"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

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

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

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

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.</p

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

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

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

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)

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

Uganda's Anti-Homosexuality Act

Editoria

Climate information services, integrated knowledge systems and the 2030 Agenda for Sustainable Development

This commentary explores the role of climate information services in supporting the achievement of the 2030 Agenda for Sustainable Development. At the centre of the commentary is a discussion of how integrated knowledge systems are critical in the formulation of high quality climate information services towards the successful achievement of the Sustainable Development Goals (SDGs). The paper drives home two major points. Firstly, that a climate service built on integrated knowledge systems will be better positioned to match user needs in terms of skill, scale and lead time. Secondly, that integrating diverse knowledge systems for effective climate information services in the context of the 2030 Agenda for Sustainable Development will present an auspicious platform for ‘leaving no one behind’ in contributing ideas towards the achievement of the targets outlined under the 17 SDGs, contributing to the inclusive approach at the centre of Agenda 2030. The commentary also advances the idea that climate information services built upon integrated knowledge systems present opportunities for more adequately addressing the needs of the global poor, including informing agricultural decision-making in rural communities to reduce malnutrition, facilitate disaster preparedness, and tackle human diseases linked to climate change - from cardiovascular deaths and respiratory illnesses, to altered transmission of infectious diseases