Children's role in the community response to HIV in Zimbabwe

Introduction: Recent debates on how to achieve an optimal HIV response are dominated by intervention strategies that fail to recognize children’s role in the community response to HIV. Whilst formal responses are key to the HIV response, they must recognize and build on indigenous community resources. This study examines adult’s perspectives on the role of children in the HIV response in the Matobo District of southern Zimbabwe. Methods: Through a mix of individual interviews (n = 19) and focus group discussions (n = 9), 90 community members who were active in social groups spoke about their community response to HIV. Transcripts were subjected to a thematic analysis and coding to generate key concepts and representations. Findings: In the wake of the HIV epidemic, traditional views of children’s social value as domestic ‘‘helpers’’ have evolved into them being regarded as capable and competent actors in the care and support of people living with HIV or AIDS, and as integral to household survival. Yet concurrent representations of children with excessive caregiving responsibilities as potentially vulnerable and at risk suggest that there is a limit to the role of children in the HIV response. Conclusion: Community volunteers and health staff delivering HIV services need to recognize the ‘‘behind the scene’’ role of children in the HIV response and ensure that children are incorporated into their modus operandi — both as social actors and as individuals in need of support

Getting off on the wrong foot? How community groups in Zimbabwe position themselves for partnerships with external agencies in the HIV response

Background: Partnerships are core to global public health responses. The HIV field embraces partnership working, with growing attention given to the benefits of involving community groups in the HIV response. However, little has been done to unpack the social psychological foundation of partnership working between well-resourced organisations and community groups, and how community representations of partnerships and power asymmetries shape the formation of partnerships for global health. We draw on a psychosocial theory of partnerships to examine community group members’ understanding of self and other as they position themselves for partnerships with non-governmental organisations. Methods: This mixed qualitative methods study was conducted in the Matobo district of Matabeleland South province in Zimbabwe. The study draws on the perspectives of 90 community group members (29 men and 61 women) who participated in a total of 19 individual in-depth interviews and 9 focus group discussions (n = 71). The participants represented an array of different community groups and different levels of experience of working with NGOs. Verbatim transcripts were imported into Atlas.Ti for thematic indexing and analysis. Results: Group members felt they played a central role in the HIV response. Accepting there is a limit to what they can do in isolation, they actively sought to position themselves as potential partners for NGOs. Partnerships with NGOs were said to enable community groups to respond more effectively as well as boost their motivation and morale. However, group members were also acutely aware of how they should act and perform if they were to qualify for a partnership. They spoke about how they had to adopt various strategies to become attractive partners and ‘supportable’ – including being active and obedient. Conclusions: Many community groups in Zimbabwe recognise their role in the HIV response and actively navigate representational systems of self and other to showcase themselves as capable actors. While this commitment is admirable, the dynamics that govern this process reflect knowledge encounters and power asymmetries that are conditioned by the aid architecture, undermining aspiring efforts for more equitable partnerships from the get-go

Understanding early uptake of PrEP by female sex workers in Zimbabwe.

Female sex workers (FSW) are prioritised for increased access to pre-exposure prophylaxis (PrEP), although rates of uptake remain sub-optimal, particularly across Southern Africa. In the first two years of its availability in Zimbabwe, 37.1% of FSW in trial sites initiated PrEP and received at least one re-supply. We conducted a qualitative study on perceptions of PrEP among 19 early users selected from sites with varying rates of PrEP initiation. Narrative interviews examined the pathways taken by FSW from hearing about PrEP, through their decision to start taking it, and early experiences. FSW appreciated PrEP's introduction within familiar and trusted "friendly" services tailored for sex workers and valued positive encouragement from clinic staff and peers over negative influence from family members. They also found PrEP difficult to understand at first, and feared side effects and rare adverse complications described in information leaflets. While FSW identified individual strategies for remembering to take their medication, they also relied on structured peer adherence support, leading some FSW to actively promote the method to other FSW as "PrEP champions". Information on how early users experience a new prevention technology such as PrEP can inform design of interventions that leverage existing support structures and target key barriers

Mobility and sex work: why, where, when? A typology of female-sex-worker mobility in Zimbabwe.

Sex-worker mobility may have implications for health and access to care but has not been described in sub-Saharan Africa. We described sex-worker mobility in Zimbabwe and a mobility typology using data from 2591 and 2839 female sex workers in 14 sites from 2013 and 2016. We used latent class analysis to identify a typology of mobile sex workers. More women travelled for work in 2016 (59%) than in 2013 (27%), usually to find clients with more money (57% of the journeys), spending a median of 21 (2013) and 24 (2016) days away. A five-class mixture model best fitted the data, with 39% women in an infrequent work-mobility class, 21% in a domestic-high-mobility class, 16% in an international-high-mobility class, 16% in an infrequent opportunistic-non-work-mobility class, and 7% who travel with clients. More-mobile classes were better educated; risk behaviours differed by class. Mobility is increasing among sex worker in Zimbabwe, multi-faceted, and not explained by other vulnerabilities

Can HIV recent infection surveillance help us better understand where primary prevention efforts should be targeted? Results of three pilots integrating a recent infection testing algorithm into routine programme activities in Kenya and Zimbabwe.

INTRODUCTION: Surveillance of recent HIV infections in national testing services has the potential to inform primary prevention programming activities. Focusing on procedures required to accurately determine recent infection, and the potential for recent infection surveillance to inform prevention efforts, we present the results of three independent but linked pilots of recency testing. METHODS: To distinguish recently acquired HIV infection from long-standing infection, in 2018 we applied a Recent Infection Testing Algorithm that combined a laboratory-based Limiting Antigen Avidity Enzyme Immunoassay with clinical information (viral-load; history of prior HIV diagnosis; antiretroviral therapy-exposure). We explored potential misclassification of test results and analysed the characteristics of participants with recent infection. We applied the algorithm in antenatal clinics providing prevention of mother-to-child transmission services in Siaya County, Kenya, outreach sites serving female sex workers in Zimbabwe, and routine HIV testing and counselling facilities in Nairobi, Kenya. In Nairobi, we also conducted recency testing among partners of HIV-positive participants. RESULTS: In Siaya County, 2.3% (10/426) of HIV-positive pregnant women were classified as recent. A risk factor analysis comparing women testing recent with those testing HIV-negative found women in their first trimester were significantly more likely to test recent than those in their second or third trimester. In Zimbabwe, 10.5% (33/313) of female sex workers testing HIV-positive through the outreach programme were classified recent. A risk factor analysis of women testing recent versus those testing HIV-negative, found no strong evidence of an association with recent infection. In Nairobi, among 532 HIV-positive women and men, 8.6% (46) were classified recent. Among partners of participants, almost a quarter of those who tested HIV-positive were classified as recent (23.8%; 5/21). In all three settings, the inclusion of clinical information helped improve the positive predictive value of recent infection testing by removing cases that were likely misclassified. CONCLUSIONS: We successfully identified recently acquired infections among persons testing HIV-positive in routine testing settings and highlight the importance of incorporating additional information to accurately classify recent infection. We identified a number of groups with a significantly higher proportion of recent infection, suggesting recent infection surveillance, when rolled-out nationally, may help in further targeting primary prevention efforts

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

INTRODUCTION: Testing for recent HIV infection can distinguish recently acquired infection from long-standing infections. Given current interest in the implementation of recent infection testing algorithms (RITA), we report our experiences in implementing a RITA in three pilot studies and highlight important issues to consider when conducting recency testing in routine settings. METHODS: We applied a RITA, incorporating a limited antigen (LAg) avidity assay, in different routine HIV service-delivery settings in 2018: antenatal care clinics in Siaya County, Kenya, HIV testing and counselling facilities in Nairobi, Kenya, and female sex workers clinics in Zimbabwe. Discussions were conducted with study coordinators, laboratory leads, and facility-based stakeholders to evaluate experiences and lessons learned in relation to implementing recency testing. RESULTS: In Siaya County 10/426 (2.3%) of women testing HIV positive were classified as recent, compared to 46/530 (8.7%) of women and men in Nairobi and 33/313 (10.5%) of female sex workers in Zimbabwe. Across the study setting, we observed differences in acceptance, transport and storage of dried blood spot (DBS) or venous blood samples. For example, the acceptance rate when testing venous blood was 11% lower than when using DBS. Integrating our study into existing services ensured a quick start of the study and kept the amount of additional resources required low. From a laboratory perspective, the LAg avidity assay was initially difficult to operationalise, but developing a network of laboratories and experts to work together helped to improve this. A challenge that was not overcome was the returning of RITA test results to clients. This was due to delays in laboratory testing, the need for multiple test results to satisfy the RITA, difficulties in aligning clinic visits, and participants opting not to return for test results. CONCLUSION: We completed three pilot studies using HIV recency testing based on a RITA in Kenya and Zimbabwe. The main lessons we learned were related to sample collection and handling, LAg avidity assay performance, integration into existing services and returning of test results to participants. Our real-world experience could provide helpful guidance to people currently working on the implementation of HIV recency testing in sub-Saharan Africa

Estimating the Population Size of Female Sex Workers in Zimbabwe: Comparison of Estimates Obtained Using Different Methods in Twenty Sites and Development of a National-Level Estimate.

BACKGROUND: National-level population size estimates (PSEs) for hidden populations are required for HIV programming and modelling. Various estimation methods are available at the site-level, but it remains unclear which are optimal and how best to obtain national-level estimates. SETTING: Zimbabwe. METHODS: Using 2015-2017 data from respondent-driven sampling (RDS) surveys among female sex workers (FSW) aged 18+ years, mappings, and program records, we calculated PSEs for each of the 20 sites across Zimbabwe, using up to 3 methods per site (service and unique object multipliers, census, and capture-recapture). We compared estimates from different methods, and calculated site medians. We estimated prevalence of sex work at each site using census data available on the number of 15-49-year-old women, generated a list of all "hotspot" sites for sex work nationally, and matched sites into strata in which the prevalence of sex work from sites with PSEs was applied to those without. Directly and indirectly estimated PSEs for all hotspot sites were summed to provide a national-level PSE, incorporating an adjustment accounting for sex work outside hotspots. RESULTS: Median site PSEs ranged from 12,863 in Harare to 247 in a rural growth-point. Multiplier methods produced the highest PSEs. We identified 55 hotspots estimated to include 95% of all FSW. FSW nationally were estimated to number 40,491, 1.23% of women aged 15-49 years, (plausibility bounds 28,177-58,797, 0.86-1.79%, those under 18 considered sexually exploited minors). CONCLUSION: There are large numbers of FSW estimated in Zimbabwe. Uncertainty in population size estimation should be reflected in policy-making

The distribution of sex acts and condom use within partnerships in a rural sub-Saharan African population

Introduction In an HIV/AIDS epidemic driven primarily by heterosexual transmission, it is important to have an understanding of the human sexual behaviour patterns that influence transmission. We analysed the distribution and predictors of within-partnership sexual behaviour and condom use in rural Zimbabwe and generated parameters for use in future modelling analyses. Methods A population-based cohort was recruited from a household census in 12 communities. A baseline survey was carried out in 1998–2000 with follow-up surveys after 3 and 5 years. Statistical distributions were fitted to reported within-partnership numbers of total, unprotected and protected sex acts in the past two weeks. Multilevel linear and logistic regression models were constructed to assess predictors of the frequency of unprotected sex and consistent condom use. Results A normal distribution of ln(sex acts+1) provided the best fit for total and unprotected sex acts for men and women. A negative binomial distribution applied to the untransformed data provided the best fit for protected sex acts. Condom use within partnerships was predominantly bimodal with at least 88% reporting zero or 100% use. Both men and women reported fewer unprotected sex acts with non-regular compared to regular partners (men: 0.26 fewer every two weeks (95% confidence interval 0.18–0.34); women: 0.16 (0.07–0.23)). Never and previously married individuals reported fewer unprotected sex acts than currently married individuals (never married men: 0.64 (0.60–0.67); previously married men: 0.59 (0.50–0.67); never married women: 0.51 (0.45–0.57); previously married women: 0.42 (0.37–0.47)). These variables were also associated with more consistent condom use. Discussion We generated parameters that will be useful for defining transmission models of HIV and other STIs, which rely on a valid representation of the underlying sexual network that determines spread of an infection. This will enable a better understanding of the spread of HIV and other STDs in this rural sub-Saharan population. Figures Table 3Table 1Figure 1Figure 2Figure 3Table 2Figure 4Table 3Table 1Figure 1Figure

Summary of data.

<p>NOTE. NA, not applicable, as individuals may be resampled from round to round but partnerships are not; hence the number of individuals in each round also does not sum across all rounds.</p><p>* Data on up to two recent partners was collected in rounds 1 and 2, and up to three for round 3. For consistency, the third reported partner was omitted for the calculated mean partners per individual and standard deviation for round 3, where one existed (n = 34 for men and n = 2 for women).</p

Overlaid histograms showing the distributions of the numbers of sex acts (total, unprotected and protected) with a specified partner within the last two weeks for (A) men and (B) women.

<p>Note that the line for total sex acts is lower than that for either unprotected or protected sex acts at zero because individuals reporting either zero unprotected or protected sex acts did not often report zero sex acts in total (due to the observed bimodal pattern of condom use described later).</p