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 &amp; 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.</p

"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

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

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

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

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. 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. 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. 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. 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

HIV prevention in individuals engaged in sex work

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

Effect of prices, distribution strategies, and marketing factors on demand for HIV self-tests in Zimbabwe: A randomized clinical trial

Importance: HIV self-testing (HIVST) is a promising approach for increasing awareness of HIV status in sub-Saharan Africa, but evidence is lacking on optimal pricing policies and delivery strategies for maximizing the impact of HIVST. Objective: Assess demand for HIV self-tests among adults and priority population subgroups under alternative pricing and distribution strategies. Design: Randomized trial between February 15, 2018 and May 25, 2018. A factorial design was used to randomly assign participants to a combination of self-test price, distribution site, and promotion message. Setting: Urban and rural communities in Zimbabwe Participants: Individuals aged ≥16 years Intervention: Participants were given a voucher enabling them to redeem an HIV self-test within 1 month at varying prices (US$0-US$3) and distribution sites (clinics or pharmacies in urban areas, retail stores or community health workers in rural areas). Vouchers included randomly assigned promotion messages that emphasized benefits of HIV testing. Main Outcome and Measure: Proportion of participants who obtained self-tests in each trial arm, measured by distributor records. Results: Among 4,787 individuals assessed for eligibility, 4,000 were enrolled. Participants’ average age was 35 years, 71% were female, and 66% were married. Self-test demand was highly price-sensitive; 260 participants (32.5%) offered free self-tests redeemed vouchers compared with 55 (6.9%) participants offered self-tests for US$0.5 (odds ratio, OR, 0.14, 95$1, $2, and$3 groups, significantly lower than the free distribution group. In pooled analyses, demand was considerably lower among participants in groups with price >$0 compared to the free distribution group (2.8% vs. 32.5%, OR 0.05, 95% CI 0.04-0.07). In urban areas, demand was significantly higher with pharmacy-based distribution versus clinic-based distribution (6.8% vs. 2.9%, adjusted odds ratio, 2.78, 95% CI 1.74–4.45). Price sensitivity was significantly higher among rural residents, men, and those who had never tested before. Promotion messages did not influence demand. Conclusions and Relevance: Demand for HIV self-tests in Zimbabwe is highly price-sensitive. Free distribution may be essential for promoting testing among high priority population groups. Pharmacy-based distribution is preferable to clinic-based distribution in urban areas. Trial Registration: NCT0355995

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

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

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

INTRODUCTION: Early diagnosis of HIV is critical for epidemic control. To achieve this, successful testing programmes are essential and test positivity is often used as a marker of their performance. The aim of this study was to analyse trends and predictors of HIV test positivity over time and explore how an understanding of seroconversion rates could build on our interpretation of this indicator among female sex workers in Zimbabwe. METHODS: We analysed HIV test data from Zimbabwe's nationally scaled sex work programme between 2009 and 2019. We defined test positivity as the proportion of all tests that were HIV positive and measured new diagnoses by estimating seroconversion rates among women with repeat tests, defined as an HIV-positive test after at least one HIV-negative test in the programme. We used logistic regression to analyse test positivity over three time-periods: 2009-2013, 2014-2017 and 2018-2019, adjusting for potential confounding by demographic factors and the mediating effects of time since last HIV test. We calculated the seroconversion rates for the same time-periods. RESULTS: During the 10-year study period, 54,503 tests were recorded in 39,462 women. Between 2009 and 2013, 18% of tests were among women who reported testing in the previous 6 months. By 2018-2019, this had increased to 57%. Between 2018 and 2019, test positivity was 9.6%, compared to 47.9% for 2009-2013 (aOR 6.08 95% CI 5.52-6.70) and 18.8% for 2014-2017 (aOR 2.17 95% CI 2.06-2.28). Adjusting for time since last test reduced effect estimates for 2009-2013 (aOR 4.03 95% CI 3.64-4.45) and 2014-2017 (aOR 1.97 95% CI 1.86-2.09) compared to 2018-2019. Among 7573 women with an initial HIV-negative test in the programme and at least one subsequent test, 464 tested HIV positive at a rate of 3.9 per 100 pyar (95% CI 3.5-4.2). CONCLUSIONS: Test positivity decreased among women testing through the programme over time, while seroconversion rates remained high. These declines were partly driven by changes in individual testing history, reflecting comprehensive coverage of testing services and greater knowledge of HIV status, but not necessarily declining rates of seroconversion. Understanding testing history and monitoring new HIV infections from repeat tests could strengthen the interpretation of test positivity and provide a better understanding of programme performance