HIV Prevalence and Risk Behaviors Among Female Sex Workers in Botswana: Results from the 2012 HIV/STI Bio-Behavioral Study.

To evaluate HIV/STI prevalence among female sex workers (FSWs) in Botswana, and assess HIV-related risk behaviors. Cross-sectional study using time-location sampling in three districts of Botswana. Adjusted HIV prevalence at district level ranged from 53.5 to 68.5 %. Syphilis prevalence ranged from 3.7 to 14.5 %; chlamydia prevalence ranged from 4.8 to 16.3 %; and gonorrhoea prevalence ranged from 8.3 to 11.7 %. FSWs had been practicing sex work for a mean of 4.7 years, and had a mean of 7.6 sex partners in the week before the survey. While 67.1 % of FSWs surveyed reported always using condoms with clients in the past month. 59.5 % reported one or more of the following: being paid more not to use a condom, having a condom break, or being forced not to use a condom by clients. Predictors of HIV infection in the multivariate analysis included: age (over 30 years), perceiving oneself to be at high risk of HIV, selling sex for 2 or more years, and having a mean of 11 or more partners in the last week. High HIV prevalence, high rates of partner exchange, a sizable population, and Inconsistent condom use combine together help fuel the country's hyper epidemic. HIV prevention interventions need to take into account the important influence of clients and boyfriends on condom use behavior.

Use of mHealth Solutions for Improving Access to Adolescents' Sexual and Reproductive Health Services in Resource-Limited Settings: Lessons From Zimbabwe.

Background: Gaps still exist in reducing new HIV infections among adolescent girls and young women (AGYW) aged 10-24 years. High Internet coverage and mobile phone penetration rates present opportunities for the use of mobile health (mHealth) to support access to health services. We present results of an FHI 360 and Zimbabwe Health Interventions-implemented mHealth intervention for reproductive health (RH) and HIV testing service (HTS) referral among AGYW aged 10-19 years between October 2019 and September 2020. Methods: Adolescent girls and young women referred for RH and HTS under the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) program had automatic reminders sent to their phones to facilitate access to services through short message service (SMS) and also using a paper-based system. These data were captured in a web-based District Health Information System (DHIS) database, which captured the referral completion status of the AGYW. Data for AGYW referred for RH and HTS for the period October 2018 to September 2019 for the paper-based system and October 2018 to September 2020 for the mHealth were extracted from District Health Information System version 2 (DHIS2) database and analyzed using SPSS to generate descriptive statistics. The Chi-square test was used to assess differences in referral completion rates by age-group; marital status, district, and type of service, as well as differences between mHealth and paper-based referral completion rates within each of the groups for the variables above. Results: A total of 8,800 AGYW referred for RH and HTS, where 4,355 and 4,445 were referred through the mHealth and paper-based systems, respectively. About 95.2% (4,148/4,355) and 87.8% (3,903/4,445) referred through mHealth and the paper-based system, respectively completed referrals. The median time for referral completion was 1 day (Range = 0-9 days) for mHealth and 11 days (Range = 0-28 days) for the paper-based system. AGYW referred through mHealth were 17.995 times more likely to complete the referral system than those referred through the paper-based system (OR =17.995; p <0.001). Conclusion: Compared to the paper-based referral system the mHealth solution resulted in a higher, service referral completion rates and shorter turnaround time. We recommend expansion of the mHealth solution to all DREAMS supported districts to increase uptake of RH and HTS among AGYW aged 10-19 years.

High HIV Positivity Rates Following Large-Scale HIV Self-Testing Implementation in Zimbabwe, 2018-2020.

Introduction: HIV self-testing (HIV-ST) is an innovative strategy to increase HIV case identification. This analysis shares the outcomes of HIV-ST implementation within the Zimbabwe HIV Care and Treatment (ZHCT) project for the period October 2018-March, 2020. Materials and Methods: We extracted HIV-ST data for the period October 2018 to March 2020 from the project database and assessed (1) the proportion of reactive HIV-ST results; (2) the concordance between reactive HIV-ST results against rapid confirmatory HIV tests using Determine™ and Chembio™ in parallel; and (3) the monthly contribution of HIV-ST to total HIV positive individuals identified within project. The Chi-square test was used to assess for statistical differences in HIV positivity between age groups, by sex and district; as well as the difference in HIV positivity between the HIV-ST and index and mobile testing strategies. Findings: Between October 2018 and March 2020, the ZHCT project distributed 11,983 HIV-ST kits; 11,924 (99.8%) were used and 2,616 (21.9%) were reactive. Of the reactive tests, 2,610 (99.8%) were confirmed HIV positive giving a final positivity rate of 21.9%, and a concordance rate of 99.8% between the HIV-ST results and the confirmatory tests. Proportion of reactive results differed by age-groups (p < 0.001); with the 35-49 years having the highest positivity rate of 25.5%. The contribution of HIV-ST to total new positives increased from 10% in October 2018 to 80% at the end of March 2020 (p < 0.001). Positivity rates from HIV-ST were significantly different by age-groups, sex and district (p = 0.04). Additionally, index and mobile testing had a higher positivity rate compared to HIV-ST (p < 0.001). Conclusion: The ZHCT project has successfully scaled up HIV self-testing which contributed significantly to HIV case finding. Countries should consider using the lessons to scale-up the intervention which will contribute in reaching under-served and undiagnosed populations.

Outcomes of Three- Versus Six-Monthly Dispensing of Antiretroviral Treatment (ART) for Stable HIV Patients in Community ART Refill Groups: A Cluster-Randomized Trial in Zimbabwe.

INTRODUCTION: Multimonth dispensing (MMD) of antiretroviral treatment (ART) aims to reduce patient-related barriers to access long-term treatment and improve health system efficiency. However, randomized evidence of its clinical effectiveness is lacking. We compared MMD within community ART refill groups (CARGs) vs. standard-of-care facility-based ART delivery in Zimbabwe. METHODS: A three-arm, cluster-randomized, pragmatic noninferiority trial was performed. Thirty health care facilities and associated CARGs were allocated to either ART collected three-monthly at facility (3MF, control); ART delivered three-monthly in CARGs (3MC); or ART delivered six-monthly in CARGs (6MC). Stable adults receiving ART ≥six months with baseline viral load (VL) <1000 copies/ml were eligible. Retention in ART care (primary outcome) and viral suppression (VS) 12 months after enrollment were compared, using regression models specified for clustering (ClinicalTrials.gov: NCT03238846). RESULTS: 4800 participants were recruited, 1919, 1335, and 1546 in arms 3MF, 3MC, and 6MC, respectively. For retention, the prespecified noninferiority limit (-3.25%, risk difference [RD]) was met for comparisons between all arms, 3MC (94.8%) vs. 3MF (93.0%), adjusted RD = 1.1% (95% CI: -0.5% to 2.8%); 6MC (95.5%) vs. 3MF: aRD = 1.2% (95% CI: -1.0% to 3.6%); and 6MC vs. 3MC: aRD = 0.1% (95% CI: -2.4% to 2.6%). VL completion at 12 months was 49%, 45%, and 8% in 3MF, 3MC, and 6MC, respectively. VS in 3MC (99.7%) was high and not different to 3MF (99.1%), relative risk = 1.0 (95% CI: 1.0-1.0). VS was marginally reduced in 6MC (92.9%) vs. 3MF, relative risk = 0.9 (95% CI: 0.9-1.0). CONCLUSION: Retention in CARGs receiving three- and six-monthly MMD was noninferior versus standard-of-care facility-based ART delivery. VS in 3MC was high. VS in six-monthly CARGs requires further evaluation.

Sustained high HIV case-finding through index testing and partner notification services: experiences from three provinces in Zimbabwe.

INTRODUCTION: Several countries in southern Africa have made significant progress towards reaching the Joint United Nations Programme on HIV/AIDS goal of ensuring that 90% of people living with HIV are aware of their status. In Zimbabwe, progress towards this "first 90" was estimated at 73% in 2016. To reach the remaining people living with HIV who have undiagnosed infection, the Zimbabwe Ministry of Health and Child Care has been promoting index testing and partner notification services (PNS). We describe the implementation of index testing and PNS under the Zimbabwe HIV Care and Treatment (ZHCT) project and the resulting uptake, HIV positivity rate and links to HIV treatment. METHODS: The ZHCT project has been implemented since March 2016, covering a total of 12 districts in three provinces. To assess the project's performance on index testing, we extracted data on HIV testing from the district health information system (DHIS 2) from March 2016 to May 2018, validated it using service registers and calculated monthly HIV positivity rates using Microsoft Excel. Data were disaggregated by district, province, sex and service delivery point. We used SPSS to assess for statistical differences in paired monthly HIV positivity rates by sex, testing site, and province. RESULTS: The average HIV positivity rate rose from 10% during the first six months of implementation to more than 30% by August 2016 and was sustained above 30% through May 2018. The overall facility HIV positivity rate was 4.1% during the same period. The high HIV positivity rate was achieved for both males and females (mean monthly HIV positivity rate of 31.3% for males and 33.7% for females), with females showing significantly higher positivity compared to males (p < 0.001). The ZHCT mean monthly HIV positivity rate from index testing (32.6%) was significantly higher than that achieved through provider-initiated testing and counselling and other facility HIV testing modalities (4.1%, p < 0.001). CONCLUSIONS: The ZHCT project has demonstrated successes in implementing index testing and PNS by attaining a high HIV positivity rate sustained over the study period. As the country moves towards HIV epidemic control, index testing and PNS are critical strategies for targeted HIV case identification.

Time taken to link newly identified HIV positive clients to care following a home-base index case HIV testing: Experience from two provinces in Zimbabwe.

BACKGROUND: Homebased index case HIV testing (HHTC) has shown higher uptake and good yield than traditional HIV testing methods. World Health Organization has called for increased operational research to evaluate HIV care processes particularly linkage to care. In this paper, we present project results of the time taken to link newly identified PLHIV to care after HHTC in the Manicaland and Midlands provinces of Zimbabwe. METHODS: We retrospectively reviewed community-facility referral data from the Zimbabwe HIV Care and Treatment project for newly diagnosed PLHIV for the period March-September 2016. A referral slip was given to a client after receiving a positive HIV results and was presented and filed upon reaching a health facility. In July 2016, the project started working with trained expert clients to assist with linkage to care. Data was entered in a spreadsheet and then imported for descriptive statistical analysis with EpiInfoTM Version 7.2.0.1. Odd ratios were used to identify factors associated with linkage to care within seven days. RESULTS: Out of 1004 newly identified PLHIV between March and September 2016, 650 (64.7%) were linked to care. The median time taken to be linked to care was four days (Interquartile range 19 days). Overall, 63.1% (410) of PLHIV were linked to care within seven days of diagnosis and 85% within 30 days. PLHIV were more likely to be linked to care within seven days of diagnosis between July and September 2016 (OR = 4.1; p< 0.001), a period when ZHCT started working with expert clients to support linkage to care. CONCLUSION: HHTC resulted in almost 63% of newly diagnosed PLHIV being linked into care within seven days, and 85% within 30 days. Linkage to care within seven days was significantly associated with the period of engaging expert clients in the project. We recommend community based HIV testing programs to work with expert clients to ensure timely linkages of new PLHIV.

Barriers to HIV service utilisation by people living with HIV in two provinces of Zimbabwe: Results from 2016 baseline assessment.

BACKGROUND: The emergence of antiretroviral therapy (ART) transformed HIV from a terminal illness to a chronic disease. However, limited access to health services remains one of many barriers to HIV service utilisation by people living with HIV (PLHIV) in low-resource settings. The goal of this study was to describe the barriers to HIV service utilisation in two provinces of Zimbabwe. METHODS: A qualitative descriptive study was conducted with PLHIV and village health workers (VHW) in eight districts within the two provinces. Convenience sampling was used to select the participants. This sampling was limited to communities supported by health facilities with more than 500 PLHIV enrolled into HIV care and treatment. Interviews were audio-recorded and transcripts were subjected to thematic content analysis. RESULTS: A total of 22 community focus group discussions (FGDs) were conducted. Barriers to using HIV services cited in PLHIV and VHW FGDs were similar. These were categorised as health system-related barriers, which include user fees, long waiting times, lack of confidentiality and negative attitudes by healthcare providers, and lack of consistent community-based HIV services. Community-related barriers cited were stigma and discrimination, food insecurity, distance to facilities and counterproductive messaging from religious sectors. Client-related factors reported were inadequate male involvement in HIV-related activities and defaulting after symptoms improved. CONCLUSION: Our assessment has indicated that there are several barriers to the utilisation of HIV services by PLHIV in the two provinces of Zimbabwe. As new strategies and programmes are being introduced in the current resource-constrained era, efforts should be made to understand the needs of the clients. If programmes are designed with an effort to address some of these challenges, there is a possibility that countries will quickly achieve the 90-90-90 targets set by The Joint United Nations Programme on HIV/AIDS.

The effectiveness and cost-effectiveness of 3- vs. 6-monthly dispensing of antiretroviral treatment (ART) for stable HIV patients in community ART-refill groups in Zimbabwe: study protocol for a pragmatic, cluster-randomized trial.

BACKGROUND: Sub-Saharan Africa is the world region with the greatest number of people eligible to receive antiretroviral treatment (ART). Less frequent dispensing of ART and community-based ART-delivery models are potential strategies to reduce the load on overburdened healthcare facilities and reduce the barriers for patients to access treatment. However, no large-scale trials have been conducted investigating patient outcomes or evaluating the cost-effectiveness of extended ART-dispensing intervals within community ART-delivery models. This trial will assess the clinical effectiveness, cost-effectiveness and acceptability of providing ART refills on a 3 vs. a 6-monthly basis within community ART-refill groups (CARGs) for stable patients in Zimbabwe. METHODS: In this pragmatic, three-arm, parallel, unblinded, cluster-randomized non-inferiority trial, 30 clusters (healthcare facilities and associated CARGs) are allocated using stratified randomization in a 1:1:1 ratio to either (1) ART refills supplied 3-monthly from the health facility (control arm), (2) ART refills supplied 3-monthly within CARGs, or (3) ART refills supplied 6-monthly within CARGs. A CARG consists of 6-12 stable patients who meet in the community to receive ART refills and who provide support to one another. Stable adult ART patients with a baseline viral load < 1000 copies/ml will be invited to participate (1920 participants per arm). The primary outcome is the proportion of participants alive and retained in care 12 months after enrollment. Secondary outcomes (measured at 12 and 24 months) are the proportions achieving virological suppression, average provider cost per participant, provider cost per participant retained, cost per participant retained with virological suppression, and average patient-level costs to access treatment. Qualitative research will assess the acceptability of extended ART-dispensing intervals within CARGs to both providers and patients, and indicators of potential facility-level decongestion due to the interventions will be assessed. DISCUSSION: Cost-effective health system models that sustain high levels of patient retention are urgently needed to accommodate the large numbers of stable ART patients in sub-Saharan Africa. This will be the first trial to evaluate extended ART-dispensing intervals within a community-based ART distribution model, and results are intended to inform national and regional policy regarding their potential benefits to both the healthcare system and patients. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03238846 . Registered on 27 July 2017.

A systems-based assessment of the PrePex device adverse events active surveillance system in Zimbabwe.

BACKGROUND: Voluntary Medical Male Circumcision (VMMC) is an effective method for HIV prevention and the World Health Organization (WHO) has recommended its expansion in 14 African countries with a high prevalence of HIV and low prevalence of male circumcision. The WHO has recently pre-qualified the PrePex device, a non-surgical male circumcision device, which reduces procedure time, can increase acceptability of VMMC, and can expand the set of potential provider cadres. The PrePex device was introduced in Zimbabwe as a way to scale-up VMMC services in the country. With the rapid scale-up of the PrePex device, as well as other similar devices, a strong surveillance system to detect adverse events (AE) is needed to monitor the safety profile of these devices. We performed a systems-based evaluation of the PrePex device AE active surveillance system in Zimbabwe. METHODS: The evaluation was based on the Centers for Disease Control and Prevention's Updated Guidelines for Evaluating Public Health Surveillance Systems. We adapted these guidelines to fit our local context. The evaluation incorporated the review of the standard operating procedures and surveillance system documents. Additionally, structured, in-person interviews were performed with key stakeholders who were users of the surveillance system at various levels. These key stakeholders were from the Ministry of Health, implementing partners, and health facilities in Harare. RESULTS: Clients were requested to return to the facility for follow-up on days 7, 14 and 49 after placement of the device. In the event of a severe AE, a standard report was generated by the health facility and relayed to the Ministry of Health Child and Care and donor agencies through predefined channels within 24 hours of diagnosis. Clinic staff reported difficulties with the amount of documentation required to follow up with clients and to report AEs. The surveillance system's acceptability among users interviewed was high, and users were motivated to identify all possible AEs related to this device. The surveillance system was purely paper-based and both duplicate and discrepant reporting forms between sites were identified. CONCLUSION: The PrePex AE active surveillance system was well accepted among participants in the health system. However, the amount of documentation which was required to follow-up with patients was a major barrier within the system, and might lead to decreased timeliness and quality of reporting. A passive surveillance system supported by electronic reporting would improve acceptance of the program.

Performance of rapid HIV testing by lay counselors in the field during the behavioral and biological surveillance survey among female sex workers and men who have sex with men in Botswana.

: The study assessed the performance of rapid HIV testing with whole blood using Kehua Bio-engineering HIV (1 + 2) and Uni-Gold HIV test kits by trained and certified lay counselors, offered to female sex workers and men who have sex with men during the 2012 survey fieldwork. The results of rapid HIV testing were compared with enzyme-linked immunosorbent assay testing performed in a parallel algorithm at the HIV Reference Laboratory. The sensitivity and the specificity of rapid HIV testing were high for men who have sex with men and female sex workers, with 98.1% and 100%, and 98.2% and 98.5%, respectively. Misclassifications occurred with rapid testing.

National guidelines not always followed when diagnosing smear-negative pulmonary tuberculosis in patients with HIV in Botswana.

BACKGROUND: Diagnosis of smear negative pulmonary tuberculosis (SNPTB) is challenging, especially in patients with HIV. The Botswana National Tuberculosis Program (BNTP) guidelines give guidance in diagnosing and treating SNPTB. Patients with chronic cough should be screened for TB by 3 sputum smear investigations. If negative, a chest x-ray (CXR) should be performed. If negative for TB, antimicrobial treatment for other infections should be started. We investigated the clinicians' use of the guidelines in clinical practice. METHODS: Data regarding the medical history (coughing period), requested and conducted investigations concerning tuberculosis diagnosis (sputum smear or culture or CXR) or alternative diagnoses (sputum microscopy or blood or sputum culture for diagnosis of other organisms), in SNPTB HIV-positive patients (outpatients and admitted patients) from 2006-2009 in a district hospital in Botswana were extracted from all available hospital medical records. Additionally, a survey was done in all doctors diagnosing SNPTB in this hospital using a self-administered questionnaire with questions regarding the application of the BNTP guidelines in practice. Descriptive analyses of collected data were performed to test the compliance to the guidelines. RESULTS: Data from medical records showed that in 47.0% (132/281) of patients, TB treatment was started without microbiological results from sputum smears. Other methods to rule out or confirm PTB were used in 2.1% (6/281); and 99.6% (280/281) of SNPTB patients had received a CXR. The survey in 7 clinicians found that all always used CXR, and all clinicians requested three sputum results only sometimes. Six out of 7 clinicians started antibiotics before starting TB treatment. Reasons clinicians gave for difficulties in following the guidelines included inability of patients to produce sputum; and laboratory delays in releasing sputum results. CONCLUSION: Between 2006 and 2009 a high proportion of SNPTB diagnoses in a district hospital in Botswana were not supported by laboratory investigation.