"What if I got rejected by the girl? I would rather stop the pills": barriers and facilitators of adherence to antiretroviral therapy for emerging adults aged 18-29 living with HIV in Zimbabwe.

Emerging adults aged 18-29 have high rates of viral non-suppression, and poorer adherence to ART when compared to older adults. Semi-structured interviews were conducted with 24 emerging adults in Zimbabwe who had a recent history of viral non-suppression, to explore barriers and facilitators of adherence to ART. Interviews were coded using inductive thematic analysis. The mean age of participants was 23, 65% were male, and 79% reported acquiring HIV at birth. Twelve barriers to adherence were identified. Hiding HIV status due to the possible negative consequences of disclosure had a significant impact on adherence to ART. This was particularly important for emerging adults navigating starting intimate relationships. Being away from home, poverty, poor mental health, isolation, significant life events, alcohol, health systems barriers, and stigma were reported as barriers to adherence. Support from peers and family after disclosure of HIV status, phone-based reminders, problem-solving strategies to adhere, knowing others living with HIV, acted as facilitators to adherence to ART. Beliefs about medicines and relationships with health care providers acted as both barriers and facilitators to adherence. Interventions to reduce stigma, foster peer support, and therapy for common mental disorders could facilitate emerging adults aged 18-29 to adhere to ART.

COVID-19 and mental health services in Sub-Saharan Africa: A critical literature review.

BACKGROUND: The COVID-19 pandemic has wrought a profound impact on mental health in Sub- Saharan Africa, exacerbating existing disparities and rendering individuals undergoing treatment particularly susceptible. This comprehensive critical review delves into the scope, nature, and extent of COVID-19 impact on mental health services in Sub- Saharan Africa, while concurrently elucidating pivotal lessons and exemplary practices learnt from periods of lockdown. METHODS: The methodology was guided by Jesson & Laccy's guide on how to conduct critical literature reviews. Articles were comprehensively sought through two academic databases (PubMed and Google Scholar), complemented by targeted searches on the WHO website and official public health websites of relevant Sub-Saharan African countries. RESULTS: The investigation reveals a surge in mental health challenges, notably marked by a significant escalation in anxiety, depression, and post-traumatic stress disorder. Disruptions to care services, financial hardships, and the pervasive effects of social isolation further compound this escalation. The pre-existing inequalities in access to and quality of care were accentuated during this crisis, with marginalized groups encountering heightened impediments to essential services. In navigating this unprecedented challenge, communities emerged as integral agents in establishing supportive networks and implementing culturally sensitive interventions. Technology, such as telemedicine and online resources, played a pivotal role in bridging access gaps, particularly in remote areas. The synthesis of best practices for supporting mental health patients during lockdowns encompasses targeted interventions for vulnerable groups, including adolescents and pregnant women. Empowering communities through economic support and mental health literacy programs was identified as crucial. The integration of technology, such as the development of robust telemedicine frameworks, virtual training in curricula, and the utilization of digital platforms for interventions and public messaging, emerged as a cornerstone in addressing access disparities. Community engagement and resilience-building strategies gained prominence, emphasizing the necessity of collaboration between healthcare providers and communities. Promotion of peer support groups, home-based care, and the preservation of traditional healing practices were underscored as essential components. CONCLUSION: The study underscores the need to adapt and optimize mental health services during emergencies. This entails prioritizing mental health within emergency response frameworks, exploring alternative service delivery methods, and fortifying data collection and research efforts.

HIV Infection in Attendees of Psychiatric Clinics in Harare, Zimbabwe; Prevalence, Associated Factors and HIV Care Uptake.

Determination of HIV prevalence among people with mental illness is necessary for developing integrated services for HIV and mental illness. This study determined HIV prevalence and uptake of HIV care among outpatients of psychiatric hospitals in Harare, Zimbabwe. HIV status was determined using open testing of 270 randomly selected consenting adult outpatients. HIV prevalence was 14.4% and the risk of acquiring HIV was similar to the general population of adults in Zimbabwe. Females were six times more likely to have HIV infection than males. Although a relatively high proportion of patients had been tested for HIV in the past (77.2%), fewer were recently tested (27.8%). Access to HIV care was high (94%) amongst patients previously diagnosed to be HIV positive. Tertiary mental health services should offer similar HIV care packages as other points of care and there is need for interventions that reduce the risk of HIV in women with mental disorders.

Depression among HIV positive pregnant women in Zimbabwe: a primary health care based cross-sectional study.

BACKGROUND: Depression is a common psychiatric disorder that is highly prevalent among people living with HIV (PLWH). Depression is linked to poor adherence to anti-retroviral medication while in the peri-natal period may affect birth outcomes. Intimate partner violence (IPV) has been linked to depression. Little is known about the factors associated with depression in HIV positive pregnant women in Zimbabwe. METHODS: We carried out a cross-sectional study in 4 busy primary care clinics offering antenatal services during the months of June through to September in 2016. Simple random sampling was used to screen HIV positive pregnant women while they waited to be attended to at each clinic. Eligible women who gave written informed consent were screened using a locally validated screening tool-the Edinburgh Postnatal Depression Scale (EPDS). RESULTS: A total of 198(85%) participants were recruited out of 234 that were approached. The mean age of participants was 26.6(SD 4.5), of these, 176 (88.9%) had secondary education or more. A total of 78 (39.4%) (95% CI 32.5-46.3) met criteria for antenatal depression according to the local version of the EPDS. Factors associated with antenatal depression after multivariate analysis were intimate partner violence (IPV) [OR 3.2 (95% CI 1.5-6.7)] and previous history of depression OR 4.1 (95% CI 2.0-8.0)]. CONCLUSION: The prevalence of antenatal depression among HIV positive pregnant women in primary care clinics is high. Factors associated with antenatal depression in pregnant HIV positive women are IPV and previous history of depression. There is need for routine screening for depression during the antenatal period and interventions targeting depression in this population should include components to address IPV.

Feasibility and Acceptability of a Task-Shifted Intervention to Enhance Adherence to HIV Medication and Improve Depression in People Living with HIV in Zimbabwe, a Low Income Country in Sub-Saharan Africa.

Using a pilot trial design in an HIV care clinic in Zimbabwe, we randomised 32 adults with poor adherence to antiretroviral therapy and at least mild depression to either six sessions of Problem-Solving Therapy for adherence and depression (PST-AD) delivered by an adherence counsellor, or to Enhanced Usual Care (Control). Acceptability of PST-AD was high, as indicated by frequency of session attendance and through qualitative analyses of exit interviews. Fidelity was >80% for the first two sessions of PST-AD but fidelity to the adherence component of PST-AD dropped by session 4. Contamination occurred, in that seven patients in the control arm received one or two PST-AD sessions before follow-up assessment. Routine health records proved unreliable for measuring HIV viral load at follow-up. Barriers to measuring adherence electronically included device failure and participant perception of being helped by the research device. The study was not powered to detect clinical differences, however, promising change at 6-months follow-up was seen in electronic adherence, viral load suppression (PST-AD arm 9/12 suppressed; control arm 4/8 suppressed) and depression (Patient Health Questionnaire-4.7 points in PST-AD arm vs. control, adjusted p value = 0.01). Results inform and justify a future randomised controlled trial of task-shifted PST-AD.

'Simulation-based learning in psychiatry for undergraduates at the University of Zimbabwe medical school'.

BACKGROUND: The use of simulated patients to teach in psychiatry has not been reported from low-income countries. This is the first study using simulation teaching in psychiatry in Africa. The aim of this study was to introduce a novel method of psychiatric teaching to medical students at the University of Zimbabwe and assess its feasibility and preliminary effectiveness. We selected depression to simulate because students in Zimbabwe are most likely to see cases of psychoses during their ward-based clinical exposure. METHODS: Zimbabwean psychiatrists adapted scenarios on depression and suicide based on ones used in London. Zimbabwean post-graduate trainee psychiatrists were invited to carry out the teaching and psychiatric nursing staff were recruited and trained in one hour to play the simulated patients (SPs). All students undertaking their psychiatry placement (n = 30) were allocated into groups for a short didactic lecture on assessing for clinical depression and then rotated around 3 scenarios in groups of 4-5 and asked to interview a simulated patient with signs of depression. Students received feedback from peers, SPs and facilitators. Students completed the Confidence in Assessing and Managing Depression (CAM-D) questionnaire before and after the simulation session and provided written free-text feedback. RESULTS: Post-graduate trainers, together with one consultant, facilitated the simulated teaching after three hours training. Student confidence scores increased from mean 15.90 to 20.05 (95% CI = 2.58- 5.71) t (20) = 5.52, (p > 0.0001) following the simulation teaching session. Free-text feedback was positive overall with students commenting that it was "helpful", "enjoyable" and "boosted confidence". CONCLUSIONS: In Zimbabwe, simulation teaching was acceptable and could be adapted with minimal effort by local psychiatrists and implemented by post-graduate trainees and one consultant, Students found it helpful and enjoyable and their confidence increased after the teaching. It offers students a broader exposure to psychiatric conditions than they receive during clinical attachment to the inpatient wards. Involving psychiatry trainees and nursing staff may be a sustainable approach in a setting with small number of consultants and limited funds to pay for professional actors.

Building mental health workforce capacity through training and retention of psychiatrists in Zimbabwe.

Despite the need to improve the quantity and quality of psychiatry training in sub-Saharan Africa (SSA), very little is known about the experiences of psychiatric trainees in the region. This is the first study examining psychiatric trainees in a low-income country in SSA. It was carried out as part of the needs assessment for a unique Medical Education Partnership Initiative (MEPI) programme to find African solutions for medical shortages in Africa. We approached all doctors who had trained in post-graduate psychiatry in Zimbabwe in 2010 and conducted in-depth qualitative interviews with all except one (n = 6). We analysed the data using constant comparison and thematic analysis. Trainees described the apprenticeship model as the programme's primary strength, through providing clinical exposure and role models. Programme weaknesses included shortages in information sources, trainee salaries, trainers, public health education, and in the mental health service. Most respondents were, however, eager to continue practising psychiatry in Zimbabwe, motivated by family ties, national commitment and helping vulnerable, stigmatized individuals. Respondents called for sub-speciality training and for infrastructure and training to do research. Resources need to be made available for psychiatric trainees in more SSA settings to develop public health competencies. However, investment in psychiatry training programmes must balance service provision with trainees' educational needs. Directing investment towards needs identified by trainees may be a cost-effective, context-sensitive way to increase retention and learning outcomes.

The prevalence and associated characteristics of Bipolar Disorder diagnosis among admitted patients at three tertiary psychiatric hospitals in Zimbabwe: A cross sectional study.

BACKGROUND: Bipolar Affective Disorder (BD) is a serious condition that affects more than 1% of the world's population. If not treated can cause disability, yet its prevalence in Zimbabwe is not known. This study explores the burden of Bipolar Disorder and its associated factors in Zimbabwe. METHODS: A cross sectional study with a sample of 272 participants was carried out at three tertiary hospitals in Zimbabwe. Data was collected using an interviewer administered questionnaire and the Mini International Neuropsychiatric Interview (M.I.N.I). The study shows the prevalence and factors associated with Bipolar Disorder at tertiary psychiatric hospitals. Data analysis was done using STATA S/E 13.0 for data management. RESULTS: The prevalence of BD in the sample was 39.3%. Factors associated with BD were, being formally employed (AOR = 3.69, 95%CI: 1.55-8.79), a history of defaulting medications (AOR = 1.90, 95%CI: 1.02-3.57) and a reported previous diagnosis of BD (AOR = 5.66, 95%CI: 2.72-11.8). CONCLUSIONS: The prevalence of BD among admitted participants in tertiary psychiatric hospitals in Zimbabwe is high. It is comparable to that from African studies done in clinical settings. There is need for in-service training for clinicians to be more vigilant in diagnosing BD.

Piloting the use of objective structured clinical examinations (OSCEs) to assess undergraduate medical students' clinical competence in psychiatry in Zimbabwe.

This report describes a pilot project which involved undergraduate medical students' clinical competence in psychiatry assessed through objective structured clinical examinations for the first time in Zimbabwe. The pilot describes how gaps in medical education can be addressed by collaborative partnerships that allow sharing of knowledge by local institutions and international experts.

Task-sharing with lay counsellors to deliver a stepped care intervention to improve depression, antiretroviral therapy adherence and viral suppression in people living with HIV: a study protocol for the TENDAI randomised controlled trial.

INTRODUCTION: Non-adherence to antiretroviral therapy (ART) is the main cause of viral non-suppression and its risk is increased by depression. In countries with high burden of HIV, there is a lack of trained professionals to deliver depression treatments. This paper describes the protocol for a 2-arm parallel group superiority 1:1 randomised controlled trial, to test the effectiveness and cost effectiveness of the TENDAI stepped care task-shifted intervention for depression, ART non-adherence and HIV viral suppression delivered by lay interventionists. METHODS AND ANALYSIS: Two hundred and ninety people living with HIV aged ≥18 years with probable depression (Patient Health Questionnaire=>10) and viral non-suppression (≥ 1000 HIV copies/mL) are being recruited from HIV clinics in towns in Zimbabwe. The intervention group will receive a culturally adapted 6-session psychological treatment, Problem-Solving Therapy for Adherence and Depression (PST-AD), including problem-solving therapy, positive activity scheduling, skills to cope with stress and poor sleep and content to target barriers to non-adherence to ART. Participants whose score on the Patient Health Questionnaire-9 remains ≥10, and/or falls by less than 5 points, step up to a nurse evaluation for possible antidepressant medication. The control group receives usual care for viral non-suppression, consisting of three sessions of adherence counselling from existing clinic staff, and enhanced usual care for depression in line with the WHO Mental Health Gap intervention guide. The primary outcome is viral suppression (<1000 HIV copies/mL) at 12 months post-randomisation. ETHICS AND DISSEMINATION: The study and its tools were approved by MRCZ/A/2390 in Zimbabwe and RESCM-18/19-5580 in the UK. Study findings will be shared through the community advisory group, conferences and open access publications. TRIAL REGISTRATION NUMBER: NCT04018391.

Z Factor: Drama as a tool to tackle mental health stigma: study design and protocol for community and public engagement in rural Zimbabwe.

Background: Mental health is slowly gaining global significance as a key health issue, yet the stigma attached to psychosis is still a major problem. There has been little in-depth exploration of sustainable, cost-effective, and replicable community engagement strategies that address mental health myths and stigma, which are major barriers to early health-seeking behaviours. In low-income countries such as Zimbabwe, cultural and spiritual beliefs are at the centre of most mental health explanatory models, perpetuating an environment where mental health conversations are a cultural taboo. Mental health interventions should be accompanied by creative, evidence-based community engagement, ensuring that interventions are suitable for local settings and giving communities a voice in directing their health initiatives.  Methods: Z Factor aimed to engage young adults and their support networks across a variety of socioeconomic groups in a rural district of Zimbabwe through their participation in an inter-ward five-staged drama competition. The focus was on psychosis, with subcategories of initial presentation/detection, seeking help/pathway to care, and the road to recovery/treatment. Each drama group's composition included a young adult and a typical support network seeking treatment from the service provider of choice. Dramas were to act as discussion starters, paving the way toward broader and deeper psychosis treatment discussions among rural communities and gaining insight into service user expectations from health research. Conclusions: Outcomes of the pilot community engagement project will be instrumental in improving understanding community perceptions about psychosis treatment and recovery in rural Zimbabwe and increasing community awareness about psychosis, as well as paving the way for initiating service provider collaboration to promote early detection and encouraging early health-seeking behaviours. The above outcomes will also inform the design of models for more responsive community and public engagement initiatives in similar low resource settings in Zimbabwe and beyond.

Validation of the Edinburgh Postnatal Depression Scale among women in a high HIV prevalence area in urban Zimbabwe.

UNLABELLED: Despite the significant burden of common mental disorders (CMD) among women in sub Saharan Africa, data on postnatal depression (PND) is very limited, especially in settings with a high HIV prevalence. The Edinburgh Postnatal Depression Scale (EPDS), a widely used screening test for PND has been validated in many countries, but not in Zimbabwe. We assessed the validity of the EPDS scale among postpartum women compared with Diagnostic Manual of Mental Disorders (DSM-IV) criteria for major depression. Six trained community counselors administered the Shona version of the EPDS to a random sample of 210 postpartum HIV-infected and uninfected women attending two primary care clinics in Chitungwiza. All women were subsequently subjected to mental status examination using DSM IV criteria for major depression by 2 psychiatrists, who were blinded to the subject's EPDS scores. Data were analyzed using receiver operating characteristic (ROC) curve analysis. Of the 210 postpartum mothers enrolled, 64 (33%) met DSM IV criteria for depression. Using a cut-off score of 11/12 on the Shona version of the EPDS for depression, the sensitivity was 88%, and specificity was 87%, with a positive predictive value of 74%, a negative predictive value of 94%, and an area under the curve of 0.82. Cronbach's alpha coefficient for the whole scale was 0.87. CONCLUSION: The Shona version of the EPDS is a reliable and valid tool to screen for PND among HIV-infected and un-infected women in Zimbabwe. Screening for PND should be integrated into routine antenatal and postnatal care in areas with high HIV prevalence.

Building Career Development Skills for Researchers: A Qualitative Study Across Four African Countries.

Background: Career development skills are widely advocated as part of research capacity building and strengthening efforts. However, there is a gap in knowledge on their acceptability in low- and middle-income countries. Objective: This study aimed to examine how a group of 16 early-career researchers in sub-Saharan Africa experienced a career development skills course and how they perceived the utility of the course. Methods: Sixteen early-career researchers registered at universities in Ethiopia, Zimbabwe, Malawi, and South Africa took part in the year-long Academic Competencies Series (ACES) course. ACES comprised ten modules covering mentoring skills, work-life balance, career strategy, teamwork, presentation skills, teaching, academic writing, engaging policy makers, grant-writing, and digital media. ACES was delivered through face-to-face workshops and via webinar as part of a broader mental health research capacity-building programme. In-depth interviews following a topic guide were conducted with participants. Interviews were recorded and transcribed verbatim. Data were analysed using Thematic Analysis. Findings: All ACES participants were interviewed (9 male, 7 female). Participants were PhD students (14) and post-docs (2). The main themes identified throughout the course were 1) Growth, in both personal and professional life; 2) Application of training, often in innovative ways but with notable constraints and obstacles; and 3) Connection with colleagues, where researchers learnt from each other and from experts, building confidence in their new skills. Participants described how face-to-face contact enhanced the perceived quality of their learning experience. Barriers included logistical obstacles to applying training, such as limited resources and being at an early career stage. Conclusions: We found that research career development skills training was highly acceptable for early-career researchers in four African countries, and was perceived as having facilitated their personal and professional growth. Our findings suggest that courses like ACES can be applied successfully and innovatively in low-income settings.

"We need more big trees as well as the grass roots": going beyond research capacity building to develop sustainable careers in mental health research in African countries.

BACKGROUND: There are substantial gaps in our knowledge regarding the aetiology of mental, neurological and substance use disorders in sub-Saharan Africa, and the cost-effectiveness and scalability of interventions to reduce the burden of these conditions on the continent. To address these gaps, international investment has focussed on building research capacity, including funding doctoral students in African countries, to support development of high quality, contextually relevant interventions. Absent, however, is an understanding of how capacity building feeds into research careers. METHODS: Within a broader mental health research capacity-building initiative (African Mental Health Research Initiative), we conducted 52 qualitative interviews with early-career researchers, policymakers, academics, and service users from four African countries (Ethiopia, Malawi, South Africa, and Zimbabwe) and with international funders of mental health research. The interview guide focused on the research context, planning, and priorities and how respondents perceive research careers and funding. Thematic analysis was applied to the transcribed interviews. RESULTS: Five components of a research career emerged: (i) research positions; (ii) research skills; (iii) funding; (iv) research commitment from African countries; and (v) advocacy. All stakeholders wanted more high-impact African researchers, but few saw a clear, replicable track for developing their careers within universities or their Ministries of Health in their African countries. This stemmed, in part, from the lack of support for infrastructure that enables high-quality research: grants administration, mentorship, university leadership, research culture, and open communication between policymakers and researchers. CONCLUSIONS: This study highlights the importance of developing research infrastructure alongside capacity-building efforts. International funders should invest in grant management at African universities which would place them at the centre of research initiatives. African universities should prioritise the creation of a research culture by developing and promoting well-defined research tracks for both clinicians and academics, investing in grant management, and raising the profile of research within their institutions.

Mental health research capacity building in sub-Saharan Africa: the African Mental Health Research Initiative.

Mental, neurological and substance use (MNS) disorders are a leading, but neglected, cause of morbidity and mortality in sub-Saharan Africa. The treatment gap for MNS is vast with only 10% of people with MNS disorders in low-income countries accessing evidence-based treatments. Reasons for this include low awareness of the burden of MNS disorders and limited evidence to support development, adaptation and implementation of effective and feasible treatments. The overall goal of the African Mental Health Research Initiative (AMARI) is to build an African-led network of MNS researchers in Ethiopia, Malawi, South Africa and Zimbabwe, who are equipped to lead high quality mental health research programs that meet the needs of their countries, and to establish a sustainable career pipeline for these researchers with an emphasis on integrating MNS research into existing programs such as HIV/AIDS. This paper describes the process leading to the development of AMARI's objectives through a theory of change workshop, successes and challenges that have been faced by the consortium in the last 4 years, and the future role that AMARI could play in further building MNS research capacity by brining on board more institutions from low- and middle-income countries with an emphasis on developing an evidence-based training curriculum and a research-driven care service.

Effect of a differentiated service delivery model on virological failure in adolescents with HIV in Zimbabwe (Zvandiri): a cluster-randomised controlled trial.

BACKGROUND: Adolescents living with HIV face challenges to their wellbeing and antiretroviral therapy adherence and have poor treatment outcomes. We aimed to evaluate a peer-led differentiated service delivery intervention on HIV clinical and psychosocial outcomes among adolescents with HIV in Zimbabwe. METHODS: 16 public primary care facilities (clusters) in two rural districts in Zimbabwe (Bindura and Shamva) were randomly assigned (1:1) to provide enhanced HIV care support (the Zvandiri intervention group) or standard HIV care (the control group) to adolescents (aged 13-19 years) with HIV. Eligible clinics had at least 20 adolescents in pre-ART or ART registers and were geographically separated by at least 10 km to minimise contamination. Adolescents were eligible for inclusion if they were living with HIV, registered for HIV care at one of the trial clinics, and either starting or already on ART. Exclusion criteria were being too physically unwell to attend clinic (bedridden), psychotic, or unable to give informed assent or consent. Adolescents with HIV at all clinics received adherence support through adult counsellors. At intervention clinics, adolescents with HIV were assigned a community adolescent treatment supporter, attended a monthly support group, and received text messages, calls, home visits, and clinic-based counselling. Implementation intensity was differentiated according to each adolescent's HIV vulnerability, which was reassessed every 3 months. Caregivers were invited to a support group. The primary outcome was the proportion of adolescents who had died or had a viral load of at least 1000 copies per µL after 96 weeks. In-depth qualitative data were collected and analysed thematically. The trial is registered with Pan African Clinical Trial Registry, number PACTR201609001767322. FINDINGS: Between Aug 15, 2016, and March 31, 2017, 500 adolescents with HIV were enrolled, of whom four were excluded after group assignment owing to testing HIV negative. Of the remaining 496 adolescents, 212 were recruited at Zvandiri intervention sites and 284 at control sites. At enrolment, the median age was 15 years (IQR 14-17), 52% of adolescents were female, 81% were orphans, and 47% had a viral load of at least 1000 copies per µL. 479 (97%) had primary outcome data at endline, including 28 who died. At 96 weeks, 52 (25%) of 209 adolescents in the Zvandiri intervention group and 97 (36%) of 270 adolescents in the control group had an HIV viral load of at least 1000 copies per µL or had died (adjusted prevalence ratio 0·58, 95% CI 0·36-0·94; p=0·03). Qualitative data suggested that the multiple intervention components acted synergistically to improve the relational context in which adolescents with HIV live, supporting their improved adherence. No adverse events were judged to be related to study procedures. Severe adverse events were 28 deaths (17 in the Zvandiri intervention group, 11 in the control group) and 57 admissions to hospital (20 in the Zvandiri intervention group, 37 in the control group). INTERPRETATION: Peer-supported community-based differentiated service delivery can substantially improve HIV virological suppression in adolescents with HIV and should be scaled up to reduce their high rates of morbidity and mortality. FUNDING: Positive Action for Adolescents Program, ViiV Healthcare.

Understanding Ethical, Legal and Societal Issues (ELSIs) in Human Biobanking and Genomics for Research and Healthcare in Zimbabwe: The Genomics Inheritance Law Ethics and Society (GILES) initiative.

Biobanks and human genomics applications are key for understanding health, disease and heredity in Africa and globally. Growing interest in these technologies calls for strengthening relevant legal, ethical and policy systems to address knowledge disparities and ensure protection of society, while supporting advancement of science. In Zimbabwe there is limited understanding of ethical, legal, and societal issues (ELSI) for biobanking and genomics. The Genomics Inheritance Law Ethics and Society (GILES) initiative was established in 2015 to explore the current status and gaps in the ethical and legal frameworks, knowledge among various stakeholders, and to establish capacity for addressing ELSI of biobanking and genomics as applied in biomedical and population research, and healthcare. A multi-methods approach was applied including document reviews, focus group discussions and in-depth interviews among health and research professionals, and community members in six provinces comprising urban, peri-urban and rural areas. Emerging findings indicates a need for updating guidelines and policies for addressing ELSI in biobanking and genomics research in Zimbabwe. Emerging terminologies such as biobanking and genomics lack clarity suggesting a need for increased awareness and educational tools for health professionals, research scientists and community members. Common concerns relating to consent processes, sample and data use and sharing, particularly where there is trans-national flow of biospecimens and data, call for nationally tailored ELSI frameworks aligned to regional and international initiatives. This paper describes the strategy undertaken for the development and implementation of the GILES project and discusses the importance of such an initiative for characterisation of ELSI of human biobanking and genomics in Zimbabwe and Africa. Conducting this explorative study among a wide range of stakeholders over a countrywide geographical regions, established one of the most comprehensive studies for ELSI of human biobanking and genomics in Africa.

Evaluating a multi-component, community-based program to improve adherence and retention in care among adolescents living with HIV in Zimbabwe: study protocol for a cluster randomized controlled trial.

BACKGROUND: World Health Organization (WHO) adolescent HIV-testing and treatment guidelines recommend community-based interventions to support antiretroviral therapy (ART) adherence and retention in care, while acknowledging that the evidence to support this recommendation is weak. This cluster randomized controlled trial aims to evaluate the effectiveness and cost-effectiveness of a psychosocial, community-based intervention on HIV-related and psychosocial outcomes. METHODS/DESIGN: We are conducting the trial in two districts. Sixteen clinics were randomized to either enhanced ART-adherence support or standard of care. Eligible individuals (HIV-positive adolescents aged 13-19 years and eligible for ART) in both arms receive ART and adherence support provided by adult counselors and nursing staff. Adolescents in the intervention arm additionally attend a monthly support group, are allocated to a designated community adolescent treatment supporter, and followed up through a short message service (SMS) and calls plus home visits. The type and frequency of contact is determined by whether the adolescent is "stable" or in need of enhanced support. Stable adolescents receive a monthly home visit plus a weekly, individualized SMS. An additional home visit is conducted if participants miss a scheduled clinic appointment or support-group meeting. Participants in need of further, enhanced, support receive bi-weekly home visits, weekly phone calls and daily SMS. Caregivers of adolescents in the intervention arm attend a caregiver support group. Trial outcomes are assessed through a clinical, behavioral and psychological assessment conducted at baseline and after 48 and 96 weeks. The primary outcome is the proportion who have died or have virological failure (viral load ≥1000 copies/ml) at 96 weeks. Secondary outcomes include virological failure at 48 weeks, retention in care (proportion of missed visits) and psychosocial outcomes at both time points. Statistical analyses will be conducted and reported in line with CONSORT guidelines for cluster randomized trials, including a flowchart. DISCUSSION: This study provides a unique opportunity to generate evidence of the impact of the on-going Zvandiri program, for adolescents living with HIV, on virological failure and psychosocial outcomes as delivered in a real-world setting. If found to reduce rates of treatment failure, this would strengthen support for further scale-up across Zimbabwe and likely the region more widely. TRIAL REGISTRATION: Pan African Clinical Trial Registry database, registration number PACTR201609001767322 (the Zvandiri trial). Retrospectively registered on 5 September 2016.

Mental health in Zimbabwe: a health systems analysis.

There has been little external analysis of Zimbabwe's mental health system. We did a systems analysis to identify bottlenecks and opportunities for mental health service improvement in Zimbabwe and to generate cost-effective, policy-relevant solutions. We combined in-depth interviews with a range of key stakeholders in health and mental health, analysis of mental health laws and policies, and publicly available data about mental health. Five themes are key to mental health service delivery in Zimbabwe: policy and law; financing and resources; criminal justice; workforce, training, and research; and beliefs about mental illness. We identified human resources, rehabilitation facilities, psychotropic medication, and community mental health as funding priorities. Moreover, we found that researchers should prioritise measuring the economic impact of mental health and exploring substance use, forensic care, and mental health integration. Our study highlights forensic services as a central component of the mental health system, which has been a neglected concept. We also describe a tailored process for mental health systems that is transferable to other low-income settings and that garners political will, builds capacity, and raises the profile of mental health.