Fidelity, Feasibility and Adaptation of a Family Planning Intervention for Young Women in Zimbabwe: Provider Perspectives and Experiences.

The CHIEDZA (Community-based Interventions to improve HIV outcomes in youth: a cluster randomised trial in Zimbabwe) trial evaluated an integrated package of HIV and sexual and reproductive health services for young people aged 16-24 years in Zimbabwe. The family planning component aimed to improve access to information, services, and contraceptives delivered by trained youth-friendly providers within a community-based setting for young women. Responsively adapting the intervention was a part of the intervention design's rationale. We investigated the factors influencing implementation fidelity, quality, and feasibility using provider experiences and perspectives. We conducted provider interviews (N = 42), non-participant (N = 18), and participant observation (N = 30) of intervention activities. The data was analyzed thematically. CHIEDZA providers were receptive to providing the family planning intervention, but contexts outside of the intervention created challenges to the intervention's fidelity. Strategic adaptations were required to ensure service quality within a youth-friendly context. These adaptations strengthened service delivery but also resulted in longer wait times, more frequent visits, and variability of Long-Acting Reversible contraceptives (LARCS) provision which depended on target-driven programming by partner organization. This study was a practical example of how tracking adaptations is vital within process evaluation methods in implementation science. Anticipating that changes will occur is a necessary pre-condition of strong evaluations and tracking adaptations ensures that lessons on feasibility of design, contextual factors, and health system factors are responded to during implementation and can improve quality. Some contextual factors are unpredictable, and implementation should be viewed as a dynamic process where responsive adaptations are necessary, and fidelity is not static. Trial registration ClinicalTrials.gov Identifier: NCT03719521. Supplementary Information: The online version contains supplementary material available at 10.1007/s43477-023-00075-6.

Human papillomavirus testing using existing nucleic acid testing platforms to screen women for cervical cancer: implementation studies from five sub-Saharan African countries.

OBJECTIVES: To demonstrate acceptability and operational feasibility of introducing human papillomavirus (HPV) testing as a principal cervical cancer screening method in public health programmes in sub-Saharan Africa. SETTING: 45 primary and secondary health clinics in Malawi, Nigeria, Senegal, Uganda and Zimbabwe. PARTICIPANTS: 15 766 women aged 25-54 years presenting at outpatient departments (Senegal only, general population) or at antiretroviral therapy clinics (all other countries, HIV-positive women only). Eligibility criteria followed national guidelines for cervical cancer screening. INTERVENTIONS: HPV testing was offered to eligible women as a primary screening for cervical cancer, and HPV-positive women were referred for visual inspection with acetic acid (VIA), and if lesions identified, received treatment or referral. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcomes were the proportion of HPV-positive women who received results and linked to VIA and the proportion of HPV-positive and VIA-positive women who received treatment. RESULTS: A total of 15 766 women were screened and tested for HPV, among whom 14 564 (92%) had valid results and 4710/14 564 (32%) were HPV positive. 13 837 (95%) of valid results were returned to the clinic and 3376 (72%) of HPV-positive women received results. Of women receiving VIA (n=2735), 715 (26%) were VIA-positive and 622 (87%) received treatment, 75% on the same day as VIA. CONCLUSIONS: HPV testing was found to be feasible across the five study countries in a public health setting, although attrition was seen at several key points in the cascade of care, namely results return to women and linkage to VIA. Once women received VIA, if eligible, the availability of on-site cryotherapy and thermal ablation allowed for same-day treatment. With sufficient resources and supportive infrastructure to ensure linkage to treatment, use of HPV testing for cervical cancer screening as recommended by WHO is a promising model in low-income and middle-income countries.

Economic implications of COVID-19 for the HIV epidemic and the response in Zimbabwe.

Understanding the economic implications of COVID-19 for the HIV epidemic and response is critical for designing policies and strategies to effectively sustain past gains and accelerate progress to end these colliding pandemics. While considerable cross-national empirical evidence exists at the global level, there is a paucity of such deep-dive evidence at national level. This article addresses this gap. While Zimbabwe experienced fewer COVID-19 cases and deaths than most countries, the pandemic has had profound economic effects, reducing gross domestic product by nearly 7% in 2020. This exacerbates the long-term economic crisis that began in 1998. This has left many households vulnerable to the economic fallout from COVID-19, with the number of the extreme poor having increased to 49% of the population in 2020 (up from 38% in 2019). The national HIV response, largely financed externally, has been one of the few bright spots. Overall, macro-economic and social conditions heavily affected the capacity of Zimbabwe to respond to COVID-19. Few options were available for borrowing the needed sums of money. National outlays for COVID-19 mitigation and vaccination amounted to 2% of GDP, with one-third funded by external donors. Service delivery innovations helped sustain access to HIV treatment during national lockdowns. As a result of reduced access to HIV testing, the number of people initiating HIV treatment declined. In the short term, there are likely to be few immediate health care consequences of the slowdown in treatment initiation due to the country's already high level of HIV treatment coverage. However, a longer-lasting slowdown could impede national progress towards ending HIV and AIDS. The findings suggest a need to finance the global commons, specifically recognising that investing in health care is investing in economic recovery.

The impact of the COVID-19 pandemic on people living with HIV in Zimbabwe.

The COVID-19 pandemic was reported from March 2020 in Zimbabwe. COVID-19 containment measures which included repeated lockdowns have disrupted community interactions, reduced working hours, restricted travel and restricted HIV services for people living with HIV (PLHIV), among others. The study adopted a cross-sectional design. Both qualitative and quantitative data were collected in all the 10 provinces and analysed. A sample size of 480 was calculated for the cross-sectional survey. Secondary data on HIV early warning indicators from 2018 to 2021 were extracted from 20 randomly selected health facilities and used for modelling. Mathematical modelling was conducted to assess the impact of COVID-19 on PLHIV. AIDS-related deaths increased from 20 100 in 2019 to 22 200 in 2020. In addition, there were significant years of life lost (yLLs) from premature mortality and years of life lost due to disability (yLDs) from COVID-19. Prevalence of COVID-19 among PLHIV was 4%. COVID-19 vaccination coverage was 64%, which is higher than the national average of 42%. Stress and breach of confidentiality as ARV medicines were given out in open spaces and fear of contracting COVID-19 were the perceived psychological issues. COVID-19 disrupted HIV service provision, increased AIDS-related deaths and caused psychological challenges.

Family Planning Experiences and Needs of Young Women Living With and Without HIV Accessing an Integrated HIV and SRH Intervention in Zimbabwe-An Exploratory Qualitative Study.

Background: People living with HIV have higher unmet family planning needs compared to those without HIV. This is heightened for young people. However, the provision of family planning for young people within HIV programmes is uncommon. We investigated family planning uptake, acceptability of, and engagement with a service offering integrated HIV and sexual and reproductive health services for youth in a community-based setting in Zimbabwe. Methods: CHIEDZA, a community-based intervention offering integrated HIV and sexual and reproductive health services to young people aged 16-24 years, is being trialed in Zimbabwe. This exploratory qualitative study was nested within an ongoing study process evaluation. Data was collected between March-May 2021 with two sets of interviews conducted: I) twelve semi-structured interviews with young women living with HIV aged 17-25 years and II) fifteen interviews conducted with young women without HIV aged between 20 and 25 years who used a contraceptive method. A thematic analysis approach was used. Results: Before engaging with CHIEDZA, young women had experienced judgmental providers, on account of their age, and received misinformation about contraceptive use and inadequate information about ART-contraceptive interactions. These presented as barriers to uptake and engagement. Upon attending CHIEDZA, all the young women reported receiving non-judgmental care. For those living with HIV, they were able to access integrated HIV and family planning services that supported them having broader sexual and reproductive needs beyond their HIV diagnosis. The family planning preference of young women living with HIV included medium to long-acting contraceptives to minimize adherence challenges, and desired partner involvement in dual protection to prevent HIV transmission. CHIEDZA's ability to meet these preferences shaped uptake, acceptability, and engagement with integrated HIV and family services. Conclusions: Recommendations for an HIV and family planning integrated service for young people living with HIV include: offering a range of services (including method-mix contraceptives) to choose from; supporting their agency to engage with the services which are most acceptable to them; and providing trained, supportive, knowledgeable, and non-judgmental health providers who can provide accurate information and counsel. We recommend youth-friendly, differentiated, person-centered care that recognize the multiple and intersecting needs of young people living with HIV.

Interrupted Access to and Use of Family Planning Among Youth in a Community-Based Service in Zimbabwe During the First Year of the COVID-19 Pandemic.

The COVID-19 pandemic has had serious impacts on economic, social, and health systems, and fragile public health systems have become overburdened in many countries, exacerbating existing service delivery challenges. This study describes the impact of the COVID-19 pandemic on family planning services within a community-based integrated HIV and sexual and reproductive health intervention for youth aged 16-24 years being trialled in Zimbabwe (CHIEDZA). It examines the experiences of health providers and clients in relation to how the first year of the pandemic affected access to and use of contraceptives.

Economic implications of COVID-19 for the HIV epidemic and the response in Zimbabwe

Understanding the economic implications of COVID-19 for the HIV epidemic and response is critical for designing policies and strategies to effectively sustain past gains and accelerate progress to end these colliding pandemics. While considerable cross-national empirical evidence exists at the global level, there is a paucity of such deep-dive evidence at national level. This article addresses this gap. While Zimbabwe experienced fewer COVID-19 cases and deaths than most countries, the pandemic has had profound economic effects, reducing gross domestic product by nearly 7% in 2020. This exacerbates the long-term economic crisis that began in 1998. This has left many households vulnerable to the economic fallout from COVID-19, with the number of the extreme poor having increased to 49% of the population in 2020 (up from 38% in 2019). The national HIV response, largely financed externally, has been one of the few bright spots. Overall, macro-economic and social conditions heavily affected the capacity of Zimbabwe to respond to COVID-19. Few options were available for borrowing the needed sums of money. National outlays for COVID-19 mitigation and vaccination amounted to 2% of GDP, with one-third funded by external donors. Service delivery innovations helped sustain access to HIV treatment during national lockdowns. As a result of reduced access to HIV testing, the number of people initiating HIV treatment declined. In the short term, there are likely to be few immediate health care consequences of the slowdown in treatment initiation due to the country's already high level of HIV treatment coverage. However, a longer-lasting slowdown could impede national progress towards ending HIV and AIDS. The findings suggest a need to finance the global commons, specifically recognising that investing in health care is investing in economic recovery

The impact of community-based integrated HIV and sexual and reproductive health services for youth on population-level HIV viral load and sexually transmitted infections in Zimbabwe: protocol for the CHIEDZA cluster-randomised trial.

Background: Youth have poorer HIV-related outcomes when compared to other age-groups. We describe the protocol for a cluster randomised trial (CRT) to evaluate the effectiveness of community-based, integrated HIV and sexual and reproductive health services for youth on HIV outcomes. Protocol: The CHIEDZA trial is being conducted in three provinces in Zimbabwe, each with eight geographically demarcated areas (clusters) (total 24 clusters) randomised 1:1 to standard of care (existing health services) or to the intervention. The intervention comprises community-based delivery of HIV services including testing, antiretroviral therapy, treatment monitoring and adherence support as well as family planning, syndromic management of sexually transmitted infections (STIs), menstrual health management, condoms and HIV prevention and general health counselling. Youth aged 16-24 years living within intervention clusters are eligible to access CHIEDZA services. A CRT of STI screening (chlamydia, gonorrhoea and trichomoniasis) is nested in two provinces (16 of 24 clusters). The intervention is delivered over a 30-month period by a multidisciplinary team trained and configured to provide high-quality, youth friendly services.Outcomes will be ascertained through a population-based survey of 18-24-year-olds. The primary outcome is HIV viral load <1000 copies/ml in those living with HIV and proportion who test positive for STIs (for the nested trial). A detailed process and cost evaluation of the trial will be conducted. Ethics and Dissemination: The trial protocol was approved by the Medical Research Council of Zimbabwe, the Biomedical Research and Training Institute Institutional Review Board and the London School of Hygiene & Tropical Medicine Research Ethics Committee. Results will be submitted to open-access peer-reviewed journals, presented at academic meetings and shared with participating communities and with national and international policy-making bodies. Trial Registration: https://clinicaltrials.gov/: NCT03719521.

Comparative analysis between self-collected and clinician-collected samples for HPV testing in public health facilities in Zimbabwe.

BACKGROUND: Cervical cancer screening programs that use visual inspection with acetic acid to identify women with pre-cancerous lesions in Zimbabwe have had limited success due to challenges with human resource constraints and patient acceptability. Nucleic acid amplification tests for human papillomavirus (HPV) have been endorsed by the World Health Organization for cervical cancer screening, along with self-collection of samples. As evidence shows self-collected sampling to be acceptable and preferable, Zimbabwe's Ministry of Health and Child Care (MOHCC) required a comparative analysis on the agreement between self- and clinician-collected samples for testing with Hologic Aptima HPV mRNA assay, to determine if self-collected samples could be used as another method to increase coverage of cervical cancer screening programs. METHODS: In four public health facilities in Zimbabwe from July to August 2020, self- and clinician-collected HPV samples were obtained from HIV-positive women aged 30-49 years for HPV testing. RESULTS: A total of 280 self- and clinician-collected samples were tested and results were found to have good agreement (κ: 0.75, 95% CI: 0.66-0.82). HPV prevalence was 43.0% (95% CI: 37.0%-49.3%) for self-samples and 48.0% (95% CI: 41.0%-54.2%) for clinician-samples. CONCLUSIONS: Self-collected sampling had good agreement with clinician-collected and its inclusion in the national cervical cancer screening policy by Zimbabwe's MOHCC is expected to increase testing coverage, especially among underserved communities such as women living with HIV, as well as decentralize access to cervical cancer screening services for lower-level facilities and increase the geographical scope of where HPV testing can be offered through the country.

Using family planning service statistics to inform model-based estimates of modern contraceptive prevalence.

The annual assessment of Family Planning (FP) indicators, such as the modern contraceptive prevalence rate (mCPR), is a key component of monitoring and evaluating goals of global FP programs and initiatives. To that end, the Family Planning Estimation Model (FPEM) was developed with the aim of producing survey-informed estimates and projections of mCPR and other key FP indictors over time. With large-scale surveys being carried out on average every 3-5 years, data gaps since the most recent survey often exceed one year. As a result, survey-based estimates for the current year from FPEM are often based on projections that carry a larger uncertainty than data informed estimates. In order to bridge recent data gaps we consider the use of a measure, termed Estimated Modern Use (EMU), which has been derived from routinely collected family planning service statistics. However, EMU data come with known limitations, namely measurement errors which result in biases and additional variation with respect to survey-based estimates of mCPR. Here we present a data model for the incorporation of EMU data into FPEM, which accounts for these limitations. Based on known biases, we assume that only changes in EMU can inform FPEM estimates, while also taking inherent variation into account. The addition of this EMU data model to FPEM allows us to provide a secondary data source for informing and reducing uncertainty in current estimates of mCPR. We present model validations using a survey-only model as a baseline comparison and we illustrate the impact of including the EMU data model in FPEM. Results show that the inclusion of EMU data can change point-estimates of mCPR by up to 6.7 percentage points compared to using surveys only. Observed reductions in uncertainty were modest, with the width of uncertainty intervals being reduced by up to 2.7 percentage points.

Designing Routine Health Checkups for Adolescents in Zimbabwe.

PURPOSE: The absence of routine health check-ups during adolescence in low- and middle-income countries is a missed opportunity for prevention, early identification, and treatment of health issues, and health promotion. We aimed to codesign the content and delivery for routine adolescent health checkups in Zimbabwe, with adolescents and key adults in their lives. METHODS: We held participatory workshops with adolescents (16 workshops; 96 adolescents) and parents (8 workshops; 95 parents), and in-depth interviews with key informants including policymakers, programmers, and healthcare workers (n = 25). Analysis was iterative and the design of the checkups was refined based on participant preferences, document review of burden of disease data, and feasibility considerations. RESULTS: Participants overwhelmingly supported the introduction of routine health checkups. Reported facilitators to attendance included free cost and desire to know one's health status. Barriers included tendencies for health service seeking only when ill, fear of diagnosis and judgment, and religious beliefs. Delivery preferences were by nonjudgmental medical professionals, in a youth friendly environment, and accompanied by youth engagement activities. Preferred location was schools for younger adolescents (10-14 years), and community settings for older adolescents (15-19 years). Prioritized content included sexual health, oral health, mental health, hearing, eyesight, growth and nutrition, anemia, immunization, and deworming, based on health burden and participant preferences. DISCUSSION: This study resulted in an outline design of two routine health checkups with stakeholders in Zimbabwe, in schools for young adolescents, and in community settings for older adolescents. Evidence of feasibility, effectiveness, and cost-effectiveness of such checkups is required.

Gaps and opportunities for cervical cancer prevention, diagnosis, treatment and care: evidence from midterm review of the Zimbabwe cervical Cancer prevention and control strategy (2016-2020).

BACKGROUND: Cervical cancer is the fourth most common cancer amongst women globally and it accounts for the majority of cancer deaths among females in Zimbabwe. The objective of this midterm review analysis was to identify the gaps and opportunities for cervical cancer prevention, diagnosis, treatment, and care to inform the next cervical cancer strategy in Zimbabwe. METHODS: A mixed methods approach was used for the midterm review. Secondary data was collected from programme documents, published and grey literature. Primary data was collected in six provinces through key informant interviews with officials and focus group discussions with beneficiaries. After data analysis, a draft report was presented to a technical working group to validate the findings and to fill in any gaps. RESULTS: This midterm review revealed a myriad of gaps of the strategy particularly in diagnosis, treatment and care of cervical cancer and the primary focus was on secondary prevention. There was no data to quantify the level of awareness and advocacy for cervical cancer prevention. Our results revealed that there was no data on the proportion of women who ever tested for cervical cancer which existed nationally. Our findings suggest that some health facilities were screening women above 50 years old using VIAC, which is an inappropriate approach for those women. Quality control of VIAC and treatment of precancers were not part of the strategy. Pathological services were not efficient and effective due to lack of resources and additionally data on investigations were not routinely collected and available at the national level. Other gaps identified were limited funding, human resources, equipment, and commodities as well as lack of leadership at the national level to coordinate the various components of the cervical cancer programme. There are also numerous opportunities identified to build upon some successes realized to date. CONCLUSIONS: Our findings emphasized the importance of effective and holistic planning in cervical cancer screening programmes in low-resource settings. In addition, huge investments are required in cervical cancer programmes and governments need to take centre role in mobilizing the requisite resources.

Effectiveness of the Sista2Sista programme in improving HIV and other sexual and reproductive health outcomes among vulnerable adolescent girls and young women in Zimbabwe.

Background: In Zimbabwe, adolescent girls and young women (AGYW) experience high rates of HIV and other sexual and reproductive health challenges. In 2013, the Zimbabwe Ministry of Health and Child Care partnered with the United Nations Population Fund to implement the Sista2Sista programme, a structured peer group intervention aimed at improving health outcomes among vulnerable in- and out-of-school AGYW.Methods: Programme data was analysed for 91 612 AGYW aged 10-24 years old who participated in Sista2Sista from 2013 to 2019. Logistic regression was used to determine odds ratios (OR) and evaluate programme exposure as a factor in a set of defined variables.Results: 58 471 AGYW (63.82%) graduated from the Sista2Sista programme by completing at least 30 of 40 exercises. Graduates were more likely to take an HIV test (2.78 OR 95% CI 2.52-3.10), less likely to get married (0.63 OR 95% CI 0.55-0.73) and less likely to drop out of school (0.60 OR 95% CI 0.53-0.69). At higher thresholds of programme completion, additional positive outcomes were observed. Participants who completed all 40 exercises were more likely to return to school (1.41 OR 95% CI 1.18-1.69), more likely to use contraception (1.38 OR 95% CI 1.21-1.56), more likely to report sexual abuse (1.76 OR 95% CI 1.17-2.66), and less likely to become pregnant as adolescents (0.41 OR 95% CI 0.24-0.72). Individual counselling improved the likelihood of programme graduation.Conclusions: The Sista2Sista programme had a positive effect on HIV and other sexual health outcomes among vulnerable AGYW in Zimbabwe. Strategies to improve graduation rates should be explored.

Applying the RE-AIM framework in a process evaluation of the introduction of the Non-Pneumatic Anti-Shock Garment in a rural district of Zimbabwe.

The Non-Pneumatic Anti-Shock Garment (NASG) is a first aid tool that can halt and reverse hypovolemic shock secondary to obstetric hemorrhage. The World Health Organization recommended the NASG for use as a temporizing measure in 2012, but uptake of the recommendation has been slow, partially because operational experience is limited. The study is a process evaluation of the introduction of NASG in a public sector health facility network in rural Zimbabwe utilizing an adapted RE-AIM, categorizing observations into the domains of: reach, effectiveness, adoption, implementation and maintenance. The location of the study was Hurungwe district, where staff members of 34 health facilities at primary (31), secondary (2) and tertiary (1) levels of care participated. We found that all facilities became skilled in using the NASG, and that the NASG was used in 10 of 11 instances of severe hemorrhage. In the cases of hypovolemic shock where the NASG was used, there were no maternal deaths and no extreme adverse outcomes related to obstetric hemorrhage in the study period. Among the 10 NASG uses, the garment was used correctly in each case. Fidelity to processes was high, especially in regard to training and cascading skills, but revisions of the NASG rotation and replacement operating procedures were required to keep clean garments stocked. Clinical documentation was also a key challenge. NASG introduction dovetailed very well with pre-existing systems for obstetric emergency response, and improved clinical outcomes. Scale-up of the NASG in the Zimbabwean public health system can be undertaken with careful attention to mentorship, drills, documentation and logistics.

"It might be a statistic to me, but every death matters.": An assessment of facility-level maternal and perinatal death surveillance and response systems in four sub-Saharan African countries.

BACKGROUND: Maternal and perinatal death surveillance and response (MPDSR) systems aim to understand and address key contributors to maternal and perinatal deaths to prevent future deaths. From 2016-2017, the US Agency for International Development's Maternal and Child Survival Program conducted an assessment of MPDSR implementation in Nigeria, Rwanda, Tanzania, and Zimbabwe. METHODS: A cross-sectional, mixed-methods research design was used to assess MPDSR implementation. The study included a desk review, policy mapping, semistructured interviews with 41 subnational stakeholders, observations, and interviews with key informants at 55 purposefully selected facilities. Using a standardised tool with progress markers defined for six stages of implementation, each facility was assigned a score from 0-30. Quantitative and qualitative data were analysed from the 47 facilities with a score above 10 ('evidence of MPDSR practice'). RESULTS: The mean calculated MPDSR implementation progress score across 47 facilities was 18.98 out of 30 (range: 11.75-27.38). The team observed variation across the national MPDSR guidelines and tools, and inconsistent implementation of MPDSR at subnational and facility levels. Nearly all facilities had a designated MPDSR coordinator, but varied in their availability and use of standardised forms and the frequency of mortality audit meetings. Few facilities (9%) had mechanisms in place to promote a no-blame environment. Some facilities (44%) could demonstrate evidence that a change occurred due to MPDSR. Factors enabling implementation included clear support from leadership, commitment from staff, and regular occurrence of meetings. Barriers included lack of health worker capacity, limited staff time, and limited staff motivation. CONCLUSION: This study was the first to apply a standardised scoring methodology to assess subnational- and facility-level MPDSR implementation progress. Structures and processes for implementing MPDSR existed in all four countries. Many implementation gaps were identified that can inform priorities and future research for strengthening MPDSR in low-capacity settings.

Does peer education go beyond giving reproductive health information? Cohort study in Bulawayo and Mount Darwin, Zimbabwe.

OBJECTIVE: Peer education is an intervention within the voluntary medical male circumcision (VMMC)-adolescent sexual reproductive health (ASRH) linkages project in Bulawayo and Mount Darwin, Zimbabwe since 2016. Little is known if results extend beyond increasing knowledge. We therefore assessed the extent of and factors affecting referral by peer educators and receipt of HIV testing services (HTS), contraception, management of sexually transmitted infections (STIs) and VMMC services by young people (10-24 years) counselled. DESIGN: A cohort study involving all young people counselled by 95 peer educators during October-December 2018, through secondary analysis of routinely collected data. SETTING: All ASRH and VMMC sites in Mt Darwin and Bulawayo. PARTICIPANTS: All young people counselled by 95 peer educators. OUTCOME MEASURES: Censor date for assessing receipt of services was 31 January 2019. Factors (clients' age, gender, marital and schooling status, counselling type, location, and peer educators' age and gender) affecting non-referral and non-receipt of services (dependent variables) were assessed by log-binomial regression. Adjusted relative risks (aRRs) were calculated. RESULTS: Of the 3370 counselled (66% men), 65% were referred for at least one service. 58% of men were referred for VMMC. Other services had 5%-13% referrals. Non-referral for HTS decreased with clients' age (aRR: ~0.9) but was higher among group-counselled (aRR: 1.16). Counselling by men (aRR: 0.77) and rural location (aRR: 0.61) reduced risks of non-referral for VMMC, while age increased it (aRR ≥1.59). Receipt of services was high (64%-80%) except for STI referrals (39%). Group counselling and rural location (aRR: ~0.52) and male peer educators (aRR: 0.76) reduced the risk of non-receipt of VMMC. Rural location increased the risk of non-receipt of contraception (aRR: 3.18) while marriage reduced it (aRR: 0.20). CONCLUSION: We found varying levels of referral ranging from 5.1% (STIs) to 58.3% (VMMC) but high levels of receipt of services. Type of counselling, peer educators' gender and location affected receipt of services. We recommend qualitative approaches to further understand reasons for non-referrals and non-receipt of services.

Correction: Abortion in Zimbabwe: A national study of the incidence of induced abortion, unintended pregnancy and post-abortion care in 2016.

[This corrects the article DOI: 10.1371/journal.pone.0205239.].

Abortion in Zimbabwe: A national study of the incidence of induced abortion, unintended pregnancy and post-abortion care in 2016.

BACKGROUND: Zimbabwe has the highest contraceptive prevalence rate in sub-Saharan Africa, but also one of the highest maternal mortality ratios in the world. Little is known, however, about the incidence of abortion and post-abortion care (PAC) in Zimbabwe. Access to legal abortion is rare, and limited to circumstances of rape, incest, fetal impairment, or to save the woman's life. OBJECTIVES: This paper estimates a) the national provision of PAC, b) the first-ever national incidence of induced abortion in Zimbabwe, and c) the proportion of pregnancies that are unintended. METHODS: We use the Abortion Incidence Complications Method (AICM), which indirectly estimates the incidence of induced abortion by obtaining a national estimate of PAC cases, and then estimates what proportion of all induced abortions in the country would result in women receiving PAC. Three national surveys were conducted in 2016: a census of health facilities with PAC capacity (n = 227), a prospective survey of women seeking abortion-related care in a nationally-representative sample of those facilities (n = 127 facilities), and a purposive sample of experts knowledgeable about abortion in Zimbabwe (n = 118). The estimate of induced abortion, along with census and Demographic Health Survey data was used to estimate unintended pregnancy. RESULTS: There were an estimated 25,245 PAC patients treated in Zimbabwe in 2016, but there were critical gaps in their care, including stock-outs of essential PAC medicines at half of facilities. Approximately 66,847 induced abortions (uncertainty interval (UI): 54,000-86,171) occurred in Zimbabwe in 2016, which translates to a national rate of 17.8 (UI: 14.4-22.9) abortions per 1,000 women 15-49. Overall, 40% of pregnancies were unintended in 2016, and one-quarter of all unintended pregnancies ended in abortion. CONCLUSION: Zimbabwe has one of the lowest abortion rates in sub-Saharan Africa, likely due to high rates of contraceptive use. There are gaps in the health care system affecting the provision of quality PAC, potentially due to the prolonged economic crisis. These findings can inform and improve policies and programs addressing unsafe abortion and PAC in Zimbabwe.

Impact of a critical health workforce shortage on child health in Zimbabwe: a country case study on progress in child survival, 2000-2013.

Despite notable progress reducing global under-five mortality rates, insufficient progress in most sub-Saharan African nations has prevented the achievement of Millennium Development Goal four (MDG#4) to reduce under-five mortality by two-thirds between 1990 and 2015. Country-level assessments of factors underlying why some African countries have not been able to achieve MDG#4 have not been published. Zimbabwe was included in a four-country study examining barriers and facilitators of under-five survival between 2000 and 2013 due to its comparatively slow progress towards MDG#4. A review of national health policy and strategy documents and analysis of qualitative data identified Zimbabwe's critical shortage of health workers and diminished opportunities for professional training and education as an overarching challenge. Moreover, this insufficient health workforce severely limited the availability, quality, and utilization of life-saving health services for pregnant women and children during the study period. The impact of these challenges was most evident in Zimbabwe's persistently high neonatal mortality rate, and was likely compounded by policy gaps failing to authorize midwives to deliver life-saving interventions and to ensure health staff make home post-natal care visits soon after birth. Similarly, the lack of a national policy authorizing lower-level cadres of health workers to provide community-based treatment of pneumonia contributed to low coverage of this effective intervention and high child mortality. Zimbabwe has recently begun to address these challenges through comprehensive policies and strategies targeting improved recruitment and retention of experienced senior providers and by shifting responsibility of basic maternal, neonatal and child health services to lower-level cadres and community health workers that require less training, are geographically broadly distributed, and are more cost-effective, however the impact of these interventions could not be assessed within the scope and timeframe of the current study.