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

Recent infection testing to inform HIV prevention responses and surveillance in a programme context: lessons from implementation within a nationally scaled female sex worker programme in Zimbabwe

INTRODUCTION

In the context of key population HIV testing programmes, identifying new HIV acquisitions, tracking incidence, and responding with prevention and treatment interventions will be critical for achieving HIV epidemic control. Laboratory tests for recently acquired HIV used as part of a "recent infection testing algorithm" (RITA), offer a potential tool to support this work. We implemented a RITA for female sex workers (FSWs) in Zimbabwe to explore opportunities and programmatic benefits.

METHODS

Between October 2021 and January 2023, recency testing was offered to FSWs attending the Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe's key populations programme. Dried blood spot (DBS) samples were taken at 86 clinic sites across 10 provinces and Laboratory LAg Avidity and viral load testing conducted. RITA results were analysed and linked to programme data to explore geographical differences and calculate HIV incidence. We describe concurrent efforts in HIV testing for social (social network testing [SNT]) and sexual (index case testing [ICT]) contacts of those testing HIV positive.

RESULTS

Among 24,976 FSWs tested at programme sites, 9.5% (2363/24,976) were confirmed HIV positive. We enrolled 55.5% (1311/2363) of eligible HIV-positive FSWs to our study, of whom 11.7% (153/1311) were identified as having recently acquired HIV. It took a median of 37 days (IQR 20-67) for samples to be processed. Enrolment rates varied between provinces but the proportion of recently acquired HIV was similar (range: 18.4% to 4.0%). Overall HIV incidence was 3.4 (95% CI 2.7-4.0) per 100py. Where results could be linked to routinely collected data, we found no evidence of a difference in test-positivity between the ICT and SNT contacts of those with recently acquired compared to those with long-term HIV.

CONCLUSIONS

Implementation of a RITA was possible within a nationally scaled sex worker programme, and while challenging to implement, can provide an understanding of transmission dynamics and HIV incidence in this context. Sub-optimal recruitment and data linkage limited the interpretation of our findings and opportunities for strategic gains though focusing on HIV prevention efforts.

From conceptualising to modelling structural determinants and interventions in HIV transmission dynamics models: a scoping review and methodological framework for evidence-based analyses

BACKGROUND

Including structural determinants (e.g. criminalisation, stigma, inequitable gender norms) in dynamic HIV transmission models is important to help quantify their population-level impacts and guide implementation of effective interventions that reduce the burden of HIV and inequalities thereof. However, evidence-based modelling of structural determinants is challenging partly due to a limited understanding of their causal pathways and few empirical estimates of their effects on HIV acquisition and transmission.

METHODS

We conducted a scoping review of dynamic HIV transmission modelling studies that evaluated the impacts of structural determinants, published up to August 28, 2023, using Ovid Embase and Medline online databases. We appraised studies on how models represented exposure to structural determinants and causal pathways. Building on this, we developed a new methodological framework and recommendations to support the incorporation of structural determinants in transmission dynamics models and their analyses. We discuss the data and analyses that could strengthen the evidence used to inform these models.

RESULTS

We identified 17 HIV modelling studies that represented structural determinants and/or interventions, including incarceration of people who inject drugs (number of studies [n] = 5), violence against women (n = 3), HIV stigma (n = 1), and housing instability (n = 1), among others (n = 7). Most studies (n = 10) modelled exposures dynamically. Almost half (8/17 studies) represented multiple exposure histories (e.g. current, recent, non-recent exposure). Structural determinants were often assumed to influence HIV indirectly by influencing mediators such as contact patterns, condom use, and antiretroviral therapy use. However, causal pathways' assumptions were sometimes simple, with few mediators explicitly represented in the model, and largely based on cross-sectional associations. Although most studies calibrated models using HIV epidemiological data, less than half (7/17) also fitted or cross-validated to data on the prevalence, frequency, or effects of exposure to structural determinants.

CONCLUSIONS

Mathematical models can play a crucial role in elucidating the population-level impacts of structural determinants and interventions on HIV. We recommend the next generation of models reflect exposure to structural determinants dynamically and mechanistically, and reproduce the key causal pathways, based on longitudinal evidence of links between structural determinants, mediators, and HIV. This would improve the validity and usefulness of predictions of the impacts of structural determinants and interventions.

Using a Programme Science approach to substantially reduce the risk of HIV transmission and acquisition in sex transactions among female sex workers in Zimbabwe

INTRODUCTION

We used a Programme Science platform, to generate evidence to support the implementation of programmes for sex workers in Africa. Female sex workers are estimated to make up 1.6% (1.3%-1.8%) of the population of women aged 15-49 years in Zimbabwe. We highlight how programme science can be used to help distinguish between when, where and with whom programmes need to be implemented and discuss two case studies that exemplify implementing better (Case study 1 (1 June 2019-30 June 2021) Optimizing implementation of a risk differentiated microplanning intervention) and implementing differently (Case study 2 (1 October 2016-30 September 2022) Reorientating implementation of DREAMS for young women selling sex).

METHODS

Zimbabwe's nationally scaled programme for sex workers was established in 2009 in partnership with sex workers to provide comprehensive services for sex workers and generate evidence for programme design, implementation and scale up. Since inception, comprehensive data have been collected from all sex workers seeking services. As the scope of service provision has expanded so has the scope of data collection and analysis. At enrolment, sex workers are assigned an alphanumeric unique identifier which links consultations within and across programme sites. We conduct descriptive analyses of the Key Population (KP) programme data to guide programme implementation and redesign, embedding programmatic qualitative enquiry as required.

RESULTS

Two case studies describing different approaches to programme optimization are presented. In the first, an optimization exercise was used to strengthen programme implementation ensuring that the KP programme got back on track after SARS-COV-2. In the second, an in-depth review of research and programme data led to a re-orientation of the DREAMS programme to ensure that young women at the highest risk of HIV acquisition were enrolled and had access to DREAMS social support interventions in turn strengthening their uptake of HIV prevention.

CONCLUSIONS

Optimizing and sustaining HIV care and treatment programmes requires effective delivery with sufficient scale and intensity for population impact. Our programme science approach guided the scale up of the KP programme in Zimbabwe, providing evidence to support strategy, implementation and ongoing management, and importantly helping us distinguish between when we needed to just implement, implement better or implement differently.

Temporal trends in, and risk factors for, HIV seroconversion among female sex workers accessing Zimbabwe's national sex worker programme, 2009-19: a retrospective cohort analysis of routinely collected HIV testing data

BACKGROUND

The frequency of new HIV infections among female sex workers in sub-Saharan Africa is poorly understood. We used routinely collected data that enable unique identification of repeat HIV testers to assess temporal trends in seroconversion and identify associated risk factors for female sex workers accessing Sisters with a Voice, Zimbabwe's national sex worker programme.

METHODS

We pooled HIV testing data gathered between Sept 15, 2009, and Dec 31, 2019, from 36 Sisters programme sites in Zimbabwe. We included female sex workers aged 16 years or older with an HIV-negative test and at least one subsequent programme test. We calculated HIV seroconversion rates (using the midpoint between the HIV-positive test and the last negative test as the seroconversion date) and estimated rate ratios to compare 2-year periods by using Poisson regression, with robust SEs to account for clustering by site and adjusting for age and testing frequency to assess temporal trends. We did sensitivity analyses to explore assumptions about seroconversion dates and the effects of variation in follow-up time on our conclusions.

FINDINGS

Our analysis included data for 6665 female sex workers, 441 (7%) of whom seroconverted. The overall seroconversion rate was 3·8 (95% CI 3·4-4·2) per 100 person-years at risk. Seroconversion rates fell with time since first negative HIV test. After adjustment, there was evidence of a decrease in seroconversion rates from 2009 to 2019 (p=0·0053). In adjusted analyses, being younger than 25 years, and having a sexually transmitted infection diagnosis at a previous visit, were significantly associated with increased seroconversion rates. Our findings were mostly robust to sensitivity analyses, but when 1 month before an HIV-positive test was used as the seroconversion date, seroconversion rates no longer fell with time.

INTERPRETATION

We identified high rates of seroconversion shortly after linkage to programme services, which emphasises the need to strengthen HIV prevention programmes from first contact with female sex workers in Zimbabwe. New infections among female sex workers remain challenging to measure, but longitudinal analysis of routine testing data can provide valuable insights into seroconversion rates and associated risk factors.

FUNDING

UN Population Fund, Deutsche Gesellschaft für Internationale Zusammenarbeit, the Bill & Melinda Gates Foundation, The Global Fund to Fight AIDS, Tuberculosis and Malaria, US President's Emergency Plan for AIDS Relief, US Agency for International Development, and the Elton John AIDS Foundation.

'I was in need of somewhere to release my hurt:' Addressing the mental health of vulnerable adolescent mothers in Harare, Zimbabwe, through self-help groups

Background

Adolescents experiencing multiple vulnerabilities, including poverty, curtailed education, transactional sex and early childbearing, are at risk of poor mental health. In Zimbabwe, girls who are pregnant or new mothers and involved in selling sex struggle to cope with the combined pressures of parenthood, financial insecurity, and social stigma. A pilot intervention brought such girls together into self-help groups to increase peer support, resources and skills.

Objective

This study aimed to explore whether and how participation in a self-help group intervention affected vulnerable young mothers’ experiences and perceptions of mental health stressors.

Methods

Self-help groups received 12 participatory sessions over 6 months. Eighteen semi-structured interviews and three focus group discussions were held with participants and drop-outs. Before and after the intervention, participants completed the locally validated 14-item Shona Symptom Questionnaire tool to indicate the probable prevalence of common mental health disorders.

Results

Adolescent girls described mutually reinforcing stressors in their lives and reported low self-esteem and anxiety. Key themes emerging from qualitative data centred around girls’ struggles with adverse life events, the burden of new motherhood, social isolation related to sex work and self-help groups as a source of hope. Participants joined groups to obtain support and felt their mental well-being improved due to new social networks, feelings of solidarity with peers, and increased confidence for positive action, that is, seeking health services for themselves and their babies. Prior to enrolment 16% showed signs of possible common mental disorders falling to 2% at follow-up.

Conclusions

Participants believed involvement in interactive self-help groups improved their mental health by strengthening peer support and engendering hope for the future. Although reduced mental distress cannot be attributed to the programme, the pilot intervention offers a low-cost approach that could be rigorously tested and adapted to a wide range of community settings.

Strategies to Identify and Reach Young Women Who Sell Sex With HIV Prevention and Care Services: Lessons Learnt From the Implementation of DREAMS Services in Two Cities in Zimbabwe

BACKGROUND

Young women who sell sex (YWSS), are underserved by available HIV prevention and care services. The Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) Partnership aimed to reduce the risk of HIV acquisition among vulnerable populations of adolescent girls and young women, including YWSS, in 10 sub-Saharan African countries. We describe 2 methods, respondent-driven sampling (RDS) and peer outreach, used to refer YWSS for DREAMS services in Zimbabwe, and compare the characteristics and engagement of YWSS referred to these services by each method. We hypothesized that RDS would identify YWSS at higher risk of HIV and those who were less engaged with HIV prevention and care services than peer outreach.

OBJECTIVE

We aimed to compare respondent-driven sampling and peer outreach in recruiting and referring high-risk populations for HIV prevention and care services.

METHODS

We used RDS, a sampling method designed to reach a representative sample of the network of key populations, and peer outreach, a programmatic approach to identify, reach, and refer YWSS for DREAMS between April and July 2017, and January 2017 and July 2018, respectively, in 2 cities in Zimbabwe. For RDS, we conducted detailed mapping to understand sex work typology and geography, and then purposively selected 10 "seed" participants in each city to initiate RDS. For peer outreach, we initiated recruitment through 18 trained and age-matched peer educators using youth-tailored community mobilization. We described the characteristics and service engagement of YWSS who accessed DREAMS services by each referral approach and assessed the association of these characteristics with referral approach using the chi-square test. Analysis was performed with and without restricting the period when RDS took place. We estimated the relative incremental costs of recruiting YWSS using each strategy for referral to DREAMS services.

RESULTS

Overall, 5386 and 1204 YWSS were referred for DREAMS services through peer outreach and RDS, respectively. YWSS referred through RDS were more likely to access DREAMS services compared to YWSS referred through peer outreach (501/1204, 41.6% vs 930/5386, 17.3%; P<.001). Regardless of referral approach, YWSS who accessed DREAMS had similar education levels, and a similar proportion tested HIV negative and reported not using a condom at the last sex act. A higher proportion of YWSS accessing DREAMS through RDS were aged 18-19 years (167/501, 33.3% vs 243/930, 26.1%; P=.004) and more likely to be aware of their HIV status (395/501, 78.8% vs 396/930, 42.6%; P<.001) compared to those accessing DREAMS services through peer outreach. The incremental cost per young woman who sells sex recruited was US $7.46 for peer outreach and US $52.81 for RDS.

CONCLUSIONS

Peer outreach and RDS approaches can reach and refer high-risk but different groups of YWSS for HIV services, and using both approaches will likely improve reach.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-DOI 10.1186/s12889-018-5085-6.

A retrospective cross sectional study assessing factors associated with retention and non-viral suppression among HIV positive FSWs receiving antiretroviral therapy from primary health care facilities in Kampala, Uganda

BACKGROUND

Patient retention in care and sustained viral load suppression are a cornerstone to improved health and quality of life, among people living with HIV. However, challenges of retention on ART remain among female sex workers (FSWs). We report lost to follow up (LTFU), viral load suppression, and the associated factors among FSWs that access HIV treatment at primary health care facilities in Kampala.

METHODS

We retrospectively abstracted and analysed patient management data of HIV positive FSWs who enrolled in care between January 2018 to December 2020. LTFU was defined as failure of a FSW to return for treatment at least 90 days from the date of their last clinic appointment. We defined viral suppression as having a last viral load of ≤ 1000 copies/ml preceding data abstraction. Data were analysed using Stata 15.1 software.

RESULTS

A total of 275 FSWs were included in our study sample. We found low retention of 85.1% (n = 234) at six months, corresponding to LTFU of 14.9 (n = 41) within the same period. Retention decreased with duration of being in care up to 73.5% (n = 202) at 24 months, and this translates to LTFU of 26.5% (n = 73). Viral load testing coverage was 62% (n = 132) and of these, 90.9% (n = 120) were virally suppressed. Factors associated with LTFU in univariable logistic regression; and viral load suppression in multivariable logistic regression models were; having a telephone contact (OR: 0.3, 95% CI: 0.1-0.9 p = 0.031), having enrolled in HIV care aged ≥ 35 years (OR: 0.5, 95% CI: 0.2-1.0 p = 0.048), (OR:0.03, 95%CI: 0.00-0.5, p = 0.016); and having good ART adherence (OR: 0.2, 95% CI: 0.1-0.5 p = 0.001), (OR:24.0, 95% CI: 3.7-153.4 p = 0.001) respectively. Having good ART adherence remained statistically significant (OR: 0.2, 95% CI: 0.08-0.53 p = 0.001) in multivariable logistic regression for LTFU.

CONCLUSION

This study found low retention among HIV diagnosed FSWs in care. Viral load suppression was acceptable and comparable to that of the general population, however viral load coverage was low. Strategies that increase retention in care and access to viral load testing such as individual client centred care models are vital to improve retention and viral load coverage among FSWs.

Factors motivating female sex workers to initiate pre- exposure prophylaxis for HIV prevention in Zimbabwe

BACKGROUND

Female sex workers (FSWs) have a 26 times greater chance of HIV infection compared to the women in the general population. The World Health Organization recommends pre-exposure prophylaxis (PrEP) for population groups with an HIV incidence of 3% or higher and FSWs in southern Africa fit this criteria. This study sought to understand factors that motivate FSWs to initiate PrEP, in Harare, Zimbabwe.

METHODS

We purposively selected and recruited 20 FSWs to participate in the study in-order to gain an in-depth understanding of factors that motivate FSWs to initiate PrEP in Harare, Zimbabwe. We identified FSW who had been initiated on PrEP at a specialized clinic providing comprehensive sexual reproductive health (SRH) services for sex workers including HIV prevention options. We used a descriptive phenomenological approach to collect and analyze the data. Data was analyzed using Colaizzi's seven steps to analyze data.

FINDINGS

Two broad themes were identified as intrinsic and extrinsic motivators. The two broad themes each have several sub-themes. The sub-themes under intrinsic motivation were (i) Self- protection from HIV infection and (ii) condoms bursting. Six sub-themes were identified as external motivators for initiating PrEP, these included (i) occupational risk associated with sex work, (ii) increased chance of offering unprotected sex as a motivator to initiate PrEP, (iii) positive encouragement from others (iv) need to take care of the children and (v) prior participation in HIV prevention research studies and (vi) Gender Based Violence.

CONCLUSIONS

Understanding the factors that motivate FSWs to initiate PrEP is critical in developing contextually appropriate strategies to promote PrEP initiation and adherence strategies within specific and eligible populations for receiving PrEP according to the WHO guidelines (2015).

Adequate funding of comprehensive community-based programs for key populations needed now more than ever to reach and sustain HIV targets

Introduction

Globally, over half of the estimated new HIV infections now occur among key populations, including men who have sex with men, sex workers, people who inject drugs, transgender individuals, and people in prisons and other closed settings, and their sexual partners. Reaching epidemic control will, for many countries, increasingly require intensified programming and targeted resource allocation to meet the needs of key populations and their sexual partners. However, insufficient funding, both in terms of overall amounts and the way the funding is spent, contributes to the systematic marginalization of key populations from needed HIV services.

Discussion

The Joint United Nations Programme on HIV/AIDS (UNAIDS) has recently highlighted the urgent need to take action to end inequalities, including those faced by key populations, which have only been exacerbated by the COVID‐19 pandemic. To address these inequalities and improve health outcomes, key population programs must expand the use of a trusted access platform, scale up differentiated service delivery models tailored to the needs of key populations, rollout structural interventions and ensure service integration. These critical program elements are often considered “extras,” not necessities, and consequently costing studies of key population programs systematically underestimate the total and unitary costs of services for key populations. Findings from a recent costing study from the LINKAGES project suggest that adequate funding for these four program elements can yield benefits in program performance. Despite this and other evidence, the lack of data on the true costs of these elements and the costs of failing to provide them prevents sufficient investment in these critical elements.

Conclusions

As nations strive to reach the 2030 UNAIDS goals, donors, governments and implementers should reconsider the true, but often hidden costs in future healthcare dollars and in lives if they fail to invest in the community‐based and community‐driven key population programs that address structural inequities. Supporting these efforts contributes to closing the remaining gaps in the 95‐95‐95 goals. The financial and opportunity cost of perpetuating inequities and missing those who must be reached in the last mile of HIV epidemic control must be considered.

Interpreting declines in HIV test positivity: an analysis of routine data from Zimbabwe's national sex work programme, 2009–2019

Introduction

Methods

Results

Conclusions

Feasibility and acceptability of a peer-led HIV self-testing model among female sex workers in Malawi: a qualitative study

Objectives

HIV testing is the gateway to HIV prevention and care services. Female sex workers (FSW) may benefit from HIV self-testing (HIVST), which offers greater control and confidentiality than other approaches. However, FSW also have unique vulnerabilities, making it critical to understand their perspective of HIVST to best contextualise HIVST to their needs. This study explored feasibility and acceptability of providing oral fluid-based peer-led HIVST to FSW to inform tailored HIVST delivery approaches.

Design

Qualitative study.

Setting

Malawi.

Participants

Thirty-nine FSW who had obtained a HIVST kit and eight peer distributors.

Results

Peer distributors’ accounts suggested that peer-led HIVST is feasible. Overall, FSW spoke positively about peer-led HIVST and younger FSW preferred it to facility-based HIV testing. FSW highlighted both greater control of their testing experience and that HIVST could allow them to avoid discriminatory attitudes frequently experienced in public facilities. Some also felt that HIVST kits could enable them to establish the HIV status of their sexual partners, better informing their decisions about condomless sex. Despite overall acceptance of HIVST, a few expressed doubts in the procedure. Some FSW already aware of their HIV-positive status reported using HIVST. A few accounts suggested peer pressure to self-test predominantly from peer distributors.

Conclusions

This study enabled us to explore feasibility and acceptability of peer-led HIVST among FSW, as well as potential shortcomings of the HIV testing modality. Peer distributors are a welcome additional model. However, they should avoid distribution in actual venues. Programmes should ensure a range of testing options are available and expand peer’s representation. Study findings will be used to tailor the HIVST distribution model to ensure its enhanced uptake among key populations in general and FSW, specifically.

"It went through the roof": an observation study exploring the rise in PrEP uptake among Zimbabwean female sex workers in response to adaptations during Covid-19

Introduction

Sisters with a Voice (Sisters), a programme providing community‐led differentiated HIV prevention and treatment services, including condoms, HIV testing, pre‐exposure prophylaxis (PrEP) and antiretroviral therapy linkage for sex workers, reached over 26,000 female sex workers (FSW) across Zimbabwe in 2020. Zimbabwe's initial Covid “lockdown” in March 2020 and associated movement restrictions interrupted clinical service provision for 6 weeks, particularly in mobile clinics, triggering the adaptation of services for the Covid‐19 context and a scale up of differentiated service delivery (DSD) models. PrEP service delivery decentralized with shifts from clinical settings towards community/home‐based, peer‐led PrEP services to expand and maintain access. We hypothesize that peer‐led community‐based provision of PrEP services influenced both demand and supply‐side determinants of PrEP uptake. We observed the effect of these adaptations on PrEP uptake among FSW accessing services in Sisters in 2020.

Methods

New FSW PrEP initiations throughout 2020 were tracked by analysing routine Sisters programme data and comparing it with national PrEP initiation data for 2020. We mapped PrEP uptake among all negative FSW attending services in Sisters alongside Covid‐19 adaptations and shifts in the operating environment throughout 2020: prior to lockdown (January–March 2020), during severe restrictions (April–June 2020), subsequent easing (July–September 2020) and during drug stockouts that followed (October–December 2020).

Results and discussion

PrEP uptake in 2020 occurred at rates <25% (315 initiations or fewer) per month prior to the emergence of Covid‐19. In response to Covid‐19 restrictions, DSD models were scaled up in April 2020, including peer demand creation, community‐based delivery, multi‐month dispensing and the use of virtual platforms for appointment scheduling and post‐PrEP initiation support. Beginning May 2020, PrEP uptake increased monthly, peaking at an initiation rate of 51% (n = 1360) in September 2020. Unexpected rise in demand coincided with national commodity shortages between October and December 2020, resulting in restriction of new initiations with sites prioritizing refills.

Conclusions

Despite the impact of Covid‐19 on the Sisters Programme and FSW mobility, DSD adaptations led to a large increase in PrEP initiations compared to pre‐Covid levels demonstrating that a peer‐led, community‐based PrEP service delivery model is effective and can be adopted for long‐term use.

Potential reduction in female sex workers' risk of contracting HIV during coronavirus disease 2019

Female sex workers' livelihoods in Zimbabwe have been severely impacted by the coronavirus disease 2019 pandemic due to closure of entertainment venues. Competition over fewer clients has reduced ability to negotiate condom use. At the same time as partner numbers have decreased, frequency of reported condomless sex has not increased, suggesting potential reduction in overall HIV and sexually transmitted infection risk and an opportunity for programmes to reach sex workers with holistic social and economic support and prevention services.

Population size estimation of seasonal forest-going populations in southern Lao PDR

Forest-going populations are key to malaria transmission in the Greater Mekong Sub-region (GMS) and are therefore targeted for elimination efforts. Estimating the size of this population is essential for programs to assess, track and achieve their elimination goals. Leveraging data from three cross-sectional household surveys and one survey among forest-goers, the size of this high-risk population in a southern province of Lao PDR between December 2017 and November 2018 was estimated by two methods: population-based household surveys and capture-recapture. During the first month of the dry season, the first month of the rainy season, and the last month of the rainy season, respectively, 16.2% [14.7; 17.7], 9.3% [7.2; 11.3], and 5.3% [4.4; 6.1] of the adult population were estimated to have engaged in forest-going activities. The capture-recapture method estimated a total population size of 18,426 [16,529; 20,669] forest-goers, meaning 61.0% [54.2; 67.9] of the adult population had engaged in forest-going activities over the 12-month study period. This study demonstrates two methods for population size estimation to inform malaria research and programming. The seasonality and turnover within this forest-going population provide unique opportunities and challenges for control programs across the GMS as they work towards malaria elimination.

The impact of the DREAMS partnership on HIV incidence among young women who sell sex in two Zimbabwean cities: results of a non-randomised study

INTRODUCTION

Young women who sell sex (YWSS) in Zimbabwe remain at high risk of HIV infection. Effective HIV prevention strategies are needed. Through support to access a combination of evidence-based interventions, including oral pre-exposure prophylaxis (PrEP), the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) partnership aimed to reduce new HIV infections among adolescent girls and young women by 40% over 24 months.

METHODS

Non-randomised 'plausibility' evaluation, powered to detect a 40% HIV incidence difference between DREAMS and non-DREAMS sites. Two large cities with DREAMS funding were included, and four smaller non-DREAMS towns for comparison. In all sites, YWSS were enrolled to a cohort through peer-referral. Women were followed up for 24 months. HIV seroconversion was the primary outcome, with secondary outcomes identified through a theory of change. Outcomes were compared between YWSS recruited in DREAMS cities and non-DREAMS towns, adjusting for individual-level confounders and HIV prevalence at enrolment.

RESULTS

From April to July 2017, 2431 women were enrolled, 1859 of whom were HIV negative at enrolment; 1019 of these women (54.8%) were followed up from March to May 2019 and included in endline analysis. Access to clinical services increased, but access to socioeconomic interventions promoted by DREAMS was limited. A total of 79 YWSS HIV seroconverted, with HIV incidence among YWSS in DREAMS cities lower (3.1/100 person-years) than in non-DREAMS towns (5.3/100 person-years). In prespecified adjusted analysis, HIV incidence was lower in DREAMS cities but with weak statistical evidence (adjusted rate ratio (RR)=0.68; 95% CI 0.40 to 1.19; p=0.18). Women in DREAMS cities were more likely to report ever and ongoing PrEP use, consistent condom use, fewer sexual partners and less intimate partner violence.

CONCLUSION

It is plausible that DREAMS lowered HIV incidence among YWSS in two Zimbabwean cities, but our evaluation provides weak statistical evidence for impact and suggests any reduction in incidence was lower than the anticipated 40% decline. We identified changes to some important 'pathways to impact' variables, including condom use.

Effect of community-based interventions targeting female sex workers along the HIV care cascade in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Female sex workers are extremely vulnerable and highly susceptible to being infected with human immunodeficiency virus. As a result, community-based targeted interventions have been recommended as one of the models of care to improve access to HIV services and continued engagement in care. We conducted a systematic review to (1) assess the effect of FSW-targeted community interventions on the improvement of HIV services access along the treatment cascade and (2) describe community-based interventions that positively affect continuation in HIV care across the HIV treatment cascade for FSWs in sub-Saharan Africa.

METHODS

We defined the 5 steps that make up the HIV care cascade and categorized them as outcomes, namely, HIV testing and diagnosis, linkage to care, receipt of ART, and achievement of viral suppression. We conducted a systematic search of randomized controlled trials, cohort, and cross-sectional studies done in sub-Saharan African countries and published from 2004 to 2020. The period was selected based on the time span within which ART was scaled up through widespread roll-out of comprehensive HIV programs in sub-Saharan Africa. We reviewed studies with data on the implementation of community interventions for any of the HIV care cascade stage. The data were analyzed using random effects meta-analysis where possible, and for the rest of the studies, data were synthesized using summary statistics.

RESULTS

The significant impact of the community interventions was observed on HIV testing, HIV diagnosis, and ART use. However, for HIV testing and ART use, the improvement was not sustained for the entire period of implementation. There were minimal interventions that had impact on HIV diagnosis, with only one community service delivery model showing significance. Generally, the interventions that had reasonable impact are those that implemented targeted and comprehensive package of HIV services provided at one location, and with unique strategies specific to each cascade stage.

CONCLUSIONS

The evidence brought forward from this review shows that the effect of community-based interventions varies across the different stages of HIV care cascade. A broad package of interventions including a combination of behavioral, biomedical, and structural, designed with specific strategies, unique to each cascade stage appears to be more effective, although information on long-term treatment outcomes and the extent to which FSWs remain engaged in care is sparse. There is need to conduct a further research to deepen the assessment of the effectiveness of community-based interventions on HIV care cascade for FSWs. This will enhance identification of evidence-based optimal interventions that will guide effective allocation of scarce resources for strategies that would have a significant impact on HIV service delivery.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020157623.

Retention of a cohort of men who have sex with men and transgender women at risk for and living with HIV in Abuja and Lagos, Nigeria: a longitudinal analysis

INTRODUCTION

Men who have sex with men (MSM), and transgender women (TGW), face specific obstacles to retention in care, particularly in settings with stigmatization such as sub-Saharan Africa. We evaluated the impacts of HIV status and other factors on loss-to-follow-up (LTFU) and visit adherence among MSM and TGW in Abuja and Lagos, Nigeria.

METHODS

TRUST/RV368 is an open cohort that provides comprehensive and integrated prevention and treatment services for HIV and sexually transmitted infections (STIs) at community venues supportive of sexual and gender minorities. Recruitment began in March 2013 and participants were followed every three months for up to 18 months. LTFU was defined as not presenting for an expected visit in the past 180 days. Visit adherence was calculated as a rate of completed visits adjusted by the number of three-month intervals elapsed since enrolment. HIV and other factors predictive of LTFU and visit adherence were evaluated using Cox proportional hazards and Poisson regression models, respectively.

RESULTS

A total of 1447 participants who completed enrolment evaluations over two visits as of November 2018 were included in these analyses. Their median age was 24 years (interquartile range [IQR]: 21 to 28) and 53% (n = 766) were living with HIV. LTFU occurred in 56% (n = 808) and visit adherence was 0.62 (95% confidence interval: 0.61 to 0.64) visits per three-month interval. Participants at risk and living with HIV had median follow-up times of 12 months (IQR: 6 to 22), and 21 months (IQR: 12 to 30), respectively (p < 0.01). After controlling for other factors, LTFU was less common among participants living with HIV or other STIs and more common among those who did not own a cell phone, sold sex and had never undergone HIV testing prior to enrolment. These factors had parallel associations with visit adherence.

CONCLUSIONS

Retention was suboptimal in Nigerian clinics designed to serve MSM and TGW. Particularly high LTFU and low visit adherence among participants at risk for HIV could complicate deployment of HIV prevention interventions. Marketing the benefits of testing, improving access to cell phones and nurturing more trust with clients may improve retention among marginalized communities in Nigeria.

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.

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.

Perspectives on oral pre-exposure prophylaxis use amongst female sex workers in Harare, Zimbabwe

BACKGROUND

Pre-exposure prophylaxis (PrEP) could provide protection from human immunodeficiency virus (HIV) infection in sexually active persons at risk. Limited data are available in Zimbabwe with regard to the perceptions about PrEP amongst female sex workers (FSWs).

OBJECTIVES

The aim of this study was to evaluate the knowledge levels of oral PrEP and the likelihood of its use amongst FSWs.

METHOD

This was a cross-sectional study in the peri-urban areas of Harare, Zimbabwe. Human immunodeficiency virus-negative FSWs were interviewed to assess their awareness of and likelihood to use PrEP. The relative importance index was used to evaluate the levels of knowledge and the likelihood of, and barriers to, PrEP use. A set of 10 questions was designed and validated that evaluated participants' understanding of PrEP. A bivariate logistic regression model was utilised to identify predictors of PrEP use.

RESULTS

A total of 131 FSWs with a median age of 25 years (interquartile range: 21-31) participated in this study. Of the 71 (54%) FSWs who had heard about PrEP, 46 (35%) participants had adequate knowledge of its use. A total of 102 (78%) participants revealed that they would be willing to continuously use PrEP if it was provided free of cost. Increasing age of the participants was associated with an increase in the likelihood of using PrEP (r = 0.0033, p = 0.038). More knowledge about PrEP increased the likelihood of its use (r = 0.21, p = 0.0153). This likelihood increased amongst participants with an unprotected sexual intercourse encounter in the preceding 3 months (r = 0.0448, p = 0.026).

CONCLUSION

Knowledge of PrEP amongst FSWs was low. To increase the uptake of PrEP, there is a need to further sensitise FSWs about this intervention. Programmes should also promote awareness training in FSW subgroups that are less likely to use PrEP.

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.