Factors Associated with Having both Male and Female Recent Sexual Partnerships Among Men Who Have Sex with Men in Harare and Bulawayo, Zimbabwe.

To better understand male and female sexual partnerships among men who have sex with men (MSM), we used data from a 2019 biobehavioral survey among MSM in Harare and Bulawayo, Zimbabwe to conduct bivariate analyses and multivariable logistic regression to determine whether sociodemographic characteristics and HIV-related factors were associated with having both male and female sexual partnerships within the last 6 months. Of included MSM (N = 1143), 31% reported both male and female partnerships in the last 6 months. Being married/cohabiting (adjusted odds ratio (aOR) = 8.58, 95% confidence interval (CI) = 4.92-14.95) or separated/divorced/widowed (aOR = 1.96, 95% CI = 1.24-3.08) vs. being single, and hazardous alcohol consumption (aOR = 1.58, 95% CI 1.19-2.09) were associated with higher odds of having both male and female recent partnerships. Being aged 35 + vs. 18-24 (aOR = 0.50, 95% CI = 0.31-0.81), condomless receptive anal intercourse at last sex with the main male partner (aOR = 0.43, 95% CI = 0.26-0.74), and positive HIV status (aOR = 0.46, 95% CI = 0.31-0.67) were associated with lower odds of recent male and female partnerships. MSM in Harare who reported harassment/abuse (aOR = 3.16, 95% CI = 1.72-5.79) had higher odds of both male and female partnerships than MSM in Bulawayo reporting harassment/abuse. The prevalence of both male and female recent partnerships (31%) was lower among MSM in this survey than in other biobehavioral surveys of MSM in sub-Saharan Africa. Findings suggest that MSM with recent male and female partnerships compared to MSM with only male recent partners have lower odds of positive HIV status and participate in behaviors that lower HIV risk; however, the direction of these relationships cannot be determined due to the cross-sectional nature of the data. The findings also suggest a possible connection between experiences of stigma of MSM behavior and not having both male and female partnerships that warrants further exploration. Accessible, stigma-free HIV testing and education programming that considers the potential overlap between the MSM and general populations via both male and female partnerships and the associated behaviors could be a key component of HIV elimination in Zimbabwe.

Presence of tuberculosis symptoms among HIV-positive men who have sex with men (MSM) in Zimbabwe.

We conducted secondary data analysis using a biobehavioral survey dataset of 1538 MSM from Zimbabwe. Survey participants were screened for the four symptoms suggestive of tuberculosis infection using the WHO TB screening algorithm. Results: All participants experienced at least one symptom suggestive of tuberculosis. 40% of HIV-positive MSM reported having had a cough in the last month and 13% of them experienced unexpected weight loss. The prevalence of experiencing any of the four TB symptoms amongst HIV-positive MSM was 23%. Contribution There is an urgent need for active TB case finding and treatment amongst HIV-positive MSM in Zimbabwe. Clinicians will need to ensure that MSM who need TB testing receive it timeously.

High Burden of Active Syphilis and Human Immunodeficiency Virus/Syphilis Coinfection Among Men Who Have Sex With Men, Transwomen, and Genderqueer Individuals in Zimbabwe.

BACKGROUND: Syphilis increases human immunodeficiency virus (HIV) acquisition risk and impacts the immunologic and virologic response among people living with HIV (PLHIV). We assessed the prevalence of active or current syphilis and HIV/syphilis and their correlates among men who have sex with men (MSM), transwomen, and genderqueer (TGW/GQ) individuals in Zimbabwe. METHODS: Among a respondent-driven sample of MSM and TGW/GQ who were tested for HIV and syphilis in Harare and Bulawayo, Zimbabwe in 2019 (n = 1511), multiple logistic regression was used to assess correlates of active syphilis. Unadjusted logistic regression was used among PLHIV (n = 340) due to small sample size. All analyses were unweighted as data did not reach convergence for HIV. RESULTS: Prevalence of active syphilis overall and among PLHIV was 5.5% and 10.1%, respectively, in Harare, and 5.6% and 11.0%, respectively, in Bulawayo. Participants were more likely to have active syphilis if they were PLHIV (adjusted odds ratio [aOR], 2.2; 95% confidence interval [CI], 1.4-3.6), aged 25-34 years (aOR, 2.2 years; 95% CI, 1.3-3.8 years; reference, 18-24 years), or self-report sexually transmitted infection symptoms (aOR, 1.8; 95% CI, 1.1-3.0). Compared with Bulawayo TGW/GQ, MSM in Harare (aOR, 0.2; 95% CI, 0.1-0.5) and Bulawayo (aOR, 0.2; 95% CI, 0.1-0.4), and TGW/GQ in Harare (aOR, 0.2; 95% CI, 0.1-0.6) were less likely to have active syphilis. Among PLHIV, coinfection was 13.0% among TGW/GQ and 9.7% among MSM. Odds of coinfection were higher for those aged 25 to 34 years (OR, 3.7 years; 95% CI, 1.2-11.1 years) and lower among Harare MSM (OR, 0.2; 95% CI, 0.1-0.7), Bulawayo MSM (OR, 0.1; 95% CI, 0.0-0.4), and Harare TGW/GQ (OR, 0.1; 95% CI, 0.0-0.4) compared with Bulawayo TGW/GQ. CONCLUSIONS: Findings highlight a high burden of syphilis among MSM and TGW/GQ and underscore the importance of HIV/syphilis detection and improved service delivery for these groups.

Stigma, Social Cohesion, and HIV Risk Among Sexual and Gender Minorities in Two Cities in Zimbabwe.

Though stigma is a recognized contributor to the disproportionate HIV burden among sexual and gender minorities (SGM) in sub-Saharan Africa, data describing this association among Zimbabwean SGM are limited. We examined relationships between SGM stigma and HIV and the potential for social cohesion to moderate the association among Zimbabwean men who have sex with men, transgender women, and genderqueer individuals. Consenting participants (n = 1511) recruited through respondent-driven sampling for a biobehavioral survey in Harare and Bulawayo completed structured interviews and received HIV testing. Reported SGM stigma was common (68.9% in Harare and 65.3% in Bulawayo) and associated with HIV infection in Harare (adjusted prevalence ratio [aPR] = 1.82, 95% confidence interval [CI] = 1.27-2.62) and Bulawayo (aPR = 1.51, 95% CI = 1.15-2.00) in relative risk regression. Social cohesion did not moderate these relationships. Findings demonstrate stigma's association with HIV vulnerability among Zimbabwean SGM, highlighting the need for stigma-mitigation to reduce HIV transmission in this population.

Optimizing Differentiated HIV Treatment Models in Urban Zimbabwe: Assessing Patient Preferences Using a Discrete Choice Experiment.

Differentiated service delivery holds great promise for streamlining the delivery of health services for HIV. This study used a discrete choice experiment to assess preferences for differentiated HIV treatment delivery model characteristics among 500 virally suppressed adults on antiretroviral therapy in Harare, Zimbabwe. Treatment model characteristics included location, consultation type, healthcare worker cadre, operation times, visit frequency and duration, and cost. A mixed effects logit model was used for parameter estimates to identify potential preference heterogeneity among participants, and interaction effects were estimated for sex and age as potential sources of divergence in preferences. Results indicated that participants preferred health facility-based services, less frequent visits, individual consultations, shorter waiting times, lower cost and, delivered by respectful and understanding healthcare workers. Some preference heterogeneity was found, particularly for location of service delivery and group vs. individual models; however, this was not fully explained by sex and age characteristics of participants. In urban areas, facility-based models, such as the Fast Track model requiring less frequent clinic visits, are likely to better align with patient preferences than some of the other community-based or group models that have been implemented. As Zimbabwe scales up differentiated treatment models for stable patients, a clear understanding of patient preferences can help in designing services that will ensure optimal utilization and improve the efficiency of service delivery.

RESUMEN: La entrega de servicios diferenciados representa una gran promesa para optimizar la prestación de servicios sanitarios para el VIH. Este estudio utilizó un experimento de elecciones discretas para evaluar las preferencias en cuanto a las características de los modelos diferenciados de prestación de tratamiento para el VIH entre 500 adultos con supresión viral bajo tratamiento antirretroviral en Harare, Zimbabue. Las características de los modelos de tratamientos incluyeron el lugar, el tipo de consulta, la estructura en la que estaba inserto el trabajador sanitario, los tiempos operativos, la frecuencia y duración de las visitas y los costos. Se utilizó un modelo de probabilidad de efectos mixtos para las estimaciones de los parámetros para identificar una posible heterogeneidad en las preferencias entre los participantes, y se estimaron los efectos de las interacciones por el sexo y la edad como fuentes potenciales de diferencia en las preferencias. Los resultados indicaron que los participantes preferían servicios basados en centros de salud, visitas menos frecuentes, consultas individuales, tiempos de espera más cortos y menores costos, proporcionados por trabajadores sanitarios respetuosos y comprensivos. Se hallaron algunas heterogeneidades en las preferencias, particularmente para el lugar de la prestación del servicio y para los modelos grupales frente a individuales; sin embargo, esto no se explicó totalmente por las características de sexo y edad de los participantes. En áreas urbanas, los modelos basados en los centros, como el modelo de atención rápida (Fast Track), que requieren visitas menos frecuentes a la clínica, probablemente concuerden mejor con las preferencias de los pacientes que los otros modelos grupales o comunitarios que se han propuesto. A medida que en Zimbabue se amplíen los modelos de tratamiento diferenciado para los pacientes estables, un claro conocimiento de las preferencias de los pacientes puede ayudar a diseñar servicios que garantizarán una utilización óptima y mejorarán la eficiencia de la prestación de servicios.

Understanding HIV and associated risk factors among religious groups in Zimbabwe.

BACKGROUND: The influence of religion and belief systems is widely recognized as an important factor in understanding of health risk perception and myths in the general fight against the HIV pandemic. This study compares the understanding of HIV risk factors and utilization of some HIV services among religious groups in Zimbabwe. METHODS: We conducted secondary data statistical analysis to investigate the understanding of HIV and associated risk factors among religious groups in Zimbabwe using 2015-2016 Zimbabwe Demographic and Health Survey (ZDHS) data. We began by investigating associations between understanding of HIV and associated risk factors among religious groups. A multivariate stepwise backward elimination method was carried out to explore factors determining understanding of HIV risk after controlling for confounding factors using the most recent ZDHS data (2015-2016). RESULTS: The results from the three surveys showed that, in general apostolic sector had low understanding of HIV and associated risk factors compared to other religious groups. Analysis of the 2015-2016 ZDHS data showed that women belonging to the apostolic sector were less likely to know where to get an HIV test odds ratio (OR) and 95% confidence interval, 0.665 (0.503-0.880) and to know that male circumcision reduces HIV transmission OR 0.863 (0.781-0.955). Women from this group had no knowledge that circumcised men can be infected if they do not use condoms OR 0.633 (0.579-0.693), nor that it is possible for a healthy-looking person to have HIV, OR 0.814 (0.719-0.921). They would not buy vegetables from a vendor with HIV OR 0.817 (0.729-0.915) and were less likely to support that HIV positive children should be allowed to attend school with HIV negative children OR 0.804 (0.680-0.950). Similar results were obtained for men in the apostolic sector. These men also did not agree that women were justified to use condoms if the husband has an Sexually Transmitted Infection (STI) OR 0.851 (0.748-0.967). CONCLUSIONS: Our results suggest that apostolic sector lack adequate knowledge of HIV and associated risk factors than other religious groups. Targeting HIV prevention programmes by religious groups could be an efficient approach for controlling HIV in Zimbabwe.

Social and structural drivers of HIV vulnerability among a respondent-driven sample of feminine and non-feminine presenting transgender women who have sex with men in Zimbabwe.

INTRODUCTION: We sought to characterize social and structural drivers of HIV vulnerability for transgender women (TGW) in Zimbabwe, where TGW are not legally recognized, and explore differences in vulnerability by feminine presentation. METHODS: A secondary analysis was conducted with a sub-sample of participants recruited from a 2019 respondent-driven sampling survey that comprised men who have sex with men, TGW and genderqueer individuals assigned male sex at birth, from two cities in Zimbabwe. Survey questionnaires captured information related to socio-demographics, sexual and substance use behaviours, and social and structural barriers to HIV services. Secondary analyses were restricted to participants who identified as female, transfemale or transwomen (236/1538) and were unweighted. Descriptive statistics were used to calculate sample estimates and chi-square and Fisher's exact tests were used to assess differences in vulnerability by feminine presentation. RESULTS: Among 236 TGW, almost half (45.3%) presented as feminine in the 6 months preceding the survey and 8.5% had ever used hormones to affirm their gender identities. Median age among TGW was 23 years (interquartile range: 20-26). Feminine presenting TGW in our sample had higher prevalence of arrest (15.9% vs. 3.9%), rejection by family/friends (38.3% vs. 14.0%), employment termination (11.2% vs. 3.9%), employment refusal (14.0% vs. 3.9%), denial of healthcare (16.8% vs. 2.3%), physical, sexual or verbal harassment or abuse (59.8% vs. 34.1%), alcohol dependence (32.7% vs. 12.4%), recent transactional sex with a male or TGW partner (30.8% vs. 13.3%) and recent non-injection drug use (38.3% vs. 20.2%) than non-feminine presenting TGW (all p-value <0.05). CONCLUSIONS: Findings suggest that TGW, particularly feminine presenting TGW, experience social and structural inequities which may contribute to HIV vulnerability. Interventions aimed at addressing inequities, including trans competency training for providers and gender-affirming, psychosocial and legal support services for TGW, might mitigate risk.

Predicting sexually transmitted infections among men who have sex with men in Zimbabwe using deep learning and ensemble machine learning models.

There is a substantial increase in sexually transmitted infections (STIs) among men who have sex with men (MSM) globally. Unprotected sexual practices, multiple sex partners, criminalization, stigmatisation, fear of discrimination, substance use, poor access to care, and lack of early STI screening tools are among the contributing factors. Therefore, this study applied multilayer perceptron (MLP), extremely randomized trees (ExtraTrees) and XGBoost machine learning models to predict STIs among MSM using bio-behavioural survey (BBS) data in Zimbabwe. Data were collected from 1538 MSM in Zimbabwe. The dataset was split into training and testing sets using the ratio of 80% and 20%, respectively. The synthetic minority oversampling technique (SMOTE) was applied to address class imbalance. Using a stepwise logistic regression model, the study revealed several predictors of STIs among MSM such as age, cohabitation with sex partners, education status and employment status. The results show that MLP performed better than STI predictive models (XGBoost and ExtraTrees) and achieved accuracy of 87.54%, recall of 97.29%, precision of 89.64%, F1-Score of 93.31% and AUC of 66.78%. XGBoost also achieved an accuracy of 86.51%, recall of 96.51%, precision of 89.25%, F1-Score of 92.74% and AUC of 54.83%. ExtraTrees recorded an accuracy of 85.47%, recall of 95.35%, precision of 89.13%, F1-Score of 92.13% and AUC of 60.21%. These models can be effectively used to identify highly at-risk MSM, for STI surveillance and to further develop STI infection screening tools to improve health outcomes of MSM.

Hepatitis B virus infection (HBV) and HIV-HBV coinfection among men who have sex with men, transgender women, and genderqueer individuals in Harare and Bulawayo Zimbabwe, 2019.

Objectives: To measure HIV and Hepatitis B virus (HBV) prevalence and associated risk behaviors among men who have sex with men (MSM) and transgender women/genderqueer individuals (TGW/GQ) in Zimbabwe. Methods: We conducted a biobehavioral survey using respondent-driven sampling (RDS) among adult MSM and TGW/GQ in Harare and Bulawayo, Zimbabwe in 2019. Participants completed a questionnaire and underwent testing for HIV and HBV. Results: Overall, 1,510 (Harare: 694, Bulawayo 816) participants were enrolled and consented to testing; 3.8 % (58) tested positive for HBV, 22.5 % (339) tested positive for HIV, and 2.2 % (33) tested positive for both HIV and HBV. HBV prevalence was higher among participants with HIV compared to HIV-negative participants (9.7 % vs. 2.1 %, p < 0.0001). Overall, HBV prevalence was not statistically different between MSM and TGW/GQ (3.7 % vs 4.5 %, p = 0.49) nor between Harare and Bulawayo (3.3 % vs 4.3 %, p = 0.33). Conclusions: Our survey demonstrates the prevalence of HBV among MSM and TGW/GQ is lower than other estimates of HBV among MSM in Africa but remains high among our survey population living with HIV highlighting the need to expand HBV testing and treatment services, especially among people with HIV in Zimbabwe.

Understanding the role of intimate partner violence on HIV transmission in Zimbabwe: Secondary data analysis of data from the Zimbabwe demographic survey 2015-2016.

Background: Gender-based violence (GBV) has been shown to have significant and long-lasting impacts on women's physical and mental health. It is, therefore, important to study its occurrence in a population and its intersect with infectious diseases such as HIV to inform the wider health promotion agenda. This study aimed to determine the association between GBV and HIV status in women and adolescent girls in Zimbabwe. Methods: A secondary data analysis of data from a cross-sectional Zimbabwe Demographic and Health Survey (ZDHS) was conducted. Statistical analysis was employed to establish the association between GBV and HIV status. Geospatial mapping was conducted using a kernel smoothing method was employed to generate a continuous kernel density surface to illustrate the local spatial variations of female HIV and GBV prevalence. Results: Women and adolescent girls suffering emotional GBV, such as those subjected to humiliation by their husbands or partners, were 1.45 (1.14-1.84) [OR (95% CIs)] times more likely to be HIV positive than those who were never humiliated. The same was true for women and adolescent girls whose husbands or partners threatened to harm them or someone they love, 1.33 (1.04-1.68). There is a relationship between women's HIV status and intimate partner aggression, such as when their partners pushed, shook, or threw something at them or physically abused them. This was also the case for those who reported that partners kicked, dragged, or beat them, tried to choke or burn them on purpose, or threatened or attacked them with a knife, gun, or other weapons. Women who experienced forced sexual violence with threats were more likely 1.61 (1.08-2.41), to be HIV positive than those women who did not experience the same. Conclusion: GBV is widely spread in Zimbabwe. There is a need for the government to implement creative strategies to reach out to survivors, especially those that are forced to have unprotected sex and are at increased risk of HIV acquisition. This manuscript raises issues that can be addressed by robust health promotion strategies to reduce the impact of the syndemic of GBV and HIV acquisition in Zimbabwe.

The Landscape of COVID-19 Vaccination in Zimbabwe: A Narrative Review and Analysis of the Strengths, Weaknesses, Opportunities and Threats of the Programme.

The ongoing COVID-19 pandemic brought unprecedented challenges for the population. The advent of national COVID-19 vaccination programmes was therefore welcome as a key control strategy for the COVID-19 pandemic, as evidence has shown that vaccination is the best strategy to reduce the adverse individual and population level adverse outcomes associated with infectious diseases such as COVID-19. Zimbabwe rolled out its vaccination programme in February 2021 with an ambitious target to vaccinate at least 60% of its eligible population by December 2021. However, by that time, the country was still to reach that target. To move the vaccination programme towards achieving this target, it is crucial to understand the strengths, weaknesses, opportunities and threats to the programme. We, therefore, with this narrative review, discuss some of the strengths, weaknesses, opportunities and threats to the programme since its rollout in February 2021. Though the programme has several strengths and opportunities to leverage on, we argue that among other challenges, the emergence of new variants of concern poses one of the biggest threats to local, regional and international vaccination programmes and requires concerted multistakeholder efforts to deal with. Additionally, addressing vaccine hesitancy remains as important as availing the vaccines to the population, to obtain the most benefits out of the programme.

HIV status, knowledge and prevention of cervical cancer amongst adolescent girls and women: a secondary data analysis.

Introduction: the objective of this manuscript was to describe the knowledge profiles and determinants of cervical cancer screening among HIV positive and negative adolescent girls and women in Zimbabwe. Methods: we conducted secondary statistical data analysis to explore the determinants of cervical cancer screening among HIV positive and negative adolescent girls and women using Zimbabwe Demographic Health survey for 2015-16. Results: a total of 9054 adolescent girls aged 15-19, and women aged 20-49 were included in the analysis and the majority (63%) of them resided in rural areas. More than two-thirds (65.9%) had attained secondary level of education. The majority (41.3%) of the adolescent girls and women belonged to the Apostolic sect. A number of key determinants have been identified for being ever screened for cervical cancer. The odds of being ever being screened increased by age, OR(CI) 4.38 (3.22-5.94), p<0.001 for women who are 40 years and older when compared to adolescent and young woman who are between 15-24 years. Conclusion: our study reports significant programmatic gaps in the provision of cervical cancer screening and treatment services in the country. The nascent Zimbabwe cervical cancer screening and treatment progamme will benefit from expansion of the number of facilities offering the services and the provision of more efficient health education to adolescent women and girls.

Characterizing acceptable and appropriate implementation strategies of a biobehavioral survey among men who have sex with men and others assigned male who have sex with men in Zimbabwe.

Key populations including men who have sex with men (MSM), female sex workers, people who inject drugs, transgender persons, and prisoners account for nearly 50% of new HIV infections globally. To inform the HIV response and monitor trends in HIV prevalence and incidence among key populations, countries have increased efforts to implement biobehavioral surveys (BBS) with these groups as part of routine surveillance. Yet the marginalized nature of populations participating in a BBS requires contextually acceptable and appropriate strategies for effective implementation. We conducted a formative assessment to inform the first BBS conducted with MSM and others assigned male who have sex with men (OAMSM) in Zimbabwe, where same-sex sexual behaviors are illegal and highly stigmatized and describe applications of our findings. Qualitative data were collected through four focus groups with 32 MSM/OAMSM and 25 in-depth interviews (15 MSM/OAMSM, 10 service providers/gatekeepers) from December 2018 to January 2019. Rapid assessment techniques were employed including rapid identification of themes from audio recordings and review of detailed field notes and memos to identify key themes. Findings from this assessment included contextually relevant considerations including behaviors and terminology to avoid when working with MSM/OAMSM in Zimbabwe, appropriate compensation amounts for survey participation, proposed data collection sites, and differences in sexual openness, marital status, and networks among younger and older MSM/OAMSM. Participants also reported strong network ties suggesting respondent-driven sampling-a peer chain referral approach-to be an appropriate recruitment method in this context. Taken together, these findings highlighted key considerations and strategies for implementation to ensure the subsequent BBS in Zimbabwe was both acceptable and appropriate. These results and applications of these results are important for informing surveillance efforts and broader HIV-related engagement efforts among MSM/OAMSM in Zimbabwe as well as in other contextually similar countries in Southern Africa.

Engagement in the pre-exposure prophylaxis (PrEP) cascade among a respondent-driven sample of sexually active men who have sex with men and transgender women during early PrEP implementation in Zimbabwe.

INTRODUCTION: Zimbabwe is scaling up pre-exposure prophylaxis (PrEP) for key populations, including men who have sex with men (MSM) and transgender women (TGW). To assess implementation and inform HIV programming, we evaluated gaps in PrEP awareness, uptake and use, and correlates of awareness and uptake among a sample of MSM, TGW and genderqueer individuals (GQ) in Harare and Bulawayo, Zimbabwe. METHODS: Respondent-driven sampling was used to recruit 1194 MSM and 344 TGW/GQ aged ≥18 to participate in a cross-sectional survey assessing HIV-related outcomes in 2019. Consenting participants completed a questionnaire on socio-demographic information, sexual risk practices and engagement in HIV services and underwent HIV testing. Descriptive statistics were used to assess the PrEP cascade. Multiple logistic regression models were used to identify factors associated with PrEP awareness and uptake among HIV-negative participants. Data were unweighted as the sample did not reach convergence on key estimates. RESULTS: Among the 1167 HIV-negative participants, most (79.2%) were MSM compared to TGW/GQ (20.8%). Median age was 24 years. Overall, 45.8% were aware of PrEP and of those, 31.3% had ever taken PrEP. Most (71.1%) reporting never taking PrEP were willing to start PrEP; the main reasons for never starting PrEP included not knowing where to access it (24.8%) and fearing side effects (20.4%). Among those who had ever taken PrEP, 74.9% had taken PrEP in the last 6 months; of these, 42.4% had taken PrEP the day of or day preceding the survey. Side effects represented the most common (59.5%) reason for discontinuing PrEP. MSM (adjusted odds ratio [aOR]: 2.5, 95% confidence interval [CI]: 1.8-3.6) and TGW/GQ in Harare (aOR: 3.1, 95% CI: 2.1-4.7), and TGW/GQ in Bulawayo (aOR: 2.4, 95% CI: 1.1-5.3) had higher awareness of PrEP than MSM in Bulawayo. Overall, TGW/GQ were more likely to have ever taken PrEP compared to MSM (aOR: 1.6, 95% CI: 1.01-2.4). CONCLUSIONS: Findings emphasize the need for tailored interventions to promote PrEP among key populations. As HIV programs in Zimbabwe continue to expand PrEP services, these data, including barriers to starting and continuing PrEP, can inform strategies to address gaps along the PrEP cascade.

HIV care cascade and associated factors among men who have sex with men, transgender women, and genderqueer individuals in Zimbabwe: findings from a biobehavioural survey using respondent-driven sampling.

BACKGROUND: Globally, men who have sex with men (MSM), transgender women, and genderqueer individuals are at greater risk for HIV than the general population although little data are available from these groups in Zimbabwe, a country with a national adult HIV prevalence of 12·9%. We aimed to examine progress towards the UNAIDS 90-90-90 treatment targets and factors associated with meeting the targets among a sample of MSM, transgender women, and genderqueer individuals in Zimbabwe. METHODS: In this cross-sectional survey in 2019, we used respondent-driven sampling to identify MSM, transgender women, and genderqueer individuals aged at least 18 years to participate in a biobehavioural survey in Harare and Bulawayo, Zimbabwe. Participants were eligible to participate if they were assigned male at birth; had engaged in anal or oral sex with a man in the past 12 months; resided in Harare or Bulawayo for at least 1 month; spoke English, Shona, or Ndebele; provided written informed consent; and were in possession of a valid recruitment coupon if applicable. Enrolled participants completed a questionnaire and underwent HIV testing, and off-site viral load testing was done on all HIV-positive samples. Unweighted bivariate analyses and multivariable logistic regression models were used to evaluate the association of sociodemographic, behavioural, and other factors with HIV-positive status awareness among MSM, transgender women, and genderqueer individuals, and with viral load suppression among MSM. Analyses were done firstly using self-reported information and then by classifying those with a viral load of less than 200 copies per mL as being aware of their status and on treatment (viral load recategorisation). FINDINGS: Among MSM, 248 (21%; 95% CI 19-24) of 1176 tested positive for HIV. Of those who tested positive, based on self-report, 119 (48%; 95% CI 42-54) reported knowing their HIV status, of whom 112 (94%; 88-98) reported using antiretroviral therapy (ART), of whom 89 (79%; 71-87) had viral load suppression. Based on viral load recategorisation, 180 (73%; 67-78) of 248 MSM testing HIV positive reported knowing their HIV status, of whom 174 (97%; 93-99) reported using ART, of whom 151 (87%; 81-91) had viral load suppression. 92 (28%; 23-33) of 335 transgender women and genderqueer individuals tested positive for HIV. Based on self-reports from these individuals 34 (37%; 27-48) of 92 participants reported knowing their HIV status, of whom 31 (91%; 76-98) reported using ART, of whom 27 (87%; 70-96%) had viral load suppression. Based on viral load recategorisation of data from transgender women and genderqueer participants, 53 (58%; 47-58) of 92 reported awareness of their HIV status, of whom 50 (94%; 84-99) reported using ART, of whom 46 (92%; 81-98) had viral load suppression. HIV-positive MSM aged 18-24 years had lower odds of being aware of their status than those aged at least 35 years (adjusted odds ratio [aOR] 0·34; 95% CI 0·13-0·92), as did HIV-positive MSM aged 25-34 years (aOR 0·26; 0·12-0·56). HIV-positive MSM aged 18-24 years also had a lower odds of having viral load suppression than those aged 35 years and older (aOR 0·35; 0·16-0·78), as did those aged 25-34 years (aOR 0·36; 0·19-0·67). No factors were significantly associated with awareness among transgender women and genderqueer individuals in multivariable models. INTERPRETATION: Our survey showed that HIV prevalence was high and the largest difference between our results and the 90-90-90 treatment targets was in HIV status awareness, indicating the need for improvements in engaging MSM (especially young MSM), transgender women, and genderqueer individuals in HIV testing services. FUNDING: US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.

Acceptability of Community-Based Tuberculosis Preventive Treatment for People Living with HIV in Zimbabwe.

As Zimbabwe expands tuberculosis preventive treatment (TPT) for people living with HIV (PLHIV), the Ministry of Health and Child Care is considering making TPT more accessible to PLHIV via less-intensive differentiated service delivery models such as Community ART Refill Groups (CARGs). We designed a study to assess the feasibility and acceptability of integrating TPT into CARGs among key stakeholders, including CARG members, in Zimbabwe. We conducted 45 key informant interviews (KII) with policy makers, implementers, and CARG leaders; 16 focus group discussions (FGD) with 136 PLHIV in CARGs; and structured observations of 8 CARG meetings. KII and FGD were conducted in English and Shona. CARG observations were conducted using a structured checklist and time-motion data capture. Ninety six percent of participants supported TPT integration into CARGs and preferred multi-month TPT dispensing aligned with ART dispensing schedules. Participants noted that the existing CARG support systems could be used for TB symptom screening and TPT adherence monitoring/support. Other perceived advantages included convenience for PLHIV and decreased health facility provider workloads. Participants expressed concerns about possible medication stockouts and limited knowledge about TPT among CARG leaders but were confident that CARGs could effectively provide community-based TPT education, adherence monitoring/support, and TB symptom screening provided that CARG leaders received appropriate training and supervision. These results are consistent with findings from pilot projects in other African countries that are scaling up both differentiated service delivery for HIV and TPT and suggest that designing contextually appropriate approaches to integrating TPT into less-intensive HIV treatment models is an effective way to reach people who are established on ART but who may have missed out on access to TPT.

Recent HIV Infection Among Men Who Have Sex with Men, Transgender Women, and Genderqueer Individuals with Newly Diagnosed HIV Infection in Zimbabwe: Results from a Respondent-Driven Sampling Survey.

In Africa, rapid testing for recent HIV infection (RTRI) is being scaled up; however, use of the recent infection testing algorithm (RITA), which uses viral load (VL) to confirm RTRI-recent infections, is not a widespread practice. We present results of recently acquired HIV infections among men who have sex with men (MSM), transgender women, and genderqueer (TGW/GQ) individuals with newly diagnosed HIV infection in Zimbabwe as per the national approach (RTRI) and applying a RITA. In 2019, 1,538 MSM and TGW/GQ in Harare and Bulawayo, Zimbabwe were recruited to participate in a biobehavioral survey using respondent-driven sampling. Consenting participants received HIV testing and all HIV-positive specimens were tested with the RTRI Asanté HIV-1 Rapid Recency Assay, and for VL and CD4 count. RTRI-recent participants with unsuppressed VL (≥1,000 copies/mL) were classified as RITA-recent. Descriptive statistics were used to summarize results among RTRI-recent and RITA-recent participants. Among those tested for HIV (1,511/1,538), 22.5% (340/1,511) tested positive and of those, 55.0% (187/340) self-reported an HIV-negative or unknown status. Among these, 8.6% (16/187) were classified as RTRI-recent and 91.4% (171/187) were classified as RTRI-long term. After accounting for VL, RITA-recency was 1.1% (2/187). Two of 16 (12.5%) RTRI-recent infections were RITA-recent. VL among RITA-recent cases were 9,052 copies/mL and 40,694 copies/mL and both had CD4 counts <500. Data highlight misclassification of recent infections among MSM and TGW/GQ with newly diagnosed HIV infection using RTRI. With the incorporation of VL, >85% of RTRI-recent cases were reclassified as RITA-long term. True characterization of recent infections may not be possible without VL testing, which remains challenging in resource-limited settings.

Predicting HIV Status among Men Who Have Sex with Men in Bulawayo & Harare, Zimbabwe Using Bio-Behavioural Data, Recurrent Neural Networks, and Machine Learning Techniques.

HIV and AIDS continue to be major public health concerns globally. Despite significant progress in addressing their impact on the general population and achieving epidemic control, there is a need to improve HIV testing, particularly among men who have sex with men (MSM). This study applied deep and machine learning algorithms such as recurrent neural networks (RNNs), the bagging classifier, gradient boosting classifier, support vector machines, and Naïve Bayes classifier to predict HIV status among MSM using the dataset from the Zimbabwe Ministry of Health and Child Care. RNNs performed better than the bagging classifier, gradient boosting classifier, support vector machines, and Gaussian Naïve Bayes classifier in predicting HIV status. RNNs recorded a high prediction accuracy of 0.98 as compared to the Gaussian Naïve Bayes classifier (0.84), bagging classifier (0.91), support vector machine (0.91), and gradient boosting classifier (0.91). In addition, RNNs achieved a high precision of 0.98 for predicting both HIV-positive and -negative cases, a recall of 1.00 for HIV-negative cases and 0.94 for HIV-positive cases, and an F1-score of 0.99 for HIV-negative cases and 0.96 for positive cases. HIV status prediction models can significantly improve early HIV screening and assist healthcare professionals in effectively providing healthcare services to the MSM community. The results show that integrating HIV status prediction models into clinical software systems can complement indicator condition-guided HIV testing strategies and identify individuals that may require healthcare services, particularly for hard-to-reach vulnerable populations like MSM. Future studies are necessary to optimize machine learning models further to integrate them into primary care. The significance of this manuscript is that it presents results from a study population where very little information is available in Zimbabwe due to the criminalization of MSM activities in the country. For this reason, MSM tends to be a hidden sector of the population, frequently harassed and arrested. In almost all communities in Zimbabwe, MSM issues have remained taboo, and stigma exists in all sectors of society.

Risk Factors for COVID-19 Infection Among Healthcare Workers. A First Report From a Living Systematic Review and meta-Analysis.

Health care workers (HCWs) are more than ten times more likely to be infected with coronavirus infectious disease 2019 (COVID-19) than the general population, thus demonstrating the burden of COVID-19 among HCWs. Factors that expose HCWs to a differentially high-risk of COVID-19 acquisition are important to elucidate, enable appropriate public health interventions to mitigate against high risk and reduce adverse outcomes from the infection. We conducted a systematic review and meta-analysis to summarize and critically analyze the existing evidence on SARS-CoV-2 risk factors among HCWs. With no geographical limitation, we included studies, in any country, that reported (i) the PCR laboratory diagnosis of COVID-19 as an independent variable (ii) one or more COVID-19 risk factors among HCWs with risk estimates (relative risk, odds ratio, or hazard ratio) (iii) original, quantitative study design, and published in English or Mandarian. Our initial search resulted in 470 articles overall, however, only 10 studies met the inclusion criteria for this review. Out of the 10 studies included in the review, inadequate/lack of protective personal equipment, performing tracheal intubation, and gender were the most common risk factors of COVID-19. Based on the random effects adjusted pooled relative risk, HCWs who reported the use of protective personal equipment were 29% (95% CI: 16% to 41%) less likely to test positive for COVID-19. The study also revealed that HCWs who performed tracheal intubations were 34% (95% CI: 14% to 57%) more likely to test positive for COVID-19. Interestingly, this study showed that female HCWs are at 11% higher risk (RR 1.11 95% CI 1.01-1.21) of COVID-19 than their male counterparts. This article presents initial findings from a living systematic review and meta-analysis, therefore, did not yield many studies; however, it revealed a significant insight into better understanding COVID-19 risk factors among HCWs; insights important for devising preventive strategies that protect them from this infection. PROSPERO registration number: CRD42020193508 available for public comments via the link below https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020193508).