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Cowan FM, Musemburi S, Matambanadzo P, Chida P, Steen R, Makandwa R, Chabata ST, Takura A, Sheets A, Yekeye R, Mugurungi O, Hensen B, Busza J, Hargreaves JR. Using a Programme Science approach to substantially reduce the risk of HIV transmission and acquisition in sex transactions among female sex workers in Zimbabwe. J Int AIDS Soc 2024; 27 Suppl 2:e26262. [PMID: 38988032 DOI: 10.1002/jia2.26262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/19/2024] [Indexed: 07/12/2024] Open
Abstract
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.
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Affiliation(s)
- Frances M Cowan
- Liverpool School of Tropical Medicine, Liverpool, UK
- Centre for Sexual Health and HIV AIDS Research Zimbabwe, Harare, Zimbabwe
| | | | | | - Phillip Chida
- Centre for Sexual Health and HIV AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Richard Steen
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Rumbidzo Makandwa
- Centre for Sexual Health and HIV AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Sungai T Chabata
- Centre for Sexual Health and HIV AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Albert Takura
- Centre for Sexual Health and HIV AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Amber Sheets
- Population Services International, Washington, DC, USA
| | | | | | | | - Joanna Busza
- London School of Hygiene and Tropical Medicine, London, UK
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Jones HS, Anderson RL, Cust H, McClelland RS, Richardson BA, Thirumurthy H, Malama K, Hensen B, Platt L, Rice B, Cowan FM, Imai-Eaton JW, Hargreaves JR, Stevens O. HIV incidence among women engaging in sex work in sub-Saharan Africa: a systematic review and meta-analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.17.23297108. [PMID: 37905066 PMCID: PMC10615019 DOI: 10.1101/2023.10.17.23297108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Introduction HIV incidence among women in sub-Saharan Africa (SSA) has declined steadily, but it is unknown whether new infections among women who engage in sex work (WESW) have declined at a similar rate. We synthesised estimates of HIV incidence among WESW in SSA and compared these to the wider female population to understand levels and trends in incidence over time. Methods We searched Medline, Embase, Global Health, Popline, Web of Science, and Google Scholar from January 1990 to October 2022, and grey literature for estimates of HIV incidence among WESW in SSA. We included studies reporting empirical estimates in any SSA country. We calculated incidence rate ratios (IRR) compared to age-district-year matched total female population incidence estimates. We conducted a meta-analysis of IRRs and used a continuous mixed-effects model to estimate changes in IRR over time. Results From 32 studies between 1985 and 2020, 2,194 new HIV infections were observed in WESW over 51,000 person-years (py). Median HIV incidence was 4.3/100py (IQR 2.8-7.0/100py), declining from a median of 5.96/100py between 1985 and 1995 to a median of 3.2/100py between 2010 and 2020. Incidence among WESW was nine times higher than in matched total population women (RR 8.6, 95%CI: 5.7-12.9), and greater in Western and Central Africa (RR 22.4, 95%CI: 11.3-44.3) than in Eastern and Southern Africa (RR 5.3, 95%CI: 3.7-7.6). Annual changes in log IRRs were minimal (-0.1% 95%CI: -6.9 to +6.8%). Conclusions Across SSA, HIV incidence among WESW remains disproportionately high compared to the total female population but showed similar rates of decline between 1990 and 2020. Improved surveillance and standardisation of approaches to obtain empirical estimates of sex worker incidence would enable a clearer understanding of whether we are on track to meet global targets for this population and better support data-driven HIV prevention programming.
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Affiliation(s)
- Harriet S Jones
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Rebecca L Anderson
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Henry Cust
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - R Scott McClelland
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Barbra A Richardson
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kalonde Malama
- University of Toronto Factor-Inwentash Faculty of Social Work, Toronto Ontario, Canada
| | - Bernadette Hensen
- Sexual and Reproductive Health Group, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Lucy Platt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Brian Rice
- Sheffield Centre for Health and Related Research (SCHARR); School of Medicine and Population Health, University of Sheffield, UK
| | - Frances M Cowan
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Jeffrey W Imai-Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - James R Hargreaves
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Oliver Stevens
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
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Birri Makota RB, Musenge E. Estimating HIV incidence over a decade in Zimbabwe: A comparison of the catalytic and Farrington models. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001717. [PMID: 37708116 PMCID: PMC10501625 DOI: 10.1371/journal.pgph.0001717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/19/2023] [Indexed: 09/16/2023]
Abstract
Over the years, numerous modelling studies have been proposed to estimate HIV incidence. As a result, this study aimed to evaluate two alternative methods for predicting HIV incidence in Zimbabwe between 2005 and 2015. We estimated HIV incidence from seroprevalence data using the catalytic and Farrington-2-parameter models. Data were obtained from 2005-06, 2010-11, and 2015 Zimbabwe Demographic Health Survey (ZDHS). These models were validated at the micro and macro-level using community-based cohort incidence and empirical estimates from UNAIDS EPP/SPECTRUM, respectively. The HIV incidence for the catalytic model was 0.32% (CI: 0.28%, 0.36%), 0.36% (CI: 0.33%, 0.39%), and 0.28% (CI: 0.26%, 0.30%), for the years 2005-06, 2010-11, and 2015, respectively. The HIV incidence for the Farrington model was 0.21% (CI: 0.16%, 0.26%), 0.22% (CI: 0.20%, 0.25%), and 0.19% (CI: 0.16%, 0.22%), for the years 2005-06, 2010-11, and 2015, respectively. According to these findings, the catalytic model estimated a higher HIV incidence rate than the Farrington model. Compared to cohort estimates, the estimates were within the observed 95% confidence interval, with 88% and 75% agreement for the catalytic and Farrington models, respectively. The limits of agreement observed in the Bland-Altman plot were narrow for all plots, indicating that our model estimates were comparable to cohort estimates. Compared to UNAIDS estimates, the catalytic model predicted a progressive increase in HIV incidence for males throughout all survey years. Without a doubt, HIV incidence declined with each subsequent survey year for all models. To improve programmatic and policy decisions in the national HIV response, we recommend the triangulation of multiple methods for incidence estimation and interpretation of results. Multiple estimating approaches should be considered to reduce uncertainty in the estimations from various models.
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Affiliation(s)
- Rutendo Beauty Birri Makota
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Eustasius Musenge
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Jones HS, Hensen B, Musemburi S, Chinyanganya L, Takaruza A, Chabata ST, Matambanadzo P, Platt L, Rice B, Cowan FM, Hargreaves JR. 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. Lancet HIV 2023; 10:e442-e452. [PMID: 37329897 DOI: 10.1016/s2352-3018(23)00110-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 04/25/2023] [Accepted: 05/02/2023] [Indexed: 06/19/2023]
Abstract
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.
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Affiliation(s)
- Harriet S Jones
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK.
| | - Bernadette Hensen
- Sexual and Reproductive Health Group, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | - Albert Takaruza
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Sungai T Chabata
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | | | - Lucy Platt
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Brian Rice
- University of Sheffield, School of Health and Related Research, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe; Faculty of Global Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - James R Hargreaves
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Busza J, Matambanadzo P, Phiri L, Meki B, Cowan FM. HIV prevention in individuals engaged in sex work. Curr Opin Infect Dis 2023; 36:1-8. [PMID: 36729746 DOI: 10.1097/qco.0000000000000891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW People who sell sex remain at disproportionate risk of acquiring HIV and should be prioritized for evidence-based HIV prevention programmes delivered at sufficient scale and intensity for effectiveness. Although new biomedical tools are becoming available, many basic lessons learned early in the HIV pandemic remain salient today and need renewed attention. RECENT FINDINGS New preexposure prophylaxis formulations, distribution systems, and delivery mechanisms are being successfully trialled and implemented, adding to well established prevention tools such as male and female condoms and lubricants. The importance of social support networks and community ownership of programmes has been consistently reaffirmed. Serious challenges remain in optimizing HIV prevention for sex workers, including providing services at the scale and intensity necessary for population level impact, addressing culturally sensitive issues of gender identity and sexual orientation, and protecting adolescents and young people who may sell sex. Pervasive social stigma, often reinforced by criminalization and police harassment, further constrain sex workers' access to available services and prevention tools. SUMMARY Meaningful community engagement and addressing the multiple social determinants of vulnerability at individual, community, and structural levels remain at the core of preventing HIV among people involved in selling sex.
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Affiliation(s)
- Joanna Busza
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Bee Meki
- Trans and Intersex Rising Zimbabwe, Zimbabwe
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe
- Department for International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Chabata ST, Makandwa R, Hensen B, Mushati P, Chiyaka T, Musemburi S, Busza J, Floyd S, Birdthistle I, Hargreaves JR, Cowan FM. 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. JMIR Public Health Surveill 2022; 8:e32286. [PMID: 35896024 PMCID: PMC9377473 DOI: 10.2196/32286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 03/31/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Sungai T Chabata
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe.,Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Rumbidzo Makandwa
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
| | - Bernadette Hensen
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Phillis Mushati
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
| | - Tarisai Chiyaka
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
| | | | - Joanna Busza
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Isolde Birdthistle
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - James R Hargreaves
- Centre for Evaluation, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe.,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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