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.

The Cost of Not Retesting: Human Immunodeficiency Virus Misdiagnosis in the Antiretroviral Therapy "Test-and-Offer" Era.

We compared estimated costs of retesting human immunodeficiency virus (HIV)-positive persons before antiretroviral therapy (ART) initiation to the costs of ART provision to misdiagnosed HIV-negative persons. Savings from averted unnecessary ART costs were greater than retesting costs within 1 year using assumptions representative of HIV testing performance in programmatic settings. Countries should implement re-testing before ART initiation.

A reconfiguration of the sex trade: How social and structural changes in eastern Zimbabwe left women involved in sex work and transactional sex more vulnerable.

Understanding the dynamic nature of sex work is important for explaining the course of HIV epidemics. While health and development interventions targeting sex workers may alter the dynamics of the sex trade in particular localities, little has been done to explore how large-scale social and structural changes, such as economic recessions-outside of the bounds of organizational intervention-may reconfigure social norms and attitudes with regards to sex work. Zimbabwe's economic collapse in 2009, following a period (2000-2009) of economic decline, within a declining HIV epidemic, provides a unique opportunity to study community perceptions of the impact of socio-economic upheaval on the sex trade. We conducted focus group discussions with 122 community members in rural eastern Zimbabwe in January-February 2009. Groups were homogeneous by gender and occupation and included female sex workers, married women, and men who frequented bars. The focus groups elicited discussion around changes (comparing contemporaneous circumstances in 2009 to their memories of circumstances in 2000) in the demand for, and supply of, paid sex, and how sex workers and clients adapted to these changes, and with what implications for their health and well-being. Transcripts were thematically analyzed. The analysis revealed how changing economic conditions, combined with an increased awareness and fear of HIV-changing norms and local attitudes toward sex work-had altered the demand for commercial sex. In response, sex work dispersed from the bars into the wider community, requiring female sex workers to employ different tactics to attract clients. Hyperinflation meant that sex workers had to accept new forms of payment, including sex-on-credit and commodities. Further impacting the demand for commercial sex work was a poverty-driven increase in transactional sex. The economic upheaval in Zimbabwe effectively reorganized the market for sex by reducing previously dominant forms of commercial sex, while simultaneously providing new opportunities for women to exchange sex in less formal and more risky transactions. Efforts to measure and respond to the contribution of sex work to HIV transmission need to guard against unduly static definitions and consider the changing socioeconomic context and how this can cause shifts in behavior.

The relationship between parental education and children's schooling in a time of economic turmoil: The case of East Zimbabwe, 2001 to 2011.

Using data collected from 1998 to 2011 in a general population cohort study in eastern Zimbabwe, we describe education trends and the relationship between parental education and children's schooling during the Zimbabwean economic collapse of the 2000s. During this period, the previously-rising trend in education stalled, with girls suffering disproportionately; however, female enrolment increased as the economy began to recover. Throughout the period, children with more educated parents continued to have better outcomes such that, at the population level, an underlying increase in the proportion of children with more educated parents may have helped to maintain the upwards education trend.

The Incidence Patterns Model to Estimate the Distribution of New HIV Infections in Sub-Saharan Africa: Development and Validation of a Mathematical Model.

BACKGROUND: Programmatic planning in HIV requires estimates of the distribution of new HIV infections according to identifiable characteristics of individuals. In sub-Saharan Africa, robust routine data sources and historical epidemiological observations are available to inform and validate such estimates. METHODS AND FINDINGS: We developed a predictive model, the Incidence Patterns Model (IPM), representing populations according to factors that have been demonstrated to be strongly associated with HIV acquisition risk: gender, marital/sexual activity status, geographic location, "key populations" based on risk behaviours (sex work, injecting drug use, and male-to-male sex), HIV and ART status within married or cohabiting unions, and circumcision status. The IPM estimates the distribution of new infections acquired by group based on these factors within a Bayesian framework accounting for regional prior information on demographic and epidemiological characteristics from trials or observational studies. We validated and trained the model against direct observations of HIV incidence by group in seven rounds of cohort data from four studies ("sites") conducted in Manicaland, Zimbabwe; Rakai, Uganda; Karonga, Malawi; and Kisesa, Tanzania. The IPM performed well, with the projections' credible intervals for the proportion of new infections per group overlapping the data's confidence intervals for all groups in all rounds of data. In terms of geographical distribution, the projections' credible intervals overlapped the confidence intervals for four out of seven rounds, which were used as proxies for administrative divisions in a country. We assessed model performance after internal training (within one site) and external training (between sites) by comparing mean posterior log-likelihoods and used the best model to estimate the distribution of HIV incidence in six countries (Gabon, Kenya, Malawi, Rwanda, Swaziland, and Zambia) in the region. We subsequently inferred the potential contribution of each group to transmission using a simple model that builds on the results from the IPM and makes further assumptions about sexual mixing patterns and transmission rates. In all countries except Swaziland, individuals in unions were the single group contributing to the largest proportion of new infections acquired (39%-77%), followed by never married women and men. Female sex workers accounted for a large proportion of new infections (5%-16%) compared to their population size. Individuals in unions were also the single largest contributor to the proportion of infections transmitted (35%-62%), followed by key populations and previously married men and women. Swaziland exhibited different incidence patterns, with never married men and women accounting for over 65% of new infections acquired and also contributing to a large proportion of infections transmitted (up to 56%). Between- and within-country variations indicated different incidence patterns in specific settings. CONCLUSIONS: It is possible to reliably predict the distribution of new HIV infections acquired using data routinely available in many countries in the sub-Saharan African region with a single relatively simple mathematical model. This tool would complement more specific analyses to guide resource allocation, data collection, and programme planning.

Wealth differentials in the impact of conditional and unconditional cash transfers on education: findings from a community-randomised controlled trial in Zimbabwe.

We investigated (1) how household wealth affected the relationship between conditional cash transfers (CCT) and unconditional cash transfers (UCT) and school attendance, (2) whether CCT and UCT affected educational outcomes (repeating a year of school), (3) if baseline school attendance and transfer conditions affected how much of the transfers participants spent on education and (4) if CCT or UCT reduced child labour in recipient households. Data were analysed from a cluster-randomized controlled trial of CCT and UCT in 4043 households from 2009 to 2010. Recipient households received $18 dollars per month plus $4 per child. CCT were conditioned on above 80% school attendance, a full vaccination record and a birth certificate. In the poorest quintile, the odds ratio of above 80% school attendance at follow-up for those with below 80% school attendance at baseline was 1.06 (p = .67) for UCT vs. CCT. UCT recipients reported spending slightly more (46.1% (45.4-46.7)) of the transfer on school expenses than did CCT recipients (44.8% (44.1-45.5)). Amongst those with baseline school attendance of below 80%, there was no statistically significant difference between CCT and UCT participants in the proportion of the transfer spent on school expenses (p = .63). Amongst those with above 80% baseline school attendance, CCT participants spent 3.5% less (p = .001) on school expenses than UCT participants. UCT participants were no less likely than those in the control group to repeat a grade of school. CCT participants had .69 (.60-.79) lower odds vs. control of repeating the previous school grade. Children in CCT recipient households spent an average of .31 fewer hours in paid work than those in the control group (p < .001) and children in the UCT arm spent an average of .15 fewer hours in paid work each week than those in the control arm (p = .06).

Effects of cash transfers on Children's health and social protection in Sub-Saharan Africa: differences in outcomes based on orphan status and household assets.

BACKGROUND: Unconditional and conditional cash transfer programmes (UCT and CCT) show potential to improve the well-being of orphans and other children made vulnerable by HIV/AIDS (OVC). We address the gap in current understanding about the extent to which household-based cash transfers differentially impact individual children's outcomes, according to risk or protective factors such as orphan status and household assets. METHODS: Data were obtained from a cluster-randomised controlled trial in eastern Zimbabwe, with random assignment to three study arms - UCT, CCT or control. The sample included 5,331 children ages 6-17 from 1,697 households. Generalized linear mixed models were specified to predict OVC health vulnerability (child chronic illness and disability) and social protection (birth registration and 90% school attendance). Models included child-level risk factors (age, orphan status); household risk factors (adults with chronic illnesses and disabilities, greater household size); and household protective factors (including asset-holding). Interactions were systematically tested. RESULTS: Orphan status was associated with decreased likelihood for birth registration, and paternal orphans and children for whom both parents' survival status was unknown were less likely to attend school. In the UCT arm, paternal orphans fared better in likelihood of birth registration compared with non-paternal orphans. Effects of study arms on outcomes were not moderated by any other risk or protective factors. High household asset-holding was associated with decreased likelihood of child's chronic illness and increased birth registration and school attendance, but household assets did not moderate the effects of cash transfers on risk or protective factors. CONCLUSION: Orphaned children are at higher risk for poor social protection outcomes even when cared for in family-based settings. UCT and CCT each produced direct effects on children's social protection which are not moderated by other child- and household-level risk factors, but orphans are less likely to attend school or obtain birth registration. The effects of UCT and CCT are not moderated by asset-holding, but greater household assets predict greater social protection outcomes. Intervention efforts need to focus on ameliorating the additional risk burden carried by orphaned children. These efforts might include caregiver education, and additional incentives based on efforts made specifically for orphaned children.

The price of sex: condom use and the determinants of the price of sex among female sex workers in eastern Zimbabwe.

BACKGROUND: Higher prices for unprotected sex threaten the high levels of condom use that contributed to the decline in Zimbabwe's human immunodeficiency virus (HIV) epidemic. To improve understanding of financial pressures competing against safer sex, we explore factors associated with the price of commercial sex in rural eastern Zimbabwe. METHODS: We collected and analyzed cross-sectional data on 311 women, recruited during October-December 2010, who reported that they received payment for their most-recent or second-most-recent sex acts in the past year. Zero-inflated negative binomial models with robust standard errors clustered on female sex worker (FSW) were used to explore social and behavioral determinants of price. RESULTS: The median price of sex was $10 (interquartile range [IQR], $5-$20) per night and $10 (IQR, $5-$15) per act. Amounts paid in cash and commodities did not differ significantly. At the most-recent sex act, more-educated FSWs received 30%-74% higher payments. Client requests for condom use significantly predicted protected sex (P < .01), but clients paid on average 42.9% more for unprotected sex. CONCLUSIONS: Within a work environment where clients' preferences determine condom use, FSWs effectively use their individual capital to negotiate the terms of condom use. Strengthening FSWs' preferences for protected sex could help maintain high levels of condom use.

Updates to the spectrum model to estimate key HIV indicators for adults and children.

BACKGROUND: The Spectrum program is used to estimate key HIV indicators for national programmes. The purpose of the study is to describe the key updates made to Spectrum in the last 2 years to produce the version used in the 2013 global estimates of HIV/AIDS. METHODS: The United Nations Programme on HIV/AIDS (UNAIDS) Reference Group on Estimates, Models and Projections regularly reviews new data and information needs and recommends updates to the methodology and assumptions used in Spectrum. The latest data from surveys, census and special studies are used to estimate key parameter values for countries and regions. RESULTS: Country-specific life tables prepared by the United National Population Division (UNPD) have been incorporated into Spectrum's demographic projections replacing the model life tables used previously. This update includes revised estimates of non-AIDS life expectancy. Incidence among all adults 15-49 years generated from curve fitting to surveillance and survey data is now split by age using incidence rate ratios derived from Analysing Longitudinal Population-based HIV/AIDS data on Africa Network data for generalized epidemics. Methods for estimating the number of AIDS orphans have been updated to include the changing effects of PMTCT and antiretroviral therapy programmes. Procedures for estimating the number of adults eligible for treatment have been updated to reflect the 2013 WHO guidelines. Program data on AIDS mortality has been used to estimate prevalence trends in Argentina, Brazil and Mexico for the 2013 estimates. CONCLUSION: Spectrum was updated for the 2013 round of HIV estimates in order to support national programmes with improved methods and data to estimating national indicators.

Community resistance to a peer education programme in Zimbabwe.

BACKGROUND: This paper presents community perceptions of a state-of-the-art peer education programme in Manicaland, Zimbabwe. While the intervention succeeded in increasing HIV knowledge among men and condom acceptability among women, and reduced HIV incidence and rates of unprotected sex among men who attended education events, it did not succeed in reducing population-level HIV incidence. To understand the possible reasons for this disappointing result, we conducted a qualitative study of local perspectives of the intervention. METHODS: Eight focus group discussions and 11 interviews with 81 community members and local project staff were conducted. Transcripts were interrogated and analysed thematically. RESULTS: We identified three factors that may have contributed to the programme's disappointing outcomes: (1) difficulties of implementing all elements of the programme, particularly the proposed income generation component in the wider context of economic strain; (2) a moralistic approach to commercial sex work by programme staff; and (3) limitations in the programme's ability to engage with social realities facing community members. CONCLUSIONS: We conclude that externally-imposed programmes that present new information without adequately engaging with local realities and constraints on action can be met by resistance to change.

Involving Communities in the Targeting of Cash Transfer Programs for Vulnerable Children: Opportunities and Challenges.

We used baseline data, collected in July-September 2009, from a randomized controlled trial of a cash transfer program for vulnerable children in eastern Zimbabwe to investigate the effectiveness, coverage, and efficiency of census- and community-based targeting methods for reaching vulnerable children. Focus group discussions and in-depth interviews with beneficiaries and other stakeholders were used to explore community perspectives on targeting. Community members reported that their participation improved ownership and reduced conflict and jealousy. However, all the methods failed to target a large proportion of vulnerable children and there was poor agreement between the community- and census-based methods.

Acceptability of conditions in a community-led cash transfer programme for orphaned and vulnerable children in Zimbabwe.

Evidence suggests that a regular and reliable transfer of cash to households with orphaned and vulnerable children has a strong and positive effect on child outcomes. However, conditional cash transfers are considered by some as particularly intrusive and the question on whether or not to apply conditions to cash transfers is an issue of controversy. Contributing to policy debates on the appropriateness of conditions, this article sets out to investigate the overall buy-in of conditions by different stakeholders and to identify pathways that contribute to an acceptability of conditions. The article draws on data from a cluster-randomized trial of a community-led cash transfer programme in Manicaland, eastern Zimbabwe. An endpoint survey distributed to 5167 households assessed community members' acceptance of conditions and 35 in-depth interviews and 3 focus groups with a total of 58 adults and 4 youth examined local perceptions of conditions. The study found a significant and widespread acceptance of conditions primarily because they were seen as fair and a proxy for good parenting or guardianship. In a socio-economic context where child grants are not considered a citizen entitlement, community members and cash transfer recipients valued the conditions associated with these grants. The community members interpreted the fulfilment of the conditions as a proxy for achievement and merit, enabling them to participate rather than sit back as passive recipients of aid. Although conditions have a paternalistic undertone and engender the sceptics' view of conditions being pernicious and even abominable, it is important to recognize that community members, when given the opportunity to participate in programme design and implementation, can take advantage of conditions and appropriate them in a way that helps them manage change and overcome the social divisiveness or conflict that otherwise may arise when some people are identified to benefit and others not.

Funding and expenditure of a sample of community-based organizations in Kenya, Nigeria, and Zimbabwe.

Over the last decade, international donors, technical specialists, and governments have come to recognize the potential of community-based organizations (CBOs) in the fight against HIV/AIDS. Recent empirical studies suggest that community engagement, including the involvement of CBOs, adds value to the national response to HIV/AIDS. With the emerging evidence of the effectiveness of engaging communities in the fight against AIDS, it is crucial to understand the economic dimension of community engagement. This article provides an analysis of funding and expenditure data collected from CBOs in three African countries: Kenya, Nigeria, and Zimbabwe. It presents descriptive information regarding CBO funding and expenditure and examines the factors associated with the total amount of funds received and with the proportions of the funds allocated to programmatic activities and program management and administration. An average CBO in the sample received US$29,800 annually or about US$2480 per month. The highest percentage of CBO funding (37%) came from multilateral organizations. CBOs in the sample spent most of their funds (71%) on programmatic activities including provision of treatment, support, care, impact mitigation, and treatment services.

Social acceptability and perceived impact of a community-led cash transfer programme in Zimbabwe.

BACKGROUND: Cash transfer programmes are increasingly recognised as promising and scalable interventions that can promote the health and development of children. However, concerns have been raised about the potential for cash transfers to contribute to social division, jealousy and conflict at a community level. Against this background, and in our interest to promote community participation in cash transfer programmes, we examine local perceptions of a community-led cash transfer programme in Eastern Zimbabwe. METHODS: We collected and analysed data from 35 individual interviews and three focus group discussions, involving 24 key informants (community committee members and programme implementers), 24 cash transfer beneficiaries, of which four were youth, and 14 non-beneficiaries. Transcripts were subjected to thematic analysis and coding to generate concepts. RESULTS: Study participants described the programme as participatory, fair and transparent - reducing the likelihood of jealousy. The programme was perceived to have had a substantial impact on children's health and education, primarily through aiding parents and guardians to better cater for their children's needs. Moreover, participants alluded to the potential of the programme to facilitate more transformational change, for example by enabling families to invest money in assets and income generating activities and by promoting a community-wide sense of responsibility for the support of orphaned and vulnerable children. CONCLUSION: Community participation, combined with the perceived impact of the cash transfer programme, led community members to speak enthusiastically about the programme. We conclude that community-led cash transfer programmes have the potential to open up for possibilities of participation and community agency that enable social acceptability and limit social divisiveness.

Effects of unconditional and conditional cash transfers on child health and development in Zimbabwe: a cluster-randomised trial.

BACKGROUND: Cash-transfer programmes can improve the wellbeing of vulnerable children, but few studies have rigorously assessed their effectiveness in sub-Saharan Africa. We investigated the effects of unconditional cash transfers (UCTs) and conditional cash transfers (CCTs) on birth registration, vaccination uptake, and school attendance in children in Zimbabwe. METHODS: We did a matched, cluster-randomised controlled trial in ten sites in Manicaland, Zimbabwe. We divided each study site into three clusters. After a baseline survey between July, and September, 2009, clusters in each site were randomly assigned to UCT, CCT, or control, by drawing of lots from a hat. Eligible households contained children younger than 18 years and satisfied at least one other criteria: head of household was younger than 18 years; household cared for at least one orphan younger than 18 years, a disabled person, or an individual who was chronically ill; or household was in poorest wealth quintile. Between January, 2010, and January, 2011, households in UCT clusters collected payments every 2 months. Households in CCT clusters could receive the same amount but were monitored for compliance with several conditions related to child wellbeing. Eligible households in all clusters, including control clusters, had access to parenting skills classes and received maize seed and fertiliser in December, 2009, and August, 2010. Households and individuals delivering the intervention were not masked, but data analysts were. The primary endpoints were proportion of children younger than 5 years with a birth certificate, proportion younger than 5 years with up-to-date vaccinations, and proportion aged 6-12 years attending school at least 80% of the time. This trial is registered with ClinicalTrials.gov, number NCT00966849. FINDINGS: 1199 eligible households were allocated to the control group, 1525 to the UCT group, and 1319 to the CCT group. Compared with control clusters, the proportion of children aged 0-4 years with birth certificates had increased by 1·5% (95% CI -7·1 to 10·1) in the UCT group and by 16·4% (7·8-25·0) in the CCT group by the end of the intervention period. The proportions of children aged 0-4 years with complete vaccination records was 3·1% (-3·8 to 9·9) greater in the UCT group and 1·8% (-5·0 to 8·7) greater in the CCT group than in the control group. The proportions of children aged 6-12 years who attended school at least 80% of the time was 7·2% (0·8-13·7) higher in the UCT group and 7·6% (1·2-14·1) in the CCT group than in the control group. INTERPRETATION: Our results support strategies to integrate cash transfers into social welfare programming in sub-Saharan Africa, but further evidence is needed for the comparative effectiveness of UCT and CCT programmes in this region. FUNDING: Wellcome Trust, the World Bank through the Partnership for Child Development, and the Programme of Support for the Zimbabwe National Action Plan for Orphans and Vulnerable Children.

Household-based cash transfer targeting strategies in Zimbabwe: are we reaching the most vulnerable children?

Census data, collected in July 2009, from 27,672 children were used to compare the effectiveness, coverage and efficacy of three household-based methods for targeting cash transfers to vulnerable children in eastern Zimbabwe: targeting the poorest households using a wealth index; targeting HIV-affected households using socio-demographic information (households caring for orphans, chronically-ill or disabled members; child-headed households); and targeting labour-constrained households using dependency ratios. All three methods failed to identify large numbers of children with poor social and educational outcomes. The wealth index approach was the most efficient at reaching children with poor outcomes whilst socio-demographic targeting reached more vulnerable children but was less efficient.

Using age-specific mortality of HIV infected persons to predict anti-retroviral treatment need: a comparative analysis of data from five African population-based cohort studies.

OBJECTIVES: To present a simple method for estimating population-level anti-retroviral therapy (ART) need that does not rely on knowledge of past HIV incidence. METHODS: A new approach to estimating ART need is developed based on calculating age-specific proportions of HIV-infected adults expected to die within a fixed number of years in the absence of treatment. Mortality data for HIV-infected adults in the pre-treatment era from five African HIV cohort studies were combined to construct a life table, starting at age 15, smoothed with a Weibull model. Assuming that ART should be made available to anyone expected to die within 3 years, conditional 3-year survival probabilities were computed to represent proportions needing ART. The build-up of ART need in a successful programme continuously recruiting infected adults into treatment as they age to within 3 years of expected death was represented by annually extending the conditional survival range. RESULTS: The Weibull model: survival probability in the infected state from age 15 = exp(-0.0073 × (age - 15)(1.69)) fitted the pooled age-specific mortality data very closely. Initial treatment need for infected persons increased rapidly with age, from 15% at age 20-24 to 32% at age 40-44 and 42% at age 60-64. Overall need in the treatment of naïve population was 24%, doubling within 5 years in a programme continually recruiting patients entering the high-risk period for dying. CONCLUSION: A reasonable projection of treatment need in an ART naive population can be made based on the age and gender profile of HIV-infected people.

Social capital and women's reduced vulnerability to HIV infection in rural Zimbabwe.

Social capital­especially through its "network" dimension (high levels of participation in local community groups)­is thought to be an important determinant of health in many contexts. We investigate its effect on HIV prevention, using prospective data from a general population cohort in eastern Zimbabwe spanning a period of extensive behavior change (1998­2003). Almost half of the initially uninfected women interviewed were members of at least one community group. In an analysis of 88 communities, individuals with higher levels of community group participation had lower incidence of new HIV infections and more of them had adopted safer behaviors, although these effects were largely accounted for by differences in socio-demographic composition. Individual women in community groups had lower HIV incidence and more extensive behavior change, even after controlling for confounding factors. Community group membership was not associated with lower HIV incidence in men, possibly refecting a propensity among men to participate in groups that allow them to develop and demonstrate their masculine identities­often at the expense of their health. Support for women's community groups could be an effective HIV prevention strategy in countries with large-scale HIV epidemics.

Monitoring trends in HIV prevalence among young people, aged 15 to 24 years, in Manicaland, Zimbabwe.

BACKGROUND: In June 2001, the United Nations General Assembly Special Session (UNGASS) set a target of reducing HIV prevalence among young women and men, aged 15 to 24 years, by 25% in the worst-affected countries by 2005, and by 25% globally by 2010. We assessed progress toward this target in Manicaland, Zimbabwe, using repeated household-based population serosurvey data. We also validated the representativeness of surveillance data from young pregnant women, aged 15 to 24 years, attending antenatal care (ANC) clinics, which UNAIDS recommends for monitoring population HIV prevalence trends in this age group. Changes in socio-demographic characteristics and reported sexual behaviour are investigated. METHODS: Progress towards the UNGASS target was measured by calculating the proportional change in HIV prevalence among youth and young ANC attendees over three survey periods (round 1: 1998-2000; round 2: 2001-2003; and round 3: 2003-2005). The Z-score test was used to compare differences in trends between the two data sources. Characteristics of participants and trends in sexual risk behaviour were analyzed using Student's and two-tailed Z-score tests. RESULTS: HIV prevalence among youth in the general population declined by 50.7% (from 12.2% to 6.0%) from round 1 to 3. Intermediary trends showed a large decline from round 1 to 2 of 60.9% (from 12.2% to 4.8%), offset by an increase from round 2 to 3 of 26.0% (from 4.8% to 6.0%). Among young ANC attendees, the proportional decline in prevalence of 43.5% (from 17.9% to 10.1%) was similar to that in the population (test for differences in trend: p value=0.488) although ANC data significantly underestimated the population prevalence decline from round 1 to 2 (test for difference in trend: p value=0.003) and underestimated the increase from round 2 to 3 (test for difference in trend: p value=0.012). Reductions in risk behaviour between rounds 1 and 2 may have been responsible for general population prevalence declines. CONCLUSIONS: In Manicaland, Zimbabwe, the 2005 UNGASS target to reduce HIV prevalence by 25% was achieved. However, most prevention gains occurred before 2003. ANC surveillance trends overall were an adequate indicator of trends in the population, although lags were observed. Behaviour data and socio-demographic characteristics of participants are needed to interpret ANC trends.