in diagnosing men in particular. Calculation of the HIV transition metrics suggest increased efforts are needed to bring the HIV epidemic under control.

Effect of Universal Testing and Treatment on HIV Incidence - HPTN 071 (PopART)

BACKGROUND

A universal testing and treatment strategy is a potential approach to reduce the incidence of human immunodeficiency virus (HIV) infection, yet previous trial results are inconsistent.

METHODS

In the HPTN 071 (PopART) community-randomized trial conducted from 2013 through 2018, we randomly assigned 21 communities in Zambia and South Africa (total population, approximately 1 million) to group A (combination prevention intervention with universal antiretroviral therapy [ART]), group B (the prevention intervention with ART provided according to local guidelines [universal since 2016]), or group C (standard care). The prevention intervention included home-based HIV testing delivered by community workers, who also supported linkage to HIV care and ART adherence. The primary outcome, HIV incidence between months 12 and 36, was measured in a population cohort of approximately 2000 randomly sampled adults (18 to 44 years of age) per community. Viral suppression (<400 copies of HIV RNA per milliliter) was assessed in all HIV-positive participants at 24 months.

RESULTS

The population cohort included 48,301 participants. Baseline HIV prevalence was 21% or 22% in each group. Between months 12 and 36, a total of 553 new HIV infections were observed during 39,702 person-years (1.4 per 100 person-years; women, 1.7; men, 0.8). The adjusted rate ratio for group A as compared with group C was 0.93 (95% confidence interval [CI], 0.74 to 1.18; P = 0.51) and for group B as compared with group C was 0.70 (95% CI, 0.55 to 0.88; P = 0.006). The percentage of HIV-positive participants with viral suppression at 24 months was 71.9% in group A, 67.5% in group B, and 60.2% in group C. The estimated percentage of HIV-positive adults in the community who were receiving ART at 36 months was 81% in group A and 80% in group B.

CONCLUSIONS

A combination prevention intervention with ART provided according to local guidelines resulted in a 30% lower incidence of HIV infection than standard care. The lack of effect with universal ART was unanticipated and not consistent with the data on viral suppression. In this trial setting, universal testing and treatment reduced the population-level incidence of HIV infection. (Funded by the National Institute of Allergy and Infectious Diseases and others; HPTN 071 [PopArt] ClinicalTrials.gov number, NCT01900977.).

Friendships Among Young South African Women, Sexual Behaviours and Connections to Sexual Partners (HPTN 068)

Friends could be influential on young women's sexual health via influences on sexual behaviours and as connections to sexual partners, but are understudied in sub-Saharan Africa. We cross-sectionally surveyed 2326 13-20 year-old young women eligible for grades 8-11 in rural South Africa about their sexual behaviour and up to three sexual partners. Participants each described five specific but unidentified friends and the relationships between them in an 'egocentric' network analysis design. We used logistic regression to investigate associations between friendship characteristics and participants' reports of ever having had sex (n = 2326) and recent condom use (n = 457). We used linear regression with random effects by participant to investigate friendship characteristics and age differences with sexual partners (n = 633 participants, 1051 partners). We found that it was common for friends to introduce young women to those who later became sexual partners, and having older friends was associated with having older sexual partners, (increase of 0.37 years per friend at least 1 year older, 95% CI 0.21-0.52, adjusted). Young women were more likely to report ever having had sex when more friends were perceived to be sexually active (adjusted OR 1.85, 95% CI 1.72-2.01 per friend) and when they discussed sex, condoms and HIV with friends. Perception of friends' condom use was not associated with participants' reported condom use. While this study is preliminary and unique in this population and further research should be conducted, social connections between friends and sexual partners and perceptions of friend sexual behaviours could be considered in the design of sexual health interventions for young women in South Africa.

Changes Over Time in HIV Prevalence and Sexual Behaviour Among Young Female Sex-Workers in 14 Sites in Zimbabwe, 2013-2016

Young female sex-workers (FSW) aged 18–24 are at high risk of HIV due to high numbers of sexual partners, difficulty negotiating condom use, increased risk of gender-based violence, and limited access to services. Here we describe changes in sexual behaviours among young FSW across Zimbabwe between 2013 and 2016, and risk factors for prevalent HIV in 2013 and 2016. FSW ≥ 18 years were recruited using respondent-driven sampling in 14 sites across Zimbabwe in 2013 and 2016 as part of the SAPPH-IRe trial. We collected data on socio-demographics and sexual behaviour and offered HIV testing. Statistical analyses were RDS-II weighted. Characteristics of young FSW aged 18–24 were described, stratified by age. Logistic regression was used to assess difference in sexual behaviours by reported HIV status between 2013 and 2016, and to explore associations with prevalent HIV in 2013 and 2016. 656 young FSW were recruited in 2013 and 503 in 2016. Characteristics of young FSW were similar across both surveys. HIV prevalence was similar at both time points (35% vs 36%) and rose steeply with age. Compared to young FSW in 2013, reported condom-less sex with a steady partner and condom-less sex with clients was higher in 2016 among women self-reporting HIV negative status (OR = 6.41; 95%CI: 3.40-12.09; P<0.001) and (OR = 1.69; 95%CI: 1.14-2.51, P = 0.008), respectively, but not among young FSW self-reporting HIV positive status (OR = 2.35; 95%CI: 0.57-9.76; P = 0.236) and (OR = 1.87; 95%CI: 0.74-4.74; P = 0.186). After adjusting for age in 2016, young FSW who had ever been married had increased odds of testing HIV positive (OR = 1.88; 95% CI 1.04–3.39; P = 0.036) compared with those who had never married. Young FSW who completed secondary education or higher were less likely to test HIV positive (OR = 0.41; 95% CI 0.20–0.83; P = 0.012) compared with those with primary education or less. Young FSW remain at very high risk of HIV. Strategies to identify young FSW when they first start selling and refer them into services that address their economic, social and sexual vulnerabilities are critical.