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.

Spatial patterns of HIV prevalence and service use in East Zimbabwe: implications for future targeting of interventions.

INTRODUCTION: Focusing resources for HIV control on geographic areas of greatest need in countries with generalized epidemics has been recommended to increase cost-effectiveness. However, socioeconomic inequalities between areas of high and low prevalence could raise equity concerns and have been largely overlooked. We describe spatial patterns in HIV prevalence in east Zimbabwe and test for inequalities in accessibility and uptake of HIV services prior to the introduction of spatially-targeted programmes. METHODS: 8092 participants in an open-cohort study were geo-located to 110 locations. HIV prevalence and HIV testing and counselling (HTC) uptake were mapped with ordinary kriging. Clusters of high or low HIV prevalence were detected with Kulldorff statistics, and the socioeconomic characteristics and sexual risk behaviours of their populations, and levels of local HIV service availability (measured in travel distance) and uptake were compared. Kulldorff statistics were also determined for HTC, antiretroviral therapy (ART), and voluntary medical male circumcision (VMMC) uptake. RESULTS: One large and one small high HIV prevalence cluster (relative risk [RR] = 1.78, 95% confidence interval [CI] = 1.53-2.07; RR = 2.50, 95% CI = 2.08-3.01) and one low-prevalence cluster (RR = 0.70, 95% CI = 0.60-0.82) were detected. The larger high-prevalence cluster was urban with a wealthier population and more high-risk sexual behaviour than outside the cluster. Despite better access to HIV services, there was lower HTC uptake in the high-prevalence cluster (odds ratio [OR] of HTC in past three years: OR = 0.80, 95% CI = 0.66-0.97). The low-prevalence cluster was predominantly rural with a poorer population and longer travel distances to HIV services; however, uptake of HIV services was not reduced. CONCLUSION: High-prevalence clusters can be identified to which HIV control resources could be targeted. To date, poorer access to HIV services in the poorer low-prevalence areas has not resulted in lower service uptake, whilst there is significantly lower uptake of HTC in the high-prevalence cluster where health service access is better. Given the high levels of risky sexual behaviour and lower uptake of HTC services, targeting high-prevalence clusters may be cost-effective in this setting. If spatial targeting is introduced, inequalities in HIV service uptake may be avoided through mobile service provision for lower prevalence areas.

The contribution of schools to supporting the well being of children affected by HIV in eastern Zimbabwe.

OBJECTIVES: Schools are often cited as a source of support for orphans and children affected by HIV/AIDS in populations experiencing generalized HIV epidemics and severe poverty. Here we investigate the success of schools at including and supporting the well being of vulnerable children in rural Zimbabwe. DESIGN: Data from a cross-sectional household survey of 4577 children (aged 6-17 years), conducted between 2009 and 2011, were linked to data on the characteristics of 28 primary schools and 18 secondary schools from a parallel monitoring and evaluation facility survey. METHODS: We construct two measures of school quality (one general and one HIV-specific) and use multivariable regression to test whether these were associated with improved educational outcomes and well being for vulnerable children. RESULTS: School quality was not associated with primary or secondary school attendance, but was associated with children's being in the correct grade for age [adjusted odds ratio 2.0, 95% confidence interval (CI) 1.2-3.5, P = 0.01]. General and HIV-specific school quality had significant positive effects on well being in the primary school-age children (coefficient 5.1, 95% CI 2.4-7.7, P < 0.01 and coefficient 3.0, 95% CI 0.4-5.6, P = 0.02, respectively), but not in the secondary school-age children (P > 0.2). There was no evidence that school quality provided an additional benefit to the well being of vulnerable children. Community HIV prevalence was negatively associated with well being in the secondary school-age children (coefficient -0.7, 95% CI -1.3 to -0.1, P = 0.03). CONCLUSIONS: General and HIV-specific school quality may enhance the well being of primary school-age children in eastern Zimbabwe. Local community context also plays an important role in child well being.