Aetiology of vaginal discharge, urethral discharge, and genital ulcer in sub-Saharan Africa: A systematic review and meta-regression.

BACKGROUND: Syndromic management is widely used to treat symptomatic sexually transmitted infections in settings without aetiologic diagnostics. However, underlying aetiologies and consequent treatment suitability are uncertain without regular assessment. This systematic review estimated the distribution, trends, and determinants of aetiologies for vaginal discharge, urethral discharge, and genital ulcer in sub-Saharan Africa (SSA). METHODS AND FINDINGS: We searched Embase, MEDLINE, Global Health, Web of Science, and grey literature from inception until December 20, 2023, for observational studies reporting aetiologic diagnoses among symptomatic populations in SSA. We adjusted observations for diagnostic test performance, used generalised linear mixed-effects meta-regressions to generate estimates, and critically appraised studies using an adapted Joanna Briggs Institute checklist. Of 4,418 identified records, 206 reports were included from 190 studies in 32 countries conducted between 1969 and 2022. In 2015, estimated primary aetiologies for vaginal discharge were candidiasis (69.4% [95% confidence interval (CI): 44.3% to 86.6%], n = 50), bacterial vaginosis (50.0% [95% CI: 32.3% to 67.8%], n = 39), chlamydia (16.2% [95% CI: 8.6% to 28.5%], n = 50), and trichomoniasis (12.9% [95% CI: 7.7% to 20.7%], n = 80); for urethral discharge were gonorrhoea (77.1% [95% CI: 68.1% to 84.1%], n = 68) and chlamydia (21.9% [95% CI: 15.4% to 30.3%], n = 48); and for genital ulcer were herpes simplex virus type 2 (HSV-2) (48.3% [95% CI: 32.9% to 64.1%], n = 47) and syphilis (9.3% [95% CI: 6.4% to 13.4%], n = 117). Temporal variation was substantial, particularly for genital ulcer where HSV-2 replaced chancroid as the primary cause. Aetiologic distributions for each symptom were largely the same across regions and population strata, despite HIV status and age being significantly associated with several infection diagnoses. Limitations of the review include the absence of studies in 16 of 48 SSA countries, substantial heterogeneity in study observations, and impeded assessment of this variability due to incomplete or inconsistent reporting across studies. CONCLUSIONS: In our study, syndrome aetiologies in SSA aligned with World Health Organization guidelines without strong evidence of geographic or demographic variation, supporting broad guideline applicability. Temporal changes underscore the importance of regular aetiologic re-assessment for effective syndromic management. PROSPERO NUMBER: CRD42022348045.

Provider and female client economic costs of integrated sexual and reproductive health and HIV services in Zimbabwe.

A retrospective facility-based costing study was undertaken to estimate the comparative cost per visit of five integrated sexual and reproductive health and HIV (human immuno-deficiency virus) services (provider perspective) within five clinic sites. These five clinics were part of four service delivery models: Non-governmental-organisation (NGO) directly managed model (Chitungwiza and New Africa House sites), NGO partner managed site (Mutare site), private-public-partnership (PPP) model (Chitungwiza Profam Clinic), and NGO directly managed outreach (operating from New Africa House site. In addition client cost exit interviews (client perspective) were conducted among 856 female clients exiting integrated services at three of the sites. Our costing approach involved first a facility bottom-up costing exercise (February to April 2015), conducted to quantify and value each resource input required to provide individual SRH and HIV services. Secondly overhead financial expenditures were allocated top-down from central office to sites and then respective integrated service based on pre-defined allocation factors derived from both the site facility observations and programme data for the prior 12 months. Costs were assessed in 2015 United States dollars (USD). Costs were assessed for HIV testing and counselling, screening and treatment of sexually transmitted infections, tuberculosis screening with smear microscopy, family planning, and cervical cancer screening and treatment employing visual inspection with acetic acid and cervicography and cryotherapy. Variability in costs per visit was evident across the models being highest for cervical cancer screening and cryotherapy (range: US$6.98-US$49.66). HIV testing and counselling showed least variability (range; US$10.96-US$16.28). In general the PPP model offered integrated services at the lowest unit costs whereas the partner managed site was highest. Significant client costs remain despite availability of integrated sexual and reproductive health and HIV services free of charge in our Zimbabwe study setting. Situating services closer to communities, incentives, transport reimbursements, reducing waiting times and co-location of sexual and reproductive health and HIV services may help minimise impact of client costs.

Neurological assessment tool for screening infants during the first year after birth: The Brief-Hammersmith Infant Neurological Examination.

AIM: To develop a short version of the original Hammersmith Infant Neurological Examination (HINE) to be used as a screening tool (Brief-HINE) and to establish if the short examination maintains good accuracy and predictive power for detecting infants with cerebral palsy (CP). METHOD: Eleven items were selected from the original HINE ('visual response'; 'trunk posture'; 'movement quantity'; 'movement quality'; 'scarf sign'; 'hip adductor angles'; 'popliteal angle'; 'pull to sit'; 'lateral tilting'; 'forward parachute reaction'; 'tendon reflexes') identifying those items previously found to be more predictive of CP in both low- and high-risk infants. In order to establish the sensitivity of the new module, the selected items were applied to existing data, previously obtained using the full HINE at 3, 6, 9, and 12 months, in 228 infants with typical development at 2 years and in 82 infants who developed CP. RESULTS: Brief-HINE scores showed good sensitivity and specificity, at each age of assessment, for detecting infants with CP. At 3 months, a score of less than 22 was associated with CP with a sensitivity of 0.88 and a specificity of 0.92; at 6, 9, and 12 months, the cut-off scores were less than 25 (sensitivity 0.93; specificity 0.87), less than 27 (sensitivity 0.95; specificity 0.81), and less than 27 (sensitivity 1; specificity 0.86) respectively. The presence of more than one warning sign, or items that are not optimal for the age of assessment, imply the need for a full examination reassessment. INTERPRETATION: These findings support the validity of the Brief-HINE as a routine screening method and the possibility of its use in clinical practice.

"Getting pregnant during COVID-19 was a big risk because getting help from the clinic was not easy": COVID-19 experiences of women and healthcare providers in Harare, Zimbabwe.

The COVID-19 pandemic and associated measures may have disrupted delivery of maternal and neonatal health services and reversed the progress made towards dual elimination of mother-to-child transmission of HIV and syphilis in Zimbabwe. This qualitative study explores the impact of the pandemic on the provision and uptake of prevention of mother-to-child transmission (PMTCT) services from the perspectives of women and maternal healthcare providers. Longitudinal in-depth interviews were conducted with 20 pregnant and breastfeeding women aged 20-39 years living with HIV and 20 healthcare workers in two maternity polyclinics in low-income suburbs of Harare, Zimbabwe. Semi-structured interviews were held after the second and third waves of COVID-19 in March and November 2021, respectively. Data were analysed using a modified grounded theory approach. While eight antenatal care contacts are recommended by Zimbabwe's Ministry of Health and Child Care, women reported only being able to access two contacts. Although HIV testing, antiretroviral therapy (ART) refills and syphilis screening services were accessible at first contact, other services such as HIV-viral load monitoring and enhanced adherence counselling were not available for those on ART. Closure of clinics and shortened operating hours during the second COVID-19 wave resulted in more antenatal bookings occurring later during pregnancy and more home deliveries. Six of the 20 (33%) interviewed women reported giving birth at home, assisted by untrained traditional midwives as clinics were closed. Babies delivered at home missed ART prophylaxis and HIV testing at birth despite being HIV-exposed. Although women faced multiple challenges, they continued to attempt to access services after delivery. These findings underline the importance of investing in robust health systems that can respond to emergency situations to ensure continuity of essential HIV prevention, treatment, and care services.

Effects of the COVID-19 pandemic on the outcomes of HIV-exposed neonates: a Zimbabwean tertiary hospital experience.

INTRODUCTION: The COVID-19 pandemic has globally impacted health service access, delivery and resources. There are limited data regarding the impact on the prevention of mother to child transmission (PMTCT) service delivery in low-resource settings. Neotree ( www.neotree.org ) combines data collection, clinical decision support and education to improve care for neonates. Here we evaluate impacts of COVID-19 on care for HIV-exposed neonates. METHODS: Data on HIV-exposed neonates admitted to the neonatal unit (NNU) at Sally Mugabe Central Hospital, Zimbabwe, between 01/06/2019 and 31/12/2021 were analysed, with pandemic start defined as 21/03/2020 and periods of industrial action (doctors (September 2019-January 2020) and nurses (June 2020-September 2020)) included, resulting in modelling during six time periods: pre-doctors' strike (baseline); doctors' strike; post-doctors' strike and pre-COVID; COVID and pre-nurses' strike; nurses' strike; post nurses' strike. Interrupted time series models were used to explore changes in indicators over time. RESULTS: Of 8,333 neonates admitted to the NNU, 904 (11%) were HIV-exposed. Mothers of 706/765 (92%) HIV-exposed neonates reported receipt of antiretroviral therapy (ART) during pregnancy. Compared to the baseline period when average admissions were 78 per week (95% confidence interval (CI) 70-87), significantly fewer neonates were admitted during all subsequent periods until after the nurses' strike, with the lowest average number during the nurses' strike (28, 95% CI 23-34, p < 0.001). Across all time periods excluding the nurses strike, average mortality was 20% (95% CI 18-21), but rose to 34% (95% CI 25, 46) during the nurses' strike. There was no evidence for heterogeneity (p > 0.22) in numbers of admissions or mortality by HIV exposure status. Fewer HIV-exposed neonates received a PCR test during the pandemic (23%) compared to the pre-pandemic periods (40%) (RR 0.59, 95% CI 0.41-0.84, p < 0.001). The proportion of HIV-exposed neonates who received antiretroviral prophylaxis during admission was high throughout, averaging between 84% and 95% in each time-period. CONCLUSION: While antiretroviral prophylaxis for HIV-exposed neonates remained high throughout, concerning data on low admissions and increased mortality, similar in HIV-exposed and unexposed neonates, and reduced HIV testing, suggest some aspects of care may have been compromised due to indirect effects of the pandemic.

Do community measures impact the effectiveness of a community led HIV testing intervention. Secondary analysis of an HIV self-testing intervention in rural communities in Zimbabwe.

BACKGROUND: There is a growing body of evidence for the role that communities can have in producing beneficial health outcomes. There is also an increasing recognition of the effectiveness and success of community-led interventions to promote public health efforts. This study investigated whether and how community-level measures facilitate a community-led intervention to achieve improved HIV outcomes. METHODS: This is a secondary analysis of survey data from a cluster randomised trial in 40 rural communities in Zimbabwe. The survey was conducted four months after the intervention was initiated. Communities were randomised 1:1 to either paid distribution arm, where HIV self-test (HIVST) kits were distributed by a paid distributor, or community-led whereby members of the community were responsible for organising and conducting the distribution of HIVST kits. We used mixed effects logistic regression to assess the effect of social cohesion, problem solving, and HIV awareness on HIV testing and prevention. RESULTS: We found no association between community measures and the three HIV outcomes (self-testing, new HIV diagnosis and linkage to VMMC or confirmatory testing). However, the interaction analyses highlighted that in high social cohesion communities, the odds of new HIV diagnosis was greater in the community-led arm than paid distribution arm (OR 2.06 95% CI 1.03-4.19). CONCLUSION: We found some evidence that community-led interventions reached more undiagnosed people living with HIV in places with high social cohesion. Additional research should seek to understand whether the effect of social cohesion is persistent across other community interventions and outcomes. TRIAL REGISTRATION: PACTR201607001701788.

Preferences for oral-fluid-based or blood-based HIV self-testing and provider-delivered testing: an observational study among different populations in Zimbabwe.

BACKGROUND: There is limited data on client preferences for different HIV self-testing (HIVST) and provider-delivered testing options and associated factors. We explored client preferences for oral-fluid-based self-testing (OFBST), blood-based self-testing (BBST) and provider-delivered blood-based testing (PDBBT) among different populations. METHODS: At clinics providing HIV testing services to general populations (1 urban, 1 rural clinic), men seeking voluntary medical male circumcision (VMMC, 1 clinic), and female sex workers (FSW, 1 clinic), clients had the option to test using OFBST, BBST or PDBBT. A pre-test questionnaire collected information on demographics and testing history. Two weeks after collecting a self-test kit, participants responded to a questionnaire. We used logistic regression to determine predictors of choices. We also conducted 20 in-depth interviews to contextualise quantitative findings. RESULTS: May to June 2019, we recruited 1244 participants of whom 249 (20%), 251 (20%), 244 (20%) and 500 (40%) were attending urban general, rural, VMMC and FSW clinics, respectively. Half (n = 619, 50%) chose OFBST, 440 (35%) and 185 (15%) chose BBST and PDBBT, respectively. In multivariable analysis comparing those choosing HIVST (OFBST and BBST combined) versus not, those who had never married aOR 0.57 (95% CI 0.34-0.93) and those previously married aOR0.56 (0.34-0.93) were less likely versus married participants to choose HIVST. HIVST preference increased with education, aOR 2.00 (1.28-3.13), 2.55 (1.28-5.07), 2.76 (1.48-5.14) for ordinary, advanced and tertiary education, respectively versus none/primary education. HIVST preference decreased with age aOR 0.97 (0.96-0.99). Urban participants were more likely than rural ones to choose HIVST, aOR 9.77 (5.47-17.41), 3.38 (2.03-5.62) and 2.23 (1.38-3.61) for FSW, urban general and VMMC clients, respectively. Comparing those choosing OFBST with those choosing BBST, less literate participants were less likely to choose oral fluid tests, aOR 0.29 (0.09-0.92). CONCLUSIONS: Most testing clients opted for OFBST, followed by BBST and lastly, PDBBT. Those who self-assessed as less healthy were more likely to opt for PDBBT which likely facilitated linkage. Results show importance of continued provision of all strategies in order to meet needs of different populations, and may be useful to inform both HIVST kit stock projections and tailoring of HIVST programs to meet the needs of different populations.

HIV incidence among women engaging in sex work in sub-Saharan Africa: a systematic review and meta-analysis.

Introduction: HIV incidence among women in sub-Saharan Africa (SSA) has declined steadily, but it is unknown whether new infections among women who engage in sex work (WESW) have declined at a similar rate. We synthesised estimates of HIV incidence among WESW in SSA and compared these to the wider female population to understand levels and trends in incidence over time. Methods: We searched Medline, Embase, Global Health, Popline, Web of Science, and Google Scholar from January 1990 to October 2022, and grey literature for estimates of HIV incidence among WESW in SSA. We included studies reporting empirical estimates in any SSA country. We calculated incidence rate ratios (IRR) compared to age-district-year matched total female population incidence estimates. We conducted a meta-analysis of IRRs and used a continuous mixed-effects model to estimate changes in IRR over time. Results: From 32 studies between 1985 and 2020, 2,194 new HIV infections were observed in WESW over 51,000 person-years (py). Median HIV incidence was 4.3/100py (IQR 2.8-7.0/100py), declining from a median of 5.96/100py between 1985 and 1995 to a median of 3.2/100py between 2010 and 2020. Incidence among WESW was nine times higher than in matched total population women (RR 8.6, 95%CI: 5.7-12.9), and greater in Western and Central Africa (RR 22.4, 95%CI: 11.3-44.3) than in Eastern and Southern Africa (RR 5.3, 95%CI: 3.7-7.6). Annual changes in log IRRs were minimal (-0.1% 95%CI: -6.9 to +6.8%). Conclusions: Across SSA, HIV incidence among WESW remains disproportionately high compared to the total female population but showed similar rates of decline between 1990 and 2020. Improved surveillance and standardisation of approaches to obtain empirical estimates of sex worker incidence would enable a clearer understanding of whether we are on track to meet global targets for this population and better support data-driven HIV prevention programming.

"They test my blood to know how much blood is in my body": the untapped potential of promoting viral load literacy to support adherence and viral suppression among adolescents living with HIV.

INTRODUCTION: Achieving sustained HIV viral suppression is a key strategy to optimize the health and wellbeing of those living with HIV. Sub-optimal adherence to antiretroviral therapy (ART) in adolescents and young people living with HIV (AYPLHIV) in Southern Africa, due to a range of social and contextual factors, including poor mental health, has presented a substantial challenge to meeting targets aimed towards improving treatment outcomes and reducing transmission. With the increasing availability of viral load (VL) testing in Southern Africa, there is an opportunity to better understand the relationship between VL literacy, wellbeing and adherence among adolescents. METHODS: We conducted qualitative interviews with 45 AYPLHIV aged 10-24 years in three districts (urban, peri-urban and rural) in Zimbabwe between March and August 2021. The sample was purposively selected to represent a range of experiences related to HIV status disclosure, gender, marital status and treatment experience. Separate workshops were conducted with 18 healthcare workers (HCWs) and 20 caregivers to better understand existing support mechanisms to AYPLHIV accessing ART. We used thematic analysis to examine adolescent VL literacy, treatment support networks, experiences of clinic interactions, VL testing procedures and barriers to adherence. RESULTS: VL literacy was consistently under-developed among participants. Comprehension of phrases commonly heard during clinic visits, such as TND (target not detected) and "high" and "low" VL, were better understood by older participants. VL testing was predominantly understood as a clinical procedure that enables HCWs to monitor treatment adherence. Absent throughout the interviews were descriptions of how viral suppression improves health and quality of life, likely fosters wellbeing and enhances self-esteem, enables participation in education and social activities, and eliminates the risk of onward transmission. CONCLUSIONS: It is imperative that we reconsider how routine VL monitoring is communicated to and understood by AYPLHIV. Reframing ART, including VL test results, in terms of the psychosocial benefits that viral suppression can generate is likely to be crucial to motivating AYPLHIV to maintain optimal treatment engagement and develop self-management approaches as they move into adulthood. Access to accurate information tailored to individual concerns and circumstances can support AYPLHIV to achieve wellbeing.

Cerebellar growth, volume and diffusivity in children cooled for neonatal encephalopathy without cerebral palsy.

Children cooled for HIE and who did not develop cerebral palsy (CP) still underperform at early school age in motor and cognitive domains and have altered supra-tentorial brain volumes and white matter connectivity. We obtained T1-weighted and diffusion-weighted MRI, motor (MABC-2) and cognitive (WISC-IV) scores from children aged 6-8 years who were cooled for HIE secondary to perinatal asphyxia without CP (cases), and controls matched for age, sex, and socioeconomic status. In 35 case children, we measured cerebellar growth from infancy (age 4-15 days after birth) to childhood. In childhood, cerebellar volumes were measured in 26 cases and 23 controls. Diffusion properties (mean diffusivity, MD and fractional anisotropy, FA) were calculated in 24 cases and 19 controls, in 9 cerebellar regions. Cases with FSIQ ≤ 85 had reduced growth of cerebellar width compared to those with FSIQ > 85 (p = 0.0005). Regional cerebellar volumes were smaller in cases compared to controls (p < 0.05); these differences were not significant when normalised to total brain volume. There were no case-control differences in MD or FA. Interposed nucleus volume was more strongly associated with IQ in cases than in controls (p = 0.0196). Other associations with developmental outcome did not differ between cases and controls.

Potential cost-effectiveness of community availability of tenofovir, lamivudine, and dolutegravir for HIV prevention and treatment in east, central, southern, and west Africa: a modelling analysis.

BACKGROUND: Post-exposure prophylaxis (PEP) offers protection from HIV after condomless sex, but is not widely available in a timely manner in east, central, southern, and west Africa. To inform the potential pilot implementation of such an approach, we modelled the effect and cost-effectiveness of making PEP consisting of tenofovir, lamivudine, and dolutegravir (TLD) freely and locally available in communities without prescription, with the aim of enabling PEP use within 24 h of condomless sex. Free community availability of TLD (referred to as community TLD) might also result in some use of TLD as pre-exposure prophylaxis (PrEP) and as antiretroviral therapy for people living with HIV. METHODS: Using an existing individual-based model (HIV Synthesis), we explicitly modelled the potential positive and negative effects of community TLD. Through the sampling of parameter values we created 1000 setting-scenarios, reflecting the uncertainty in assumptions and a range of settings similar to those seen in east, central, southern, and west Africa (with a median HIV prevalence of 14·8% in women and 8·1% in men). For each setting scenario, we considered the effects of community TLD. TLD PEP was assumed to have at least 90% efficacy in preventing HIV infection after condomless sex with a person living with HIV. FINDINGS: The modelled effects of community TLD availability based on an assumed high uptake of TLD resulted in a mean reduction in incidence of 31% (90% range over setting scenarios, 6% increase to 57% decrease) over 20 years, with an HIV incidence reduction over 50 years in 91% of the 1000 setting scenarios, deaths averted in 55% of scenarios, reduction in costs in 92% of scenarios, and disability-adjusted life-years averted in 64% of scenarios with community TLD. Community TLD was cost-effective in 90% of setting scenarios and cost-saving (with disability-adjusted life-years averted) in 58% of scenarios. When only examining setting scenarios in which there was lower uptake of community TLD, community TLD is cost-effective in 92% of setting scenarios. INTERPRETATION: The introduction of community TLD, enabling greater PEP access, is a promising approach to consider further in pilot implementation projects. FUNDING: Bill & Melinda Gates Foundation to the HIV Modelling Consortium.

Impact of the COVID-19 pandemic on the provision and uptake of services for the prevention of mother-to-child transmission of HIV in Zimbabwe.

Zimbabwe is targeting elimination of mother-to-child transmission of HIV by December 2025, however the COVID-19 pandemic challenged health service delivery globally. Monthly aggregated data were extracted from DHIS-2 for all facilities delivering antenatal care (ANC). ZIMSTAT and Spectrum demographic estimates were used for population-level denominators. Programme indicators are among those in HIV care and population indicators reflect the total population. The mean estimated proportion of pregnant women booking for ANC per month did not change (91% pre-pandemic vs 91% during pandemic, p = 0.95), despite dropping to 47% in April 2020. At a programme-level, the estimated proportion of women who received at least one HIV test fell in April 2020 (3.6% relative reduction vs March (95% CI 2.2-5.1), p<0.001) with gradual recovery towards pre-pandemic levels. The estimated proportion of women who were retested among those initially negative in pregnancy fell markedly in April 2020 (39% reduction (32-45%), p<0.001) and the subsequent increase was much slower, only reaching 39% by September 2021 compared to average 53% pre-pandemic. The mean estimated proportion of pregnant women with HIV on ART was unchanged at programme-level (98% vs 98%, p = 0.26), but decreased at population-level (86% vs 80%, p = 0.049). Antiretroviral prophylaxis coverage decreased among HIV-exposed infants, at programme- (94% vs 87%, p = 0.001) and population-levels (76% vs 68%, p<0.001). There was no significant change in HIV-exposed infants receiving EID (programme: 107% vs 103%, p = 0.52; population: 87% vs 79%, p = 0.081). The estimated proportion of infants with HIV diagnosed fell from 27% to 18%, (p<0.001), while the estimated proportion on ART was stable at a programme (88% vs 90%, p = 0.82) but not population (22% vs 16%, p = 0.004) level. Despite a drop at the start of the pandemic most programme indicators rapidly recovered. At a population-level indicators were slower to return, suggesting less women with HIV identified in care.

Temporal trends in, and risk factors for, HIV seroconversion among female sex workers accessing Zimbabwe's national sex worker programme, 2009-19: a retrospective cohort analysis of routinely collected HIV testing data.

BACKGROUND: The frequency of new HIV infections among female sex workers in sub-Saharan Africa is poorly understood. We used routinely collected data that enable unique identification of repeat HIV testers to assess temporal trends in seroconversion and identify associated risk factors for female sex workers accessing Sisters with a Voice, Zimbabwe's national sex worker programme. METHODS: We pooled HIV testing data gathered between Sept 15, 2009, and Dec 31, 2019, from 36 Sisters programme sites in Zimbabwe. We included female sex workers aged 16 years or older with an HIV-negative test and at least one subsequent programme test. We calculated HIV seroconversion rates (using the midpoint between the HIV-positive test and the last negative test as the seroconversion date) and estimated rate ratios to compare 2-year periods by using Poisson regression, with robust SEs to account for clustering by site and adjusting for age and testing frequency to assess temporal trends. We did sensitivity analyses to explore assumptions about seroconversion dates and the effects of variation in follow-up time on our conclusions. FINDINGS: Our analysis included data for 6665 female sex workers, 441 (7%) of whom seroconverted. The overall seroconversion rate was 3·8 (95% CI 3·4-4·2) per 100 person-years at risk. Seroconversion rates fell with time since first negative HIV test. After adjustment, there was evidence of a decrease in seroconversion rates from 2009 to 2019 (p=0·0053). In adjusted analyses, being younger than 25 years, and having a sexually transmitted infection diagnosis at a previous visit, were significantly associated with increased seroconversion rates. Our findings were mostly robust to sensitivity analyses, but when 1 month before an HIV-positive test was used as the seroconversion date, seroconversion rates no longer fell with time. INTERPRETATION: We identified high rates of seroconversion shortly after linkage to programme services, which emphasises the need to strengthen HIV prevention programmes from first contact with female sex workers in Zimbabwe. New infections among female sex workers remain challenging to measure, but longitudinal analysis of routine testing data can provide valuable insights into seroconversion rates and associated risk factors. FUNDING: UN Population Fund, Deutsche Gesellschaft für Internationale Zusammenarbeit, the Bill & Melinda Gates Foundation, The Global Fund to Fight AIDS, Tuberculosis and Malaria, US President's Emergency Plan for AIDS Relief, US Agency for International Development, and the Elton John AIDS Foundation.

HIV prevalence, risk behaviour, and treatment and prevention cascade outcomes among cisgender men, transgender women, and transgender men who sell sex in Zimbabwe: a cross-sectional analysis of programme data.

BACKGROUND: There is a paucity of evidence on HIV vulnerabilities and service engagements among people who sell sex in sub-Saharan Africa and identify as cisgender men, transgender women, or transgender men. We aimed to describe sexual risk behaviours, HIV prevalence, and access to HIV services among cisgender men, transgender women, and transgender men who sell sex in Zimbabwe. METHODS: We did a cross-sectional analysis of routine programme data that were collected between July 1, 2018, and June 30, 2020, from cisgender men who sell sex, transgender women who sell sex, and transgender men who sell sex, as part of accessing sexual and reproductive health and HIV services provided through the Sisters with a Voice programme, at 31 sites across Zimbabwe. All people who sell sex reached by the programme had routine data collected, including routine HIV testing, and were referred using a network of peer educators. Sexual risk behaviours, HIV prevalence, and HIV services uptake during the period from July, 2018, to June, 2020, were analysed through descriptive statistics by gender group. FINDINGS: A total of 1003 people who sell sex were included in our analysis: 423 (42·2%) cisgender men, 343 (34·2%) transgender women, and 237 (23·6%) transgender men. Age-standardised HIV prevalence estimates were 26·2% (95% CI 22·0-30·7) among cisgender men, 39·4% (34·1-44·9) among transgender women, and 38·4% (32·1-45·0) among transgender men. Among people living with HIV, 66·0% (95% CI 55·7-75·3) of cisgender men, 74·8% (65·8-82·4) of transgender women, and 70·2% (59·3-79·7) of transgender men knew their HIV status, and 15·5% (8·9-24·2), 15·7% (9·5-23·6), and 11·9% (5·9-20·8) were on antiretroviral therapy, respectively. Self-reported condom use was consistently low across gender groups, ranging from 26% (95% CI 22-32) for anal sex among transgender women to 32% (27-37) for vaginal sex among cisgender men. INTERPRETATION: These unique data show that people who sell sex and identify as cisgender men, transgender women, or transgender men in sub-Saharan Africa have high HIV prevalences and risk of infection, with alarmingly low access to HIV prevention, testing, and treatment services. There is an urgent need for people-centred HIV interventions for these high-risk groups and for more inclusive HIV policies and research to ensure we truly attain universal access for all. FUNDING: Aidsfonds Netherlands.

Facilitators and barriers to engaging with the DREAMS initiative among young women who sell sex aged 18-24 in Zimbabwe: a qualitative study.

BACKGROUND: Adolescent girls and young women (AGYW) are at high risk of contracting HIV and exchanging sex for financial or material support heightens their risk. In Zimbabwe, the DREAMS initiative integrated education and employment opportunities within HIV health promotion and clinical services for vulnerable young women, including those who sell sex. While most participants accessed health services, fewer than 10% participated in any social programmes. METHODS: We conducted semi-structured qualitative interviews with 43 young women aged 18-24 to understand their experiences of engaging with the DREAMS programme. We purposively sampled participants for diversity in level of education, type and location of selling sex. We analysed the data by applying the Theoretical Domains Framework to explore facilitators and barriers to engaging with DREAMS. RESULTS: Eligible women were motivated by hopes of escaping poverty, and their longer-term engagement was sustained through exposure to new social networks, including friendships with less vulnerable peers. Barriers included opportunity costs and expenses such as transport or equipment required for job placements. Participants also described pervasive stigma and discrimination related to their involvement in selling sex. Interviews highlighted the young women's struggles in a context of entrenched social and material deprivation and structural discrimination that hindered their ability to take up most of the social services offered. CONCLUSIONS: This study demonstrates that while poverty was a key driver of participation in an integrated package of support, it also constrained the ability of highly vulnerable young women to benefit fully from the DREAMS initiative. Multi-layered HIV prevention approaches such as DREAMS that seek to alter complex and longstanding social and economic deprivation address many of the challenges faced by YWSS but will only succeed if the underlying drivers of HIV risk among YWSS are also addressed.

Relationships between early postnatal cranial ultrasonography linear measures and neurodevelopment at 2 years in infants born at <30 weeks' gestational age without major brain injury.

OBJECTIVE: To explore relationships of early postnatal cranial ultrasonography (cUS) linear measures of brain size and brain growth with neurodevelopment at 2 years in infants born <30 weeks' gestational age (GA) and free of major brain injury. DESIGN: Prospective observational cohort study. SETTING: Tertiary neonatal intensive care unit. PATIENTS: 139 infants born <30 weeks' GA, free of major brain injury on neonatal cUS and without congenital or chromosomal anomalies known to affect neurodevelopment. INTERVENTION: Linear measures of brain tissue and fluid spaces made from cUS at 1-week, 1-month and 2-months' postnatal age. MAIN OUTCOME MEASURES: Cognitive, language and motor scores on the Bayley Scales of Infant and Toddler Development, third edition at 2 years' corrected age. RESULTS: 313 scans were evaluated from the 131 children who were assessed at 2 years. Larger measures of the corpus callosum at 1 week, 1 month and 2 months, cerebellum and vermis at 2 months and faster positive growth of the cerebellum and vermis between 1 month and 2 months, were related to higher cognitive and language scores at 2 years. No relation between tissue measures and motor scores was found. Larger measures, and faster rate of increase, of fluid spaces within the first weeks after birth were related to better cognitive, language and motor outcomes at 2 years. CONCLUSIONS: Early postnatal cUS linear measures of brain tissue were related to cognitive and language development at 2 years in infants born <30 weeks' GA without major brain injury. Relationships between cUS linear measures of fluid spaces in the early postnatal period and later neurodevelopment warrant further exploration.

HIV prevention in individuals engaged in sex work.

PURPOSE OF REVIEW: People who sell sex remain at disproportionate risk of acquiring HIV and should be prioritized for evidence-based HIV prevention programmes delivered at sufficient scale and intensity for effectiveness. Although new biomedical tools are becoming available, many basic lessons learned early in the HIV pandemic remain salient today and need renewed attention. RECENT FINDINGS: New preexposure prophylaxis formulations, distribution systems, and delivery mechanisms are being successfully trialled and implemented, adding to well established prevention tools such as male and female condoms and lubricants. The importance of social support networks and community ownership of programmes has been consistently reaffirmed. Serious challenges remain in optimizing HIV prevention for sex workers, including providing services at the scale and intensity necessary for population level impact, addressing culturally sensitive issues of gender identity and sexual orientation, and protecting adolescents and young people who may sell sex. Pervasive social stigma, often reinforced by criminalization and police harassment, further constrain sex workers' access to available services and prevention tools. SUMMARY: Meaningful community engagement and addressing the multiple social determinants of vulnerability at individual, community, and structural levels remain at the core of preventing HIV among people involved in selling sex.