Relationships between changes in HIV risk perception and condom use in East Zimbabwe 2003-2013: population-based longitudinal analyses

Background: Perceiving a personal risk for HIV infection is considered important for engaging in HIV prevention behaviour and often targeted in HIV prevention interventions. However, there is limited evidence for assumed causal relationships between risk perception and prevention behaviour and the degree to which change in behaviour is attributable to change in risk perception is poorly understood. This study examines longitudinal relationships between changes in HIV risk perception and in condom use and the public health importance of changing risk perception. Methods: Data on sexually active, HIV-negative adults (15-54 years) were taken from four surveys of a general-population open-cohort study in Manicaland, Zimbabwe (2003-2013). Increasing condom use between surveys was modelled in generalised estimating equations dependent on change in risk perception between surveys. Accounting for changes in other socio-demographic and behavioural factors, regression models examined the bi-directional relationship between risk perception and condom use, testing whether increasing risk perception is associated with increasing condom use and whether increasing condom use is associated with decreasing risk perception. Population attributable fractions (PAFs) were estimated. Results: One thousand, nine hundred eighty-eight males and 3715 females participated in ≥2 surveys, contributing 8426 surveys pairs. Increasing risk perception between two surveys was associated with higher odds of increasing condom use (males: adjusted odds ratio [aOR] = 1.39, 95% confidence interval [CI] = 0.85-2.28, PAF = 3.39%; females: aOR = 1.41 [1.06-1.88], PAF = 6.59%), adjusting for changes in other socio-demographic and behavioural factors. Those who decreased risk perception were also more likely to increase condom use (males: aOR = 1.76 [1.12-2.78]; females: aOR = 1.23 [0.93-1.62]) compared to those without change in risk perception. Conclusions: Results on associations between changing risk perception and increasing condom use support hypothesised effects of risk perception on condom use and effects of condom use on risk perception (down-adjusting risk perception after adopting condom use). However, low proportions of change in condom use were attributable to changing risk perception, underlining the range of factors influencing HIV prevention behaviour and the need for comprehensive approaches to HIV prevention

Accuracy of HIV risk perception in East Zimbabwe 2003–2013

Risk perception for HIV infection is an important determinant for engaging in HIV prevention behaviour. We investigate the degree to which HIV risk perception is accurate, i.e. corresponds to actual HIV infection risks, in a general-population open-cohort study in Zimbabwe (2003–2013) including 7201 individuals over 31,326 person-years. Risk perception for future infection (no/yes) at the beginning of periods between two surveys was associated with increased risk of HIV infection (Cox regression hazard ratio = 1.38 [1.07–1.79], adjusting for socio-demographic characteristics, sexual behaviour, and partner behaviour). The association was stronger among older people (25+ years). This suggests that HIV risk perception can be accurate but the higher HIV incidence (1.27 per 100 person-years) illustrates that individuals may face barriers to HIV prevention behaviour even when they perceive their risks. Gaps in risk perception are underlined by the high incidence among those not perceiving a risk (0.96%), low risk perception even among those reporting potentially risky sexual behaviour, and, particularly, lack of accuracy of risk perception among young people. Innovative interventions are needed to improve accuracy of risk perception but barriers to HIV prevention behaviours need to be addressed too, which may relate to the partner, community, or structural factors

A longitudinal review of national HIV policy and progress made in health facility implementation in Eastern Zimbabwe.

BACKGROUND: In recent years, WHO has made major changes to its guidance on the provision of HIV care and treatment services. We conducted a longitudinal study from 2013 to 2015 to establish how these changes have been translated into national policy in Zimbabwe and to measure progress in implementation within local health facilities. METHODS: National HIV programme policy guidelines published between 2003 and 2013 (n = 9) and 2014 and 2015 (n = 5) were reviewed to assess adoption of WHO recommendations on HIV testing services, prevention of mother-to-child transmission (PMTCT) of HIV, and provision of antiretroviral therapy (ART). Changes in local implementation of these policies over time were measured in two rounds of a survey conducted at 36 health facilities in Eastern Zimbabwe in 2013 and 2015. RESULTS: High levels of adoption of WHO guidance into national policy were recorded, including adoption of new recommendations made in 2013-2015 to introduce PMTCT Option B+ and to increase the threshold for ART initiation from CD4 ≤ 350 cells/mm3 to ≤ 500 cells/mm3. New strategies to implement national HIV policies were introduced such as the decentralisation of ART services from hospitals to clinics and task-shifting of care from doctors to nurses. The proportions of health facilities offering free HIV testing and counselling, PMTCT (including Option B+) and ART services increased substantially from 2013 to 2015, despite reductions in numbers of health workers. Provision of provider-initiated HIV testing remained consistently high. At least one test-kit stock-out in the prior year was reported in most facilities (2013: 69%; 2015: 61%; p = 0.44). Stock-outs of first-line ART and prophylactic drugs for opportunistic infections remained low. Repeat testing for HIV-negative individuals within 3 months decreased (2013: 97%; 2015: 72%; p = 0.01). Laboratory testing remained low across both survey rounds, despite policy and operational guidelines to expand coverage of diagnostic services. CONCLUSIONS: Good progress has been made in implementing international guidance on HIV service delivery in Zimbabwe. Further novel implementation strategies may be needed to achieve the latest targets for universal ART eligibility