Hot, horny and healthy-online intervention to incentivize HIV and sexually transmitted infections (STI) testing among young Mexican MSM: a feasibility study.

BACKGROUND: Encouraging Mexican men who have sex with men (MSM) to learn about and get tested for human immunodeficiency virus (HIV) is essential not only to initiate early treatment and reduce complications related to acquired immune deficiency syndrome (AIDS) but also to avoid new infections. HIV testing for MSM in Mexico remains a challenge, in part because of the stigma and discrimination they face in their daily lives and perceived discrimination in health care services. Thus, innovative approaches are needed to increase the uptake of health prevention services among this population. Games for health and gamification are now established approaches to achieving desired behavior change. Gamified interventions have been successfully deployed in various health domains, including HIV awareness, treatment, and prevention. The aim of this 2015 study was to develop a phone-based game and linked online platform with gamification elements to incentivize HIV and sexually transmitted infections (STI) testing, normalize asking partners about serostatus, and increase HIV and STI knowledge among young Mexican MSM. This paper describes its implementation process and feasibility assessment. METHODS: The study consisted of three phases. The first phase was the formative research, which consisted of 6 focus groups and rapid prototyping to determine the most effective and appropriate design for the intervention. The second phase consisted of piloting and implementing the intervention over five weeks among 62 MSM, aged between 18 and 35 years old. Lastly, we assessed the feasibility of the intervention over three dimensions: acceptability, demand, and implementation. We conducted ten semi-structured interviews with participants and used a mixed-methods approach, including qualitative and quantitative evaluation methods. RESULTS: Overall, the conceptual components of the intervention were perceived as acceptable, which leads us to believe that the formative phase captured our participants' needs and perceptions. However, we underestimated the complexity of the technical challenges involved. Participants' high standards and expectations of an interactive product based on their experience with industrially produced games impacted their patterns of use. Nevertheless, they perceived the platform as a good-quality information source. Gamification elements such as badges, points, and prizes were perceived as fun, exciting, and motivating, and 71% of participants engaged in at least one activity to earn points. CONCLUSIONS: A game-based intervention, coupled with an online platform that incorporates gamification elements to motivate HIV and STI testing in young Mexican MSM is feasible. Successfully scaling such an intervention to a broader audience would require reducing the complexity of the intervention, working with a local technical partner to develop and implement a more efficient platform, improving the quality of the graphics, and a re-design of the point system.

Protocol for the evaluation of the population-level impact of Zimbabwe's prevention of mother-to-child HIV transmission program option B+: a community based serial cross-sectional study.

BACKGROUND: WHO recommends that HIV infected women receive antiretroviral therapy (ART) minimally during pregnancy and breastfeeding ("Option B"), or ideally throughout their lives regardless of clinical stage ("Option B+") (Coovadia et al., Lancet 379:221-228, 2012). Although these recommendations were based on clinical trials demonstrating the efficacy of ART during pregnancy and breastfeeding, the population-level effectiveness of Option B+ is unknown, as are retention on ART beyond the immediate post-partum period, and the relative impact and cost-effectiveness of Option B+ compared to Option A (Centers for Disease Control and Prevention, Morb Mortal Wkly Rep 62:148-151, 2013; Ahmed et al., Curr Opin HIV AIDS 8:473-488, 2013). To address these issues, we conducted an impact evaluation of Zimbabwe's prevention of mother to child transmission programme conducted between 2011 and 2018 using serial, community-based cross-sectional serosurveys, which spanned changes in WHO recommendations. Here we describe the rationale for the design and analysis. METHODS/DESIGN: Our method is to survey mother-infant pairs residing in the catchment areas of 157 health facilities randomly selected from 5 of 10 provinces in Zimbabwe. We collect questionnaires, blood samples from mothers and babies for HIV antibody and viral load testing, and verbal autopsies for deceased mothers/babies. Using this approach, we collected data from two previous time points: 2012 (pre-Option A standard of care), 2014 (post-Option A / pre-Option B+) and will collect a third round of data in 2017-18 (post Option B+ implementation) to monitor population-level trends in mother-to-child transmission of HIV (MTCT) and HIV-free infant survival. In addition, we will collect detailed information on facility level factors that may influence service delivery and costs. DISCUSSION: Although the efficacy of antiretroviral therapy (ART) during pregnancy and breastfeeding for prevention of mother-to-child transmission of HIV (PMTCT) has been well-documented in randomized trials, little evidence exists on the population-level impact and cost-effectiveness of Option B+ or the influence of the facility on implementation (Siegfried et al., Cochrane Libr 7:CD003510, 2017). This study will provide essential data on these gaps and will provide estimates on retention in care among Option B+ clients after the breastfeeding period. TRIAL REGISTRATION: NCT03388398 Retrospectively registered January 3, 2018.

Unintended pregnancy and subsequent postpartum long-acting reversible contraceptive use in Zimbabwe.

BACKGROUND: The postpartum period is an opportune time for contraception adoption, as women have extended interaction with the reproductive healthcare system and therefore more opportunity to learn about and adopt contraceptive methods. This may be especially true for women who experience unintended pregnancy, a key target population for contraceptive programs and programs to eliminate mother-to-child HIV transmission. Among women in Zimbabwe surveyed in 2014, we examined the relationship between pregnancy intention associated with a woman's most recent pregnancy, and her subsequent postpartum contraceptive use. METHODS: In our analysis we utilized a dataset from a random selection of catchment areas in Zimbabwe to examine the association between pregnancy intention of most recent pregnancy and subsequent postpartum contraceptive use using multinomial logistic regression models. We also explored whether this association differed by women's HIV status. Finally, we examined the association between pregnancy intention and changes in contraception from the pre- to postpartum periods. RESULTS: Findings suggest that women who reported that their pregnancy was unintended adopted less modern (all non-traditional) contraceptive methods overall, but adopted long-acting reversible contraception (LARC) more frequently than women reporting an intended pregnancy (OR 1.41; CI 1.18, 1.68). Among HIV-positive women, this relationship was particularly strong (OR 3.12; CI 1.96, 4.97). However, when examining changes in contraceptive use from the pre-pregnancy to the postpartum period, women who had an unintended pregnancy had lower odds of changing to a more effective method postpartum overall (OR 0.71; CI 0.64, 0.79). CONCLUSIONS: We did not find evidence of higher modern method adoption in the postpartum period among women with an unintended pregnancy. However, women who were already on a method in the pre-pregnancy period were catalyzed to move to more effective methods (such as LARC) postpartum. This study provides evidence of low modern (non-traditional) method adoption in general in the postpartum period among a vulnerable sub-population in Zimbabwe (women who experience unintended pregnancy). Simultaneously, however, it shows a relatively greater portion specifically of LARC use among women with an unintended pregnancy. Further research is needed to more closely examine the motivations behind these contraceptive decisions in order to better inform distribution and counseling programs.

Stick To It: pilot study results of an intervention using gamification to increase HIV screening among young men who have sex with men in California.

BACKGROUND: In the United States, young men who have sex with men (YMSM) experience a disproportionate burden of HIV and sexually transmitted infections (STIs). Mobile health (mHealth) interventions, including those that incorporate elements of games ("gamification"), have the potential to improve YMSM engagement in desirable sexual health services and behaviors. Gamification leverages theory and tools from behavioral science to motivate people to engage in a behavior in a context of fun. The objective of the study was to determine whether an intervention using gamification is acceptable to YMSM in California and potentially increases repeat HIV screening. METHODS: Eligible YMSM were: (I) 18-26 years, (II) born as and/or self-identified as male, (III) reported male sexual partners, and (IV) lived in a zip code adjacent to one of the two study clinics in Oakland and Hollywood, California. The gamification intervention, Stick To It, had four components: (I) recruitment (clinic-based and online), (II) online enrollment, (III) online activities, and (IV) 'real-world' activities at the clinic. Participants earned points through online activities that could be redeemed for a chance to win prizes during HIV/STI screening and care visits. The primary outcome was intervention acceptability measured with participant engagement data and in-depth interviews. The secondary outcome was the intervention's preliminary effectiveness on repeat HIV screening within 6 months, restricted to the subset of men who provided consent for review of medical records and who had ≥6 months of follow-up. Outcomes were compared to a historical control group of similar YMSM who attended study clinics in the 12 months prior to intervention implementation. RESULTS: Overall, 166 of 313 (53%) eligible YMSM registered. After registration, 93 (56%) participants completed enrollment and 31 (19%) completed ≥1 online activity in the subsequent 6 months. Points were redeemed in clinic by 11% of the 166 users (27% and 5% of those who enrolled in the clinic and online, respectively). Despite moderate engagement, participants provided a positive assessment of the program in interviews, reporting that the inclusion of game elements was motivating. The analysis of repeat HIV testing was assessed among 31 YMSM who consented to medical record review and who had ≥6 months of follow-up. During follow-up, 15 (48%) received ≥2 HIV tests compared to 157 (30%) of a historical comparison group of 517 similar YMSM who lived in the same zip codes and who received care at the same clinics before the intervention (OR =2.15, 95% CI: 1.03-4.47, P=0.04). CONCLUSIONS: Engagement in the intervention was modest, with YMSM who enrolled in a clinic more actively engaged than YMSM who enrolled online. Among the subset of participants recruited in the clinic, repeat HIV screening was higher than a comparison group of similar YMSM attending the same clinic in the prior year.

An Intervention Using Gamification to Increase Human Immunodeficiency Virus and Sexually Transmitted Infection Screening Among Young Men Who Have Sex With Men in California: Rationale and Design of Stick To It.

BACKGROUND: In the United States, young men who have sex with men (YMSM) remain disproportionately affected by human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). Although routine HIV/STI screening is pivotal to the timely diagnosis of HIV and STIs, initiation of appropriate treatment, and reduced onward disease transmission, repeat screening is underused. Novel interventions that incorporate elements of games, an approach known as gamification, have the potential to increase routinization of HIV/STI screening among YMSM. OBJECTIVE: The study aims to test the hypothesis that an incentive-based intervention that incorporates elements of gamification can increase routine HIV/STI screening among YMSM in California. METHODS: The study consists of a formative research phase to develop the intervention and an implementation phase where the intervention is piloted in a controlled research setting. In the formative research phase, we use an iterative development process to design the intervention, including gathering information about the feasibility, acceptability, and expected effectiveness of potential game elements (eg, points, leaderboards, rewards). These activities include staff interviews, focus group discussions with members of the target population, and team meetings to strategize and develop the intervention. The final intervention is called Stick To It and consists of 3 components: (1) online enrollment, (2) Web-based activities consisting primarily of quizzes and a countdown "timer" to facilitate screening reminders, and (3) in-person activities that occur at 2 sexual health clinics. Participants earn points through the Web-based activities that are then redeemed for chances to win various prizes during clinic visits. The pilot study is a quasi-experimental study with a minimum of 60 intervention group participants recruited at the clinics, at community-based events, and online. We will compare outcomes in the intervention group with a historical control group consisting of individuals meeting the inclusion criteria who attended study clinics in the 12 months prior to intervention implementation. Eligible participants in the pilot study (1) are 18 to 26 years old, (2) were born or identify as male, 3) report male sexual partners, and 4) have a zip code of residence within defined areas in the vicinity of 1 of the 2 implementation sites. The primary outcome is repeat HIV/STI screening within 6 months. RESULTS: This is an ongoing research study with initial results expected in the fourth quarter of 2017. CONCLUSIONS: We will develop and pilot test a gamification intervention to encourage YMSM to be regularly screened for HIV/STIs. The results from this research will provide preliminary evidence about the potential effectiveness of using gamification to amplify health-related behavioral change interventions. Further, the research aims to determine the processes that are essential to developing and implementing future health-related gamification interventions. TRIAL REGISTRATION: Clinicaltrials.gov NCT02946164; https://clinicaltrials.gov/ct2/show/NCT02946164 (Archived by WebCite at http://www.webcitation.org/6ri3G4HwD).

HIV-1 Vertical Transmission in Zimbabwe in 622 Mother and Infant Pairs: Rethinking the Contribution of Mannose Binding Lectin Deficiency in Africa.

Vertical transmission of human immunodeficiency virus (HIV) remains a major global health problem. We assessed the association of mannose binding lectin (MBL) deficiency and vertical transmission of HIV. Novel diagnostics would be a major breakthrough in this regard. MBL is a liver-derived protein and a key component of the innate immune system. MBL levels may be classified as normal, intermediate, or deficient in the plasma and can use MBL2 haplotypes as a proxy. These haplotypes comprise polymorphisms in the MBL2 gene and promoter region and are known to result in varying levels of MBL deficiency. MBL deficiency can be defined as presence of A/O and O/O genotypes in the mothers and their children. MBL deficiency leads to defective opsonization activities of the innate immune system and increased susceptibility to several infections, including HIV-1. We determined the prevalence of MBL deficiency, using MBL2 haplotypes among 622 HIV-positive Zimbabwean mothers and their children aged 9-18 months old, in relation to the HIV-1 vertical transmission risk. The median age of the mothers was 30 (26-34, interquartile range [IQR]) years, and the babies' median age was 13 (11-15, IQR) months old at the time of enrollment. From the sample of 622 mothers who were HIV-1 infected, 574 babies were HIV negative and 48 were HIV-1-positive babies, giving a transmission rate of 7.7%. MBL2 normal structural allele A and variants B (codon 5 A>G), C (codon 57 A>G), and promoter region SNPs -550(H/L) and -221(X/Y) were detected. Prevalence of haplotype-predicted MBL deficiency was 34% among the mothers and 32% among the children. We found no association between maternal MBL2 deficiency and HIV-1 transmission to their children. We found no difference in the distribution of HIV-1 infected and uninfected children between the MBL2 genotypes of the mothers and those of the children. Taken together, the present study in a large sample of mother-infant pairs in Zimbabwe adds to the emerging literature and the hypothesis that MBL2 variation as predicted by haplotypes does not influence the vertical transmission risk for HIV. Research from other populations from the African continent is called for to test this hypothesis further.

Option A improved HIV-free infant survival and mother to child HIV transmission at 9-18 months in Zimbabwe.

OBJECTIVE: We evaluated the impact of Option A on HIV-free infant survival and mother-to-child transmission (MTCT) in Zimbabwe. DESIGN: Serial cross-sectional community-based serosurveys. METHODS: We analyzed serosurvey data collected in 2012 and 2014 among mother-infant pairs from catchment areas of 132 health facilities from five of 10 provinces in Zimbabwe. Eligible infants (alive or deceased) were born 9-18 months before each survey to mothers at least 16 years old. We randomly selected mother-infant pairs and conducted questionnaires, verbal autopsies, and collected blood samples. We estimated the HIV-free infant survival and MTCT rate within each catchment area and compared the 2012 and 2014 estimates using a paired t test and number of HIV infections averted because of the intervention. RESULTS: We analyzed 7249 mother-infant pairs with viable maternal specimens collected in 2012 and 8551 in 2014. The mean difference in the catchment area level MTCT between 2014 and 2012 was -5.2 percentage points (95% confidence interval = -8.1, -2.3, P < 0.001). The mean difference in the catchment area level HIV-free survival was 5.5 percentage points (95% confidence interval = 2.6, 8.5, P < 0.001). Between 2012 and 2014, 1779 infant infections were averted compared with the pre-Option A regimen. The association between HIV-free infant survival and duration of Option A implementation was NS at the multivariate level (P = 0.093). CONCLUSION: We found a substantial and statistically significant increase in HIV-free survival and decrease in MTCT among infants aged 9-18 months following Option A rollout in Zimbabwe. This is the only evaluation of Option A and shows the effectiveness of Option A and Zimbabwe's remarkable progress toward eMTCT.

Targeting elimination of mother-to-child HIV transmission efforts using geospatial analysis of mother-to-child HIV transmission in Zimbabwe.

BACKGROUND: We assessed Zimbabwe's progress toward elimination of mother-to-child HIV transmission (MTCT) under Option A. METHODS: We analyzed 2012 and 2014 cross-sectional serosurvey data from mother-infant pairs residing in the same 157 health facility catchment areas randomly sampled from five provinces. Eligible women were at least 16 years and mothers/caregivers of infants born 9-18 months prior. We aggregated individual-level questionnaire and HIV serostatus within catchment areas or district to estimate MTCT and the number of HIV-infected infants; these data were mapped using facility global positioning system coordinates. RESULTS: A weighted population of 8800 and 10 404 mother-infant pairs was included from 2012 and 2014, respectively. In 2014, MTCT among HIV-exposed infants was 6.7% (95% confidence interval: 5.2, 8.6), not significantly different from 2012 (8.8%, 95% confidence interval: 6.9, 11.1, P = 0.13). From 2012 to 2014, self-reported antiretroviral therapy or prophylaxis among HIV-infected women increased from 59 to 65% (P = 0.05), as did self-reported infant antiretroviral prophylaxis (63 vs. 67%, P = 0.08). In 2014, 65 (41%), 55 (35%), and 37 (24%) catchment areas had the same, lower, and higher MTCT rate as in 2012, respectively. MTCT in 2014 varied by catchment areas (median = 0%, mean = 4.9%, interquartile range = 0-10%) as did the estimated number of HIV-infected infants (median = 0, mean = 1.1, interquartile range = 0-1.0). Also in 2014, 106 (68%) catchment areas had MTCT = 0%. Geovisualization revealed clustering of catchment areas where both MTCT and the estimated number of HIV-infected infants were relatively high. CONCLUSION: Although MTCT is declining in Zimbabwe, geospatial analysis indicates facility-level variability. Catchment areas with high MTCT rates and a high burden of HIV-infected infants should be the highest priority for service intensification.

Facility-based delivery in the context of Zimbabwe's HIV epidemic--missed opportunities for improving engagement with care: a community-based serosurvey.

BACKGROUND: In developing countries, facility-based delivery is recommended for maternal and neonatal health, and for prevention of mother-to-child HIV transmission (PMTCT). However, little is known about whether or not learning one's HIV status affects one's decision to deliver in a health facility. We examined this association in Zimbabwe. METHODS: We analyzed data from a 2012 cross-sectional community-based serosurvey conducted to evaluate Zimbabwe's accelerated national PMTCT program. Eligible women (≥16 years old and mothers of infants born 9-18 months before the survey) were randomly sampled from the catchment areas of 157 health facilities in five of ten provinces. Participants were interviewed about where they delivered and provided blood samples for HIV testing. RESULTS: Overall 8796 (77 %) mothers reported facility-based delivery; uptake varied by community (30-100%). The likelihood of facility-based delivery was not associated with maternal HIV status. Women who self-reported being HIV-positive before delivery were as likely to deliver in a health facility as women who were HIV-negative, irrespective of when they learned their status - before (adjusted prevalence ratio (PRa) = 1.04, 95% confidence interval (CI) = 1.00-1.09) or during pregnancy (PRa = 1.05, 95% CI = 1.01-1.09). Mothers who had not accessed antenatal care or tested for HIV were most likely to deliver outside a health facility (69%). Overall, however 77% of home deliveries occurred among women who had accessed antenatal care and were HIV-tested. CONCLUSIONS: Uptake of facility-based delivery was similar among HIV-infected and HIV-uninfected mothers, which was somewhat unexpected given the substantial technical and financial investment aimed at retaining HIV-positive women in care in Zimbabwe.

Evaluating the Impact of Zimbabwe's Prevention of Mother-to-Child HIV Transmission Program: Population-Level Estimates of HIV-Free Infant Survival Pre-Option A.

OBJECTIVE: We estimated HIV-free infant survival and mother-to-child HIV transmission (MTCT) rates in Zimbabwe, some of the first community-based estimates from a UNAIDS priority country. METHODS: In 2012 we surveyed mother-infant pairs residing in the catchment areas of 157 health facilities randomly selected from 5 of 10 provinces in Zimbabwe. Enrolled infants were born 9-18 months before the survey. We collected questionnaires, blood samples for HIV testing, and verbal autopsies for deceased mothers/infants. Estimates were assessed among i) all HIV-exposed infants, as part of an impact evaluation of Option A of the 2010 WHO guidelines (rolled out in Zimbabwe in 2011), and ii) the subgroup of infants unexposed to Option A. We compared province-level MTCT rates measured among women in the community with MTCT rates measured using program monitoring data from facilities serving those communities. FINDINGS: Among 8568 women with known HIV serostatus, 1107 (12.9%) were HIV-infected. Among all HIV-exposed infants, HIV-free infant survival was 90.9% (95% confidence interval (CI): 88.7-92.7) and MTCT was 8.8% (95% CI: 6.9-11.1). Sixty-six percent of HIV-exposed infants were still breastfeeding. Among the 762 infants born before Option A was implemented, 90.5% (95% CI: 88.1-92.5) were alive and HIV-uninfected at 9-18 months of age, and 9.1% (95%CI: 7.1-11.7) were HIV-infected. In four provinces, the community-based MTCT rate was higher than the facility-based MTCT rate. In Harare, the community and facility-based rates were 6.0% and 9.1%, respectively. CONCLUSION: By 2012 Zimbabwe had made substantial progress towards the elimination of MTCT. Our HIV-free infant survival and MTCT estimates capture HIV transmissions during pregnancy, delivery and breastfeeding regardless of whether or not mothers accessed health services. These estimates also provide a baseline against which to measure the impact of Option A guidelines (and subsequently Option B+).

Implementation and Operational Research: Uptake of Services and Behaviors in the Prevention of Mother-to-Child HIV Transmission Cascade in Zimbabwe.

OBJECTIVE: To examine the uptake of services and behaviors in the prevention of mother-to-child HIV transmission (PMTCT) cascade in Zimbabwe and to determine factors associated with MTCT and maternal antiretroviral therapy (ART) or antiretroviral (ARV) prophylaxis. DESIGN: Analysis of cross-sectional data from mother-infant pairs. METHODS: We analyzed baseline data collected in 2012 as part of the impact evaluation of Zimbabwe's Accelerated National PMTCT Program. Using multistage cluster sampling, eligible mother-infant pairs were randomly sampled from the catchment areas of 157 facilities in 5 provinces, tested for HIV infection, and interviewed about PMTCT service utilization. RESULTS: Of 8800 women, 94% attended ≥ 1 antenatal care visit, 92% knew their HIV serostatus during pregnancy, 77% delivered in a health facility, and 92% attended the 6-8 week postnatal visit. Among 1075 (12%) HIV-infected women, 59% reported ART/ARV prophylaxis and 63% of their HIV-exposed infants received ARV prophylaxis. Among HIV-exposed infants, maternal receipt of ART/ARV prophylaxis was protective against MTCT [adjusted prevalence ratio (PR(a)): 0.41, 95% confidence interval (CI): 0.23 to 0.74]. Factors associated with receipt of maternal ART/ARV prophylaxis included ≥ 4 antenatal care visits (PR(a): 1.18, 95% CI: 1.01 to 1.38), institutional delivery (PR(a): 1.31, 95% CI: 1.13 to 1.52), and disclosure of serostatus (PRa: 1.30, 95% CI: 1.12 to 1.49). CONCLUSIONS: These data from women in the community indicate gaps in the PMTCT cascade before the accelerated program, which may have been missed by examination of health facility data alone. These gaps were especially noteworthy for services targeted specifically to HIV-infected women and their infants, such as maternal and infant ART/ARV prophylaxis.

Food insecurity is a barrier to prevention of mother-to-child HIV transmission services in Zimbabwe: a cross-sectional study.

BACKGROUND: Food insecurity (FI) is the lack of physical, social, and economic access to sufficient food for dietary needs and food preferences. We examined the association between FI and women's uptake of services to prevent mother-to-child HIV transmission (MTCT) in Zimbabwe. METHODS: We analyzed cross-sectional data collected in 2012 from women living in five of ten provinces. Eligible women were ≥16 years old, biological mothers of infants born 9-18 months before the interview, and were randomly selected using multi-stage cluster sampling. Women and infants were tested for HIV and interviewed about health service utilization during pregnancy, delivery, and post-partum. We assessed FI in the past four weeks using a subset of questions from the Household Food Insecurity Access Scale and classified women as living in food secure, moderately food insecure, or severely food insecure households. RESULTS: The weighted population included 8,790 women. Completion of all key steps in the PMTCT cascade was reported by 49%, 45%, and 38% of women in food secure, moderately food insecure, and severely food insecure households, respectively (adjusted prevalence ratio (PRa) = 0.95, 95% confidence interval (CI): 0.90, 1.00 (moderate FI vs. food secure), PRa = 0.86, 95% CI: 0.79, 0.94 (severe FI vs. food secure)). Food insecurity was not associated with maternal or infant receipt of ART/ARV prophylaxis. However, in the unadjusted analysis, among HIV-exposed infants, 13.3% of those born to women who reported severe household food insecurity were HIV-infected compared to 8.2% of infants whose mothers reported food secure households (PR = 1.62, 95% CI: 1.04, 2.52). After adjustment for covariates, this association was attenuated (PRa = 1.42, 95% CI: 0.89, 2.26). There was no association between moderate food insecurity and MTCT in unadjusted or adjusted analyses (PRa = 0.68, 95% CI: 0.43, 1.08). CONCLUSIONS: Among women with a recent birth, food insecurity is inversely associated with service utilization in the PMTCT cascade and severe household food insecurity may be positively associated with MTCT. These preliminary findings support the assessment of FI in antenatal care and integrated food and nutrition programs for pregnant women to improve maternal and child health.

Population-level impact of Zimbabwe's National Behavioural Change Programme.

OBJECTIVE: To assess the impact of Zimbabwe's National Behavioural Change Programme (NBCP) on biological and behavioral outcomes. METHODS: Representative household biobehavioral surveys of 18- to 44-year-olds were conducted in randomly selected enumeration areas in 2007 and 2011 to 2012. We examined program impact on HIV prevalence among young women, nonregular partnerships, condom use with nonregular partners, and HIV testing, distinguishing between highly exposed and low-exposed communities and individuals. We conducted (1) difference-in-differences analyses with communities as unit of analysis and (2) analyses of key outcomes by individual-level program exposure. RESULTS: Four thousand seven hundred seventy-six people were recruited in 2007 and 10,059 in 2011 to 2012. We found high exposure to NBCP in 2011. Prevalence of HIV and reported risky behaviors declined between 2007 and 2011. Community-level analyses showed a smaller decline in HIV prevalence among young women in highly exposed areas (11.0%-10.1%) than low-exposed areas (16.9%-10.3%, P = 0.078). Among young men, uptake of nonregular partners declined more in highly exposed areas (25%-16.8%) than low-exposed areas (21.9%-20.7%, P = 0.055) and HIV testing increased (27.2%-46.1% vs. 31.0%-34.4%, P = 0.004). Individual-level analyses showed higher reported condom use with nonregular partners among highly exposed young women (53% vs. 21% of unexposed counterparts, P = 0.037). CONCLUSIONS: We conducted the first impact evaluation of a NBCP and found positive effects of program exposure on key behaviors among certain gender and age groups. HIV prevalence among young women declined but could not be attributed to program exposure. These findings suggest substantial program effects regarding demand creation and justify program expansion.

Unmet need for family planning, contraceptive failure, and unintended pregnancy among HIV-infected and HIV-uninfected women in Zimbabwe.

BACKGROUND: Prevention of unintended pregnancies among women living with HIV infection is a strategy recommended by the World Health Organization for prevention of mother-to-child transmission of HIV (PMTCT). We assessed pregnancy intentions and contraceptive use among HIV-positive and HIV-negative women with a recent pregnancy in Zimbabwe. METHODS: We analyzed baseline data from the evaluation of Zimbabwe's Accelerated National PMTCT Program. Eligible women were randomly sampled from the catchment areas of 157 health facilities offering PMTCT services in five provinces. Eligible women were ≥16 years old and mothers of infants (alive or deceased) born 9 to 18 months prior to the interview. Participants were interviewed about their HIV status, intendedness of the birth, and contraceptive use. RESULTS: Of 8,797 women, the mean age was 26.7 years, 92.8% were married or had a regular sexual partner, and they had an average of 2.7 lifetime births. Overall, 3,090 (35.1%) reported that their births were unintended; of these women, 1,477 (47.8%) and 1,613 (52.2%) were and were not using a contraceptive method prior to learning that they were pregnant, respectively. Twelve percent of women reported that they were HIV-positive at the time of the survey; women who reported that they were HIV-infected were significantly more likely to report that their pregnancy was unintended compared to women who reported that they were HIV-uninfected (44.9% vs. 33.8%, p<0.01). After adjustment for covariates, among women with unintended births, there was no association between self-reported HIV status and lack of contraception use prior to pregnancy. CONCLUSIONS: Unmet need for family planning and contraceptive failure contribute to unintended pregnancies among women in Zimbabwe. Both HIV-infected and HIV-uninfected women reported unintended pregnancies despite intending to avoid or delay pregnancy, highlighting the need for effective contraceptive methods that align with pregnancy intentions.

Understanding out-migration among female sex workers in South India.

BACKGROUND: Migrant sex workers are known to be vulnerable to HIV. There is substantial female sex worker (FSW) mobility between the borders of Maharashtra and Karnataka, but little programming emphasis on migrant FSWs in India. We sought to understand the individual/cultural, structural, and contextual determinants of migration among FSWs from Karnataka. METHODS: A cross-sectional face-to-face interview of 1567 FSWs from 142 villages in 3 districts of northern Karnataka, India was conducted from January to June 2008. Villages having 10+ FSWs, a large number of whom were migrant, were selected following mapping of FSWs. Multinomial logistic regression was conducted to identify characteristics associated with migrant (travelled for ≥ 2 weeks outside the district past year) and mobile (travelled for <2 weeks outside the district past year) FSWs; adjusting for age and district. RESULTS: Compared with nonmigrants, migrant FSWs were more likely to be brothel than street based (Adjusted Odds Ratio (AOR): 5.7; 95% confidence interval: 1.6-20.0), have higher income from sex work (Adjusted Odds Ratio (AOR): 42.2; 12.6-142.1), speak >2 languages (AOR: 5.6; 2.6-12.0), have more clients (AOR per client: 2.9; 1.2-7.2), and have more sex acts per day (AOR per sex act: 3.5; 1.3-9.3). Mobile FSWs had higher income from sex work (AOR: 13.2; 3.9-44.6) relative to nonmigrants, but not as strongly as for migrant FSWs. CONCLUSION: Out-migration of FSWs in Karnataka was strongly tied to sex work characteristics; thus, the structure inherent in sex work should be capitalized on when developing HIV preventive interventions. The important role of FSWs in HIV epidemics, coupled with the potential for rapid spread of HIV with migration, requires the most effective interventions possible for mobile and migrant FSWs.

Change over time (2007-2009) in HIV preventive behaviours, evidence from two serial population-based surveys in rural Zimbabwe.

OBJECTIVE: To assess reported HIV knowledge and attitudes, sexual behaviours and HIV testing in Zimbabwe. METHODS: Representative household surveys of all 18-24 year olds and a proportion of 25-44 year olds were conducted in six purposefully selected rural districts in two provinces in 2007 and 2009. Both surveys used the same methods and questionnaires. We compared differences in reported HIV knowledge, sexual behaviours and HIV testing, controlling for differences in socio-demographics at baseline, using cross-tabulations and multivariate regression analyses. RESULTS: Analysis was restricted to districts included in both baseline (n = 1891) and mid-term (n = 2746) surveys. Comparisons indicate increased reports of HIV knowledge (35%vs. 22% had high knowledge) and more favourable individual attitudes towards HIV. There was an increase in reported HIV testing (men: 41%vs. 31%, women: 55%vs. 36%) and condom use (men: adjusted odds ratio (AOR) = 1.35, women: AOR = 1.22) and a decrease in number of sexual partners (men: 67%vs. 49% reported 1 partner/previous 6 months, women: 77%vs. 68%). CONCLUSIONS: As Zimbabwe continues to document declines in HIV prevalence, this analysis offers insight into recent and continuing positive changes in knowledge, attitudes and behaviours among the rural population.

The Female Sex Work Industry in a District of India in the Context of HIV Prevention.

HIV prevalence in India remains high among female sex workers. This paper presents the main findings of a qualitative study of the modes of operation of female sex work in Belgaum district, Karnataka, India, incorporating fifty interviews with sex workers. Thirteen sex work settings (distinguished by sex workers' main places of solicitation and sex) are identified. In addition to previously documented brothel, lodge, street, dhaba (highway restaurant), and highway-based sex workers, under-researched or newly emerging sex worker categories are identified, including phone-based sex workers, parlour girls, and agricultural workers. Women working in brothels, lodges, dhabas, and on highways describe factors that put them at high HIV risk. Of these, dhaba and highway-based sex workers are poorly covered by existing interventions. The paper examines the HIV-related vulnerability factors specific to each sex work setting. The modes of operation and HIV-vulnerabilities of sex work settings identified in this paper have important implications for the local programme.

Positive attitudes to pediatric HIV testing: findings from a nationally representative survey from Zimbabwe.

OBJECTIVE: Early HIV testing and diagnosis are paramount for increasing treatment initiation among children, necessary for their survival and improved health. However, uptake of pediatric HIV testing is low in high-prevalence areas. We present data on attitudes towards pediatric testing from a nationally representative survey in Zimbabwe. METHODS: All 18-24 year olds and a proportion of 25-49 year olds living in randomly selected enumeration areas from all ten Zimbabwe provinces were invited to self-complete an anonymous questionnaire on a personal digital assistant, and 16,719 people agreed to participate (75% of eligibles). RESULTS: Most people think children can benefit from HIV testing (91%), 81% of people who looked after children know how to access testing for their children and 92% would feel happier if their children were tested. Notably, 42% fear that, if tested, children may be discriminated against by some community members and 28% fear their children are HIV positive. People who fear discrimination against children who have tested for HIV are more likely than their counterparts to perceive their community as stigmatizing against HIV positive people (43% vs. 29%). They are also less likely to report positive attitudes to HIV themselves (49% vs. 74%). Only 28% think it is possible for children HIV-infected at birth to live into adolescence without treatment. Approximately 70% of people (irrespective of whether they are themselves parents) think HIV-infected children in their communities can access testing and treatment. CONCLUSIONS: Pediatric HIV testing is the essential gateway to prevention and care services. Our data indicate positive attitudes to testing children, suggesting a conducive environment for increasing uptake of pediatric testing in Zimbabwe. However, there is a need to better understand the barriers to pediatric testing, such as stigma and discrimination, and address the gaps in knowledge regarding HIV/AIDS in children.

Prevalence and factors associated with knowledge of and willingness for male circumcision in rural Zimbabwe.

OBJECTIVE: To explore male circumcision (MC) prevalence, knowledge, attitudes and intentions among rural Zimbabweans. METHODS: Representative survey of 18-44 year olds in two provinces, as part of an evaluation of the Zimbabwe National Behaviour Change Programme. We conducted univariate, bivariate and multivariate analyses. Linear regression was employed to predict knowledge of MC (composite index) and logistic regression to predict knowledge that MC prevents HIV, willingness (oneself or one's partner) to undergo MC, and willingness to have son circumcised. RESULTS: Two thousand seven hundred and forty-six individuals participated in the survey (87% of eligibles). About two-thirds were women (64%). Twenty per cent of men reported being circumcised, while 17% of women reported having a circumcised partner. Knowledge of MC and its health benefits was low. Attitudes towards MC were relatively positive. If it could prevent HIV, 52% of men reported that they would undergo MC and 58% of women indicated that they would like their partners to be circumcised. Seventy-five per cent of men who reported being HIV positive were willing to undergo MC, against 52% of those who reported HIV negative status. Reported acceptability of neonatal circumcision was high with 58% of men and 60% of women reporting that they would have their sons circumcised if it protected them against HIV. Fear of adverse effects was highlighted as a barrier to MC acceptability. CONCLUSION: More knowledge about MC's health benefits positively affects people's attitudes towards MC. The relatively high MC acceptability suggests an enabling environment for the scale-up programme.

Devising a female sex work typology using data from Karnataka, India.

BACKGROUND: We examine the extent to which an existing sex work typology captures human immunodeficiency virus (HIV) risk in Karnataka and propose a systematic approach for devising evidence-based typologies. METHODS: The proposed approach has four stages: (i) identifying main places of solicitation and places of sex; (ii) constructing possible typologies based on either or both of these criteria; (iii) analysing variations in indicators of risk, such as HIV/sexually transmitted infection (STI) prevalence and client volume, across the categories of the typologies; and (iv) identifying the simplest typology that captures the risk variation experienced by female sex workers (FSWs) across different settings. Analysis is based on data from 2312 participants in integrated biological and behavioural assessments of FSWs conducted in Karnataka, India. Logistic regression was used to predict HIV/STI status (high-titre syphilis, gonorrhea or chlamydia) and linear regression to predict client volume. RESULTS: Our analysis suggests that the most appropriate typology in Karnataka consists of the following categories: brothel to brothel (i.e. solicit and have sex in brothels) (11% of sampled FSWs); home to home (32%), street to home (11%), street to rented room (9%), street to lodge (22%), street to street (9%) and other FSWs (8%). Street to lodge FSWs had high HIV (30%) and STI prevalence (27%), followed by brothel to brothel FSWs (34 and 13%, respectively). CONCLUSIONS: The proposed typology identifies street to lodge FSWs as being at particularly high risk, which was obscured by the existing typology that distinguishes between FSWs based on place of solicitation alone.