HIV decline in Zimbabwe due to reductions in risky sex? Evidence from a comprehensive epidemiological review

Background Recent data from antenatal clinic (ANC) surveillance and general population surveys suggest substantial declines in human immunodeficiency virus (HIV) prevalence in Zimbabwe. We assessed the contributions of rising mortality, falling HIV incidence and sexual behaviour change to the decline in HIV prevalence. Methods Comprehensive review and secondary analysis of national and local sources on trends in HIV prevalence, HIV incidence, mortality and sexual behaviour covering the period 1985-2007. Results HIV prevalence fell in Zimbabwe over the past decade (national estimates: from 29.3% in 1997 to 15.6% in 2007). National census and survey estimates, vital registration data from Harare and Bulawayo, and prospective local population survey data from eastern Zimbabwe showed substantial rises in mortality during the 1990s levelling off after 2000. Direct estimates of HIV incidence in male factory workers and women attending pre- and post-natal clinics, trends in HIV prevalence in 15-24-year-olds, and back-calculation estimates based on the vital registration data from Harare indicated that HIV incidence may have peaked in the early 1990s and fallen during the 1990s. Household survey data showed reductions in numbers reporting casual partners from the late 1990s and high condom use in non-regular partnerships between 1998 and 2007. Conclusions These findings provide the first convincing evidence of an HIV decline accelerated by changes in sexual behaviour in a southern African country. However, in 2007, one in every seven adults in Zimbabwe was still infected with a life-threatening virus and mortality rates remained at crisis leve

Brand equity and willingness to pay for condoms in zimbabwe

<p>Abstract</p> <p>Background</p> <p>Zimbabwe suffers from one of the greatest burdens of HIV/AIDS in the world that has been compounded by social and economic instability in the past decade. However, from 2001 to 2009 HIV prevalence among 15-49 year olds declined from 26% to approximately 14%. Behavior change and condom use may in part explain this decline.</p> <p>PSI-Zimbabwe socially markets the Protector Plus (P+) branded line of condoms. When Zimbabwe converted to a dollar-based economy in 2009, the price of condoms was greatly increased and new marketing efforts were undertaken. This paper evaluates the role of condom marketing, a multi-dimensional scale of brand peceptions (brand equity), and price in condom use behavior.</p> <p>Methods</p> <p>We randomly sampled sexually active men age 15-49 from 3 groups - current P+ users, former users, and free condom users. We compared their brand equity and willingness to pay based on survey results. We estimated multivariable logistic regression models to compare the 3 groups.</p> <p>Results</p> <p>We found that the brand equity scale was positive correlated with willingness to pay and with condom use. Former users also indicated a high willingness to pay for condoms. We found differences in brand equity between the 3 groups, with current P+ users having the highest P+ brand equity. As observed in previous studies, higher brand equity was associated with more of the targeted health behavior, in this case and more consistent condom use.</p> <p>Conclusions</p> <p>Zimbabwe men have highly positive brand perceptions of P+. There is an opportunity to grow the total condom market in Zimbabwe by increasing brand equity across user groups. Some former users may resume using condoms through more effective marketing. Some free users may be willing to pay for condoms. Achieving these objectives will expand the total condom market and reduce HIV risk behaviors.</p

Innovative demand creation strategies to increase voluntary medical male circumcision uptake: a pragmatic randomised controlled trial in Zimbabwe.

INTRODUCTION: Reaching men aged 20-35 years, the group at greatest risk of HIV, with voluntary medical male circumcision (VMMC) remains a challenge. We assessed the impact of two VMMC demand creation approaches targeting this age group in a randomised controlled trial (RCT). METHODS: We conducted a 2×2 factorial RCT comparing arms with and without two interventions: (1) standard demand creation augmented by human-centred design (HCD)-informed approach; (2) standard demand creation plus offer of HIV self-testing (HIVST). Interpersonal communication (IPC) agents were the unit of randomisation. We observed implementation of demand creation over 6 months (1 May to 31 October 2018), with number of men circumcised assessed over 7 months. The primary outcome was the number of men circumcised per IPC agent using the as-treated population of actual number of months each IPC agent worked. We conducted a mixed-methods process evaluation within the RCT. RESULTS: We randomised 140 IPC agents, 35 in each arm. 132/140 (94.3%) attended study training and 105/132 (79.5%) reached at least one client during the trial period and were included in final analysis. There was no evidence that the HCD-informed intervention increased VMMC uptake versus no HCD-informed intervention (incident rate ratio (IRR) 0.87, 95% CI 0.38 to 2.02; p=0.75). Nor did offering men a HIVST kit at time of VMMC mobilisation (IRR 0.65, 95% CI 0.28 to 1.50; p=0.31). Among IPC agents that reported reaching at least one man with demand creation, both the HCD-informed intervention and HIVST were deemed useful. There were some challenges with trial implementation; <50% of IPC agents converted any men to VMMC, which undermined our ability to show an effect of demand creation and may reflect acceptability and feasibility of the interventions. CONCLUSION: This RCT did not show evidence of an effect of HCD-informed demand intervention or HIVST on VMMC uptake. Findings will inform future design and implementation of demand creation evaluations. TRIAL REGISTRATION NUMBER: PACTR201804003064160

Relative efficiency of demand creation strategies to increase voluntary medical male circumcision uptake: a study conducted as part of a randomised controlled trial in Zimbabwe.

BACKGROUND: Supply and demand-side factors continue to undermine voluntary medical male circumcision (VMMC) uptake. We assessed relative economic costs of four VMMC demand creation/service-delivery modalities as part of a randomised controlled trial in Zimbabwe. METHODS: Interpersonal communication agents were trained and incentivised to generate VMMC demand across five districts using four demand creation modalities (standard demand creation (SDC), demand creation plus offer of HIV self-testing (HIVST), human-centred design (HCD)-informed approach, HCD-informed demand creation approach plus offer of HIVST). Annual provider financial expenditure analysis and activity-based-costing including time-and-motion analysis across 15 purposively selected sites accounted for financial expenditures and donated inputs from other programmes and funders. Sites represented three models of VMMC service-delivery: static (fixed) model offering VMMC continuously to walk-in clients at district hospitals and serving as a district hub for integrated mobile and outreach services, (2) integrated (mobile) modelwhere staff move from the district static (fixed) site with their commodities to supplement existing services or to recently capacitated health facilities, intermittently and (3) mobile/outreach model offering VMMC through mobile clinic services in more remote sites. RESULTS: Total programme cost was $752 585 including VMMC service-delivery costs and average cost per client reached and cost per circumcision were$58 and $174, respectively. Highest costs per client reached were in the HCD arm-$68 and lowest costs in standard demand creation ($52) and HIVST ($55) arms, respectively. Highest cost per client circumcised was observed in the arm where HIVST and HCD were combined ($226) and the lowest in the HCD alone arm ($160). Across the three VMMC service-delivery models, unit cost was lowest in static (fixed) model ($54) and highest in integrated mobile model ($63). Overall, economies of scale were evident with unit costs lower in sites with higher numbers of clients reached and circumcised. CONCLUSIONS: There was high variability in unit costs across arms and sites suggesting opportunities for cost reductions. Highest costs were observed in the HCD+HIVST arm when combined with an integrated service-delivery setting. Mobilisation programmes that intensively target higher conversion rates as exhibited in the SDC and HCD arms provide greater scope for efficiency by spreading costs. TRIAL REGISTRATION NUMBER: PACTR201804003064160

Efficiency in PrEP Delivery: Estimating the Annual Costs of Oral PrEP in Zimbabwe.

Although oral PrEP is highly effective at preventing HIV acquisition, optimizing continuation among beneficiaries is challenging in many settings. We estimated the costs of delivering oral PrEP to populations at risk of HIV in seven clinics in Zimbabwe. Full annual economic costs of oral PrEP initiations and continuation visits were estimated from the providers' perspective for a six-clinic NGO network and one government SGBV clinic in Zimbabwe (January-December 2018). Disaggregating costs of full initiation and incremental follow-up visits enabled modeling of the impact of duration of continuation on the cost per person-year ($pPY) on PrEP. 4677 people initiated oral PrEP, averaging 2.7 follow-up visits per person. Average cost per person initiated was$238 ($183-$302 across the NGO clinics; $86 in the government facility). The full cost per initiation visit, including central and direct costs, was$178, and the incremental cost per follow-up visit, capturing only additional resources used directly in the follow up visits, was $22. The average duration of continuation was 3.0 months, generating an average$pPY of $943, ranging from$839 among adolescent girls and young women to $1219 in men. Oral PrEP delivery costs varied substantially by scale of initiations and by duration of continuation and type of clinic. Extending the average oral PrEP continuation from 2.7 to 5 visits (about 6 months) would greatly improve service efficiency, cutting the$pPY by more than half

ZIMBABWE (2009): EVALUATING COVERAGE AND QUALITY OF COVERAGE OF PROTECTOR PLUS CONDOMS IN ZIMBABWE. ROUND FOUR

This round of MAP survey was conducted to assess the geographical coverage and quality of coverage of Protector Plus male condoms using districts and selected high risk areas as supervision areas. In addition, the study also estimated levels of penetration by computing the proportion of outlets stocking condoms. Lot Quality Assurance Sampling techniques (LQAS) was used to draw a sample of 19 Wards within each geographic category. A sample size of 19 gives reasonably accurate estimates with an acceptable error margin for decision making (Annex). Geographic categories, also called supervision areas, in which data was collected included: districts (all 61 districts were included), and high risk areas (19 growth points and 5 border towns). In cases where districts had fewer that 19 Wards a census of all the Wards was done. Wards where no outlets could be found were considered to be with no coverage i.e. no replacement was done. In the sampled Wards a comprehensive auditing of all outlets was done because the universe of outlets is not known. This LQAS assessment of coverage determines the proportion of wards in each supervision area in which Protector Plus condoms are available. LQAS also determines quality of coverage, i.e. the proportion of wards in each supervision area, in which Protector Plus conforms to additional minimum standards of quality. Data were collected in May-June 2009. Processing of data was done with Health Mapper and SPSS Version 17.0

Zimbabwe (2006): Concurrent Heterosexual Partnerships, HIV Risk and Related Determinants among the General Population, Zimbabwe

To better understand concurrent sexual relationships in Zimbabwe, Population Services International commissioned a qualitative study to increase understanding of potential psycho social determinants for engagement in these relationships. The current study design was guided by PSI's PERForM framework and utilized methodologies from FoQus on Scales (Chapman & Patel, 2004; Population Services International, Zimbabwe, 2007). FoQus on Scales provides a qualitative methodological approach to increase "emic" (insiders) perspectives in the processes of describing the contexts of specific health-related behaviors. A stratified purposeful sampling strategy was utilized with stratification based on gender, age (18 to 24 years; 25 to 40 years), and residency (urban; rural). Two types of focus groups were conducted including those designed to identify and de fine emergent determinants (phase one) and those designed to verify and define existing determinants (phase two). A total of twenty four focus groups were conducted with six participants per focus group. Urban participants were from Harare and rural participants were from Nzvimbo, Musiiwa, Shamva, Murehwa, and Mubaira, all located within 200 kilometers of Harare. Semi-structured interview guides were utilized to conduct the focus groups. The data analysis included four primary steps: 1) coding of data; 2) compilation of data by codes; 3) synthesis of the data; and, 4) review of data to develop/adapt definitions for the identified and verified determinants

Zimbabwe (2009): Maternal and Child Health TRaC Study Evaluating Malaria Prevention Behavior among Adults in Malaria Endemic Areas of Zimbabwe. Round One

Specifically, this survey investigates baseline levels in mosquito net ownership and use and malaria treatment with ACT drugs behaviors as well as monitoring indicators of opportunity, ability, and motivation in all malarial areas of Zimbabwe. In addition, the study assesses impact of PSI Zimbabwe's social marketing instruments. Findings on malaria treatment will be reported separately. The study utilized a two stage cluster design. In the first stage, enumeration areas (EAs) were randomly selected using probability proportionate to size. EAs are geographic areas used for sampling purposes. In the second stage, households within the selected EAs were selected using simple random sampling. In households where more than one eligible respondent was available, a respondent was randomly selected using the Kish grid method. If there were no people at a selected household, two callbacks were done before substitution with the adjacent household. At least three callbacks were done before substituting the selected person in selected household. Substitution was also done when the initially selected respondent refused to be interviewed. A sample size of 1,509 interviews were conducted in the malaria endemic areas. Analysis was performed using SPSS version 16.0 and results presented in PSI Dashboard format. Comparison was made between PSI program areas vers us non-program areas, all in malarial areas, using UNIANOVA controlling for socio-demographic characteristics and geographic location. The segmentation models were based on binary logistic regression in which explanatory variables were dropped if found not to significantly contribute to explanation of the variance. Adjusted means or proportions were presented for explanatory variables which remained in the final logistic regression model, adjusting for significant explanatory variables in the model as well as the design variable (Enumeration Area)

Zimbabwe (2006): HIV Prevention TRaC Study among the General Population (15-49 years) Second Round

For all the two survey rounds, adult population, ages 15-49 years were interviewed. The respondents were chosen from the same enumeration areas as was in the first round for comparability. A total of 2200 respondents were interviewed in the 2006 survey. This is equally split between urban and rural areas (50% urban and 50% rural). Additionally, more than half of the sample is not married (51%), is between the ages of 15-29 (68%), and has secondary education (65%). The gender distribution is 48% women and 52% men. For the two rounds, the data collection tool was a questionnaire using dichotomous (yes/no) measures questions to measure population characteristics, exposure to (recall of) PSI activities, reported behaviors, and the presumed determinants of those behaviors grouped under the headings of opportunity, ability and motivation per the PSI Behavior Change Framework (Chapman and Patel, 2004). Four and five-point Likert scales were also used to provide a richer measure of behavioral determinants such as perceptions of product and service availability, outcome expectations and other constructs. The measures for these variables were constructed based on prior research and were included in the analysis after conducting a reliability and validity check where applicable. After data collection, logistic regression, analysis of variance, and other descriptive statistics were used to perform the monitoring, evaluation, and segmentation analysis

Zimbabwe (2009): FOQus for Marketing Planning, Concept development for Multiple Concurrent Sexual Partnerships

FoQus for Marketing Planning is the process of exploring the determinants of behavior of a target audience and shaping and refining an idea into a complete description for branding a behavior, product or service. It uses qualitative research to facilitate more effective social marketing activities and give voice to the target audience. FoQus for Marketing Plannning uses segmentation data from previous TRaC studies, as well as any formative qualitative research that has been conducted, in order to further establish and explore the various determinants of behavior of the target population. Together, researchers and marketers identify the primary areas of inquiry, which will be researched and will drive programming and branding decision-making. The six-step process listed below is used to design the concept. For steps one through four qualitative methods are used to generate insight and understanding relevant for designing social marketing communication activities. The last two steps involve application of these findings to create specific social marketing outputs