11 research outputs found

    "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.

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    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

    Differentiated prevention and care to reduce the risk of HIV acquisition and transmission among female sex workers in Zimbabwe: study protocol for the 'AMETHIST' cluster randomised trial

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    BACKGROUND: Female sex workers (FSW) in sub-Saharan Africa are disproportionately affected by HIV and are critical to engage in HIV prevention, testing and care services. We describe the design of our evaluation of the 'AMETHIST' intervention, nested within a nationally-scaled programme for FSW in Zimbabwe. We hypothesise that the implementation of this intervention will result in a reduction in the risk of HIV transmission within sex work. METHODS: The AMETHIST intervention (Adapted Microplanning to Eliminate Transmission of HIV in Sex Transactions) is a risk-differentiated intervention for FSW, centred around the implementation of microplanning and self-help groups. It is designed to support uptake of, and adherence to, HIV prevention, testing and treatment behaviours among FSW. Twenty-two towns in Zimbabwe were randomised to receive either the Sisters programme (usual care) or the Sisters programme plus AMETHIST. The composite primary outcome is defined as the proportion of all FSW who are at risk of either HIV acquisition (HIV-negative and not fully protected by prevention interventions) or of HIV transmission (HIV-positive, not virally suppressed and not practicing consistent condom use). The outcome will be assessed after 2 years of intervention delivery in a respondent-driven sampling survey (total n = 4400; n = 200 FSW recruited at each site). Primary analysis will use the 'RDS-II' method to estimate cluster summaries and will adapt Hayes and Moulton's '2-step' method produce adjusted effect estimates. An in-depth process evaluation guided by our project trajectory will be undertaken. DISCUSSION: Innovative pragmatic trials are needed to generate evidence on effectiveness of combination interventions in HIV prevention and treatment in different contexts. We describe the design and analysis of such a study. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR202007818077777 . Registered on 2 July 2020

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

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    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

    Individual level perspectives of HIV recent infection testing among female sex workers in Zimbabwe

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    Issue: In 2022 the United States President’s Emergency Plan for AIDS Relief released a guidance proposing recency testing to be adopted as a key component of new real-time HIV surveillance systems for resource allocation at a local level (1). In response to this, the Foundation of AIDS Research (amfAR) highlighted their concerns regarding ethical and human rights issues relating to consent, risks of harms, inaccuracy of test results and more (2). Through sharing our learnings we aim to contribute to the debate around individual level utility and ethical concerns, and to understanding how we can further support recency testing in real world settings as informed by the perspectives of those being tested. From June to November 2018, we carried out in-depth interviews with fourteen female sex workers (FSWs) recruited from Zimbabwe’s national Sisters with a Voice sex worker programme. We aimed to explore experiences and perspectives of clinic users to assess the feasibility and utility of integrating a Recent Infection Testing Algorithm into routine programme service delivery for FSWs. Participants were aged 25 to 46 years with interviews taking place in Bulawayo, Gweru, Harare, Karoi, and Mutare. Lessons Learnt: In support of amfAR’s concerns, several participants mentioned the potential physical and psychological harm of receiving their recency results including distress and fear of violence from themselves and/or their partners. However, it is hard to disentangle if these harms are linked to the return of the additional recency test or the positive HIV test. Additionally, participants mentioned several benefits to returning recency results including better understanding of their status and health, and incentive to take their HIV medication. We also found that some participants did not properly understand what recency testing was and some reported that they felt obliged to participate out of a sense of duty. These results highlight issues of consent, where even in healthcare settings with large amounts of trust, a structural power imbalance still exists and patients can feel an increased sense of responsibility for their health and that of their community. Recommendations: There is a need for more community engagement to rightly make patients active agents in their healthcare decisions. We think that the choice of whether patients should receive their recency results should reside with the patients themselves. After providing patients with information regarding the risks of receiving their recency results, they should have the ability to decide what is best for them. By deciding what is best for them without involving them in the decision, we exacerbate power imbalances and risk undermining patient’s trust of programmes

    Differentiated prevention and care to reduce the risk of HIV acquisition and transmission among female sex workers in Zimbabwe : study protocol for the ‘AMETHIST’ cluster randomised trial

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    Background: Female sex workers (FSW) in sub-Saharan Africa are disproportionately affected by HIV and are critical to engage in HIV prevention, testing and care services. We describe the design of our evaluation of the ‘AMETHIST’ intervention, nested within a nationally-scaled programme for FSW in Zimbabwe. We hypothesise that the implementation of this intervention will result in a reduction in the risk of HIV transmission within sex work. Methods: The AMETHIST intervention (Adapted Microplanning to Eliminate Transmission of HIV in Sex Transactions) is a risk-differentiated intervention for FSW, centred around the implementation of microplanning and self-help groups. It is designed to support uptake of, and adherence to, HIV prevention, testing and treatment behaviours among FSW. Twenty-two towns in Zimbabwe were randomised to receive either the Sisters programme (usual care) or the Sisters programme plus AMETHIST. The composite primary outcome is defined as the proportion of all FSW who are at risk of either HIV acquisition (HIV-negative and not fully protected by prevention interventions) or of HIV transmission (HIV-positive, not virally suppressed and not practicing consistent condom use). The outcome will be assessed after 2 years of intervention delivery in a respondent-driven sampling survey (total n = 4400; n = 200 FSW recruited at each site). Primary analysis will use the ‘RDS-II’ method to estimate cluster summaries and will adapt Hayes and Moulton’s ‘2-step’ method produce adjusted effect estimates. An in-depth process evaluation guided by our project trajectory will be undertaken. Discussion: Innovative pragmatic trials are needed to generate evidence on effectiveness of combination interventions in HIV prevention and treatment in different contexts. We describe the design and analysis of such a study. Trial registration: Pan African Clinical Trials Registry PACTR202007818077777. Registered on 2 July 2020

    Protocol of an individual participant data meta-analysis to quantify the impact of high ambient temperatures on maternal and child health in Africa (HE 2 AT IPD)

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    Introduction: Globally, recognition is growing of the harmful impacts of high ambient temperatures (heat) on health in pregnant women and children. There remain, however, major evidence gaps on the extent to which heat increases the risks for adverse health outcomes, and how this varies between settings. Evidence gaps are especially large in Africa. We will conduct an individual participant data (IPD) meta-analysis to quantify the impacts of heat on maternal and child health in sub-Saharan Africa. A detailed understanding and quantification of linkages between heat, and maternal and child health is essential for developing solutions to this critical research and policy area. Methods and analysis: We will use IPD from existing, large, longitudinal trial and cohort studies, on pregnant women and children from sub-Saharan Africa. We will systematically identify eligible studies through a mapping review, searching data repositories, and suggestions from experts. IPD will be acquired from data repositories, or through collaboration with data providers. Existing satellite imagery, climate reanalysis data, and station-based weather observations will be used to quantify weather and environmental exposures. IPD will be recoded and harmonised before being linked with climate, environmental, and socioeconomic data by location and time. Adopting a one-stage and two-stage meta-analysis method, analytical models such as time-to-event analysis, generalised additive models, and machine learning approaches will be employed to quantify associations between exposure to heat and adverse maternal and child health outcomes. Ethics and dissemination: The study has been approved by ethics committees. There is minimal risk to study participants. Participant privacy is protected through the anonymisation of data for analysis, secure data transfer and restricted access. Findings will be disseminated through conferences, journal publications, related policy and research fora, and data may be shared in accordance with data sharing policies of the National Institutes of Health. PROSPERO registration number: CRD42022346068

    Implemention of a Laboratory Information System in Zimbabwe

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    Objective: Understand the challenges that exist in the Zimbabwe health systems, that could be addressed through the integration of a Laboratory Information Management System (LIMS).Understand key aspects for consideration when selecting and adapting a LIMS in a resource limited setting.Showcase improvements in laboratory information management processes following adoption of a LIMS.Introduction: Zimbabwe's National Health Laboratory Services faces multiple challenges related to inadequate financial support and skilled human resources, insufficient infrastructure, and inefficient tracking of clinical samples collected by health facilities. The slow turnaround time and poor management of the sample testing process, as well as delivery of results remain critical challenges. Compounding these problems further is a manual system for tracking large volumes of samples. This laborious and time-consuming process is inefficient for management of high amounts of incoming medical samples, frequently resulting in incomplete and inaccurate data. Additionally, health facilities are unable to monitor clinical samples and results in transit, leading to misplaced samples and missing results. Furthermore, although the laboratory service runs on a tiered network system - with lower level laboratories referring surveillance samples to higher level laboratories, processing of samples is not fulfilled promptly. The solutions to these challenges are divergent - sometimes even pointing in different directions. To this end, the Zimbabwe Ministry of Health and Child Care (MoHCC) has identified and integrated a LIMS to improve tracking of samples from the time of collection through results delivery.Methods: Our methods included an environmental needs assessment, user requirement analysis, followed by a LIMS customization and integration. The overarching aim has been to integrate the electronic open source BIKA LIMS into Zimbabwe’s national health information systems (HIS), to improve laboratory information management.The user requirements gathering exercise, included focus group discussion meetings with potential LIMS users, and direct observations, to guide the establishment of LIMS specifications. The needs assessment focused on the system functionality. Specifically, it investigated those aspects that would improve the ability: to track clinical samples such as creating and activating an ‘alerting’ capability when results are not reported within the set turnaround time; for users to see lists and counts of clinical samples at various testing levels; to uniquely identify samples received in the laboratories. Guided by these requirements, an environmental scan of off-the-shelf and open source LIMS platforms was conducted to identify a few options for the Zimbabwe context. Primary factors for shortlisting included: an existing community of practice for support; interoperability; customizability and configurability; and local awareness of the platform. In a LIMS national user’s meeting, involving relevant levels of the health system (Laboratories, Central, Provincial and District hospitals), a review of LIMS platform options was performed to narrow down selections. It evaluated the extent to which the user requirements (Workflow, equipment interface, result management, inter-operable, quality control, and stock management) were being met. Based on the evaluation, a single system (LIMS) was selected, adopted and adapted for use at six representative laboratories, including Zimbabwe’s National Microbiology Reference Laboratory.On-Site classroom and desk-side training, for knowledge transfer to local LIMS users, characterised the implementation phase. Local champions were identified from laboratory technicians and equipped to offer first line support. Both on-site and remote support was provided to LIMS users. The monitoring phase is ongoing, using interview guides and LIMS user meetings to understand challenges and ways to improve the system.Results: A LIMS was successfully customized and integrated into Zimbabwe’s national health information system infrastracture in six regional laboratories, to improve overall laboratory information management, timeliness of reporting and quality control. Since its full implementation between 2013 and 2017, average turnaround time for results improved significantly from 10 to 21 days in 2013 to only 3 days in 2017. Data quality improved; the number of untested clinical samples reduced from an average of 6 in 100 in 2013, to average of less or equal to 1 in 100, in 2017 . Also, there have been observed improvements in Zimbabwe's laboratory information management workflow and results reporting. High user satisfaction and increased LIMS use have led to the demand for LIMS expansion to additional laboratories. The LIMS has also managed to reduce the time required to produce disease notification reports.Conclusions: LIMS are proving to be an effective method for tracking samples and laboratory results in low resource settings like Zimbabwe. LIMS has provided an efficient way for record, store, and track timely reporting of laboratory data, allowing for improved quality of data. Overall, LIMS has increased efficiency in laboratory workflow and introduced the ability to adequately track samples from time of collection

    Facilitators and barriers to engaging with the DREAMS initiative among young women who sell sex aged 18–24 in Zimbabwe: a qualitative study

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    Background: Adolescent girls and young women (AGYW) are at high risk of contracting HIV and exchanging sex for financial or material support heightens their risk. In Zimbabwe, the DREAMS initiative integrated education and employment opportunities within HIV health promotion and clinical services for vulnerable young women, including those who sell sex. While most participants accessed health services, fewer than 10% participated in any social programmes. Methods: We conducted semi-structured qualitative interviews with 43 young women aged 18–24 to understand their experiences of engaging with the DREAMS programme. We purposively sampled participants for diversity in level of education, type and location of selling sex. We analysed the data by applying the Theoretical Domains Framework to explore facilitators and barriers to engaging with DREAMS. Results: Eligible women were motivated by hopes of escaping poverty, and their longer-term engagement was sustained through exposure to new social networks, including friendships with less vulnerable peers. Barriers included opportunity costs and expenses such as transport or equipment required for job placements. Participants also described pervasive stigma and discrimination related to their involvement in selling sex. Interviews highlighted the young women’s struggles in a context of entrenched social and material deprivation and structural discrimination that hindered their ability to take up most of the social services offered. Conclusions: This study demonstrates that while poverty was a key driver of participation in an integrated package of support, it also constrained the ability of highly vulnerable young women to benefit fully from the DREAMS initiative. Multi-layered HIV prevention approaches such as DREAMS that seek to alter complex and longstanding social and economic deprivation address many of the challenges faced by YWSS but will only succeed if the underlying drivers of HIV risk among YWSS are also addressed

    HIV prevalence, risk behaviour, and treatment and prevention cascade outcomes among cisgender men, transgender women, and transgender men who sell sex in Zimbabwe: a cross-sectional analysis of programmatic data

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    Background: There is limited evidence about the HIV vulnerabilities and service engagements among people who sell sex in sub-Saharan Africa identifying as cisgender men, transgender women or transgender men. We present unique data describing the sexual risk behaviour, HIV prevalence, and access to HIV services among cisgender men (MWSS), transgender women (TGWWSS), and transgender men (TGMWSS) who sell sex in Zimbabwe. Methods: From July 2018, CeSHHAR expanded its community and clinical services to include SW in their diversity more broadly. All SW reached by the programme have routine data collected, including routine HIV testing, and were referred using a network of peer educators. Sexual risk behaviour, HIV prevalence, and HIV services uptake over the period July 2018 to June 2020 were analysed through descriptive statistics by gender group. Findings: In total, 423 MWSS, 343 TGWWSS, and 237 TGMWSS were included. Age standardized HIV prevalence estimates were 26·2% [95% CI: 22·0; 30·7] for MWSS, 39·4% [95% CI: 34·1; 44·9] for TGWWSS, and 38·4% [95% CI: 32·1; 45·0] for TGMWSS. Among those living with HIV, respectively 66·0% [95% CI: 55·7; 75·3], 74·8% [95% CI: 65·8; 82·4], and 70·2% [95% CI: 59·3; 79·7] knew their status, and respectively 15·5% [95% CI: 8·9; 24·2], 15·7% [95% CI: 9·5; 23·6] and 11·9% [95% CI: 5·9; 20·8] were on ART. Self-reported condom use was consistently low across gender groups, ranging from 28% to 55%. Interpretation: These unique data demonstrate that people who sell sex identifying as cisgender men, transgender women or transgender men in sub-Saharan Africa face high HIV prevalence and risk, coinciding with alarmingly low access to HIV prevention, testing and treatment services. There is an urgent need for people-centred HIV interventions for these high-risk groups and for more inclusive HIV policies and research to ensure we truly attain universal access for all
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