Social and structural drivers of HIV vulnerability among a respondent-driven sample of feminine and non-feminine presenting transgender women who have sex with men in Zimbabwe.

INTRODUCTION: We sought to characterize social and structural drivers of HIV vulnerability for transgender women (TGW) in Zimbabwe, where TGW are not legally recognized, and explore differences in vulnerability by feminine presentation. METHODS: A secondary analysis was conducted with a sub-sample of participants recruited from a 2019 respondent-driven sampling survey that comprised men who have sex with men, TGW and genderqueer individuals assigned male sex at birth, from two cities in Zimbabwe. Survey questionnaires captured information related to socio-demographics, sexual and substance use behaviours, and social and structural barriers to HIV services. Secondary analyses were restricted to participants who identified as female, transfemale or transwomen (236/1538) and were unweighted. Descriptive statistics were used to calculate sample estimates and chi-square and Fisher's exact tests were used to assess differences in vulnerability by feminine presentation. RESULTS: Among 236 TGW, almost half (45.3%) presented as feminine in the 6 months preceding the survey and 8.5% had ever used hormones to affirm their gender identities. Median age among TGW was 23 years (interquartile range: 20-26). Feminine presenting TGW in our sample had higher prevalence of arrest (15.9% vs. 3.9%), rejection by family/friends (38.3% vs. 14.0%), employment termination (11.2% vs. 3.9%), employment refusal (14.0% vs. 3.9%), denial of healthcare (16.8% vs. 2.3%), physical, sexual or verbal harassment or abuse (59.8% vs. 34.1%), alcohol dependence (32.7% vs. 12.4%), recent transactional sex with a male or TGW partner (30.8% vs. 13.3%) and recent non-injection drug use (38.3% vs. 20.2%) than non-feminine presenting TGW (all p-value <0.05). CONCLUSIONS: Findings suggest that TGW, particularly feminine presenting TGW, experience social and structural inequities which may contribute to HIV vulnerability. Interventions aimed at addressing inequities, including trans competency training for providers and gender-affirming, psychosocial and legal support services for TGW, might mitigate risk.

Seroprevalence of SARS-CoV-2 in 10 Regional Capitals of Cameroon, October-December 2020.

BACKGROUND: Cameroon was among the most affected African countries during the first wave of the COVID-19 pandemic; however, the true prevalence of SARS-CoV-2 remains unknown. METHODS: From October to December 2020, we conducted a cross-sectional, age-stratified SARS-CoV-2 seroepidemiological survey at 30 purposively selected community-based sites across Cameroon's 10 regional capitals, sampling 10,000 individuals aged 5 years or older. We employed a parallel SARS-CoV-2 antibody testing algorithm (WANTAI ELISA and Abbott Architect) to improve both the positive predictive value and negative predictive value of seroprevalence. RESULTS: The overall weighted and adjusted seroprevalence of SARS-CoV-2 antibodies across the 10 urban capitals of Cameroon was 10.5% (95% CI: 9.1%-12.0%) among participants aged ≥5 years. Of the 9332 participants, 730 males (13.1%, 95% CI: 11.5%-14.9%) had SARS-CoV-2 antibodies compared to 293 females (8.0%, 95% CI: 6.8%-9.3%). Among those who reported a comorbidity at the time of testing, 15.8% (95% CI: 12.8%-19.4%) were seropositive. We estimated that over 2 million SARS-CoV-2 infections occurred in the 10 regional capitals of Cameroon between October and December 2020, compared to 21,160 cases officially reported at that time translating to one laboratory-confirmed case being reported for every 110 SARS-CoV-2 infections across the 10 urban capitals. CONCLUSION: This study's findings point to extensive and under-reported circulation of SARS-CoV-2 in Cameroon-an almost 100-fold more cases compared to the number of cases reported to the World Health Organization. This finding highlights the importance of conducting serosurveys, especially in settings where access to testing may be limited and to repeat such surveys as part of pandemic tracking.

Epigenetic aging in older people living with HIV in Eswatini: a pilot study of HIV and lifestyle factors and epigenetic aging.

BACKGROUND: People living with HIV (PLHIV) on effective antiretroviral therapy are living near-normal lives. Although they are less susceptible to AIDS-related complications, they remain highly vulnerable to non-communicable diseases. In this exploratory study of older PLHIV (OPLHIV) in Eswatini, we investigated whether epigenetic aging (i.e., the residual between regressing epigenetic age on chronological age) was associated with HIV-related parameters, and whether lifestyle factors modified these relationships. We calculated epigenetic aging focusing on the Horvath, Hannum, PhenoAge and GrimAge epigenetic clocks, and a pace of biological aging biomarker (DunedinPACE) among 44 OPLHIV in Eswatini. RESULTS: Age at HIV diagnosis was associated with Hannum epigenetic age acceleration (EAA) (ß-coefficient [95% Confidence Interval]; 0.53 [0.05, 1.00], p = 0.03) and longer duration since HIV diagnosis was associated with slower Hannum EAA (- 0.53 [- 1.00, - 0.05], p = 0.03). The average daily dietary intake of fruits and vegetables was associated with DunedinPACE (0.12 [0.03, 0.22], p = 0.01). The associations of Hannum EAA with the age at HIV diagnosis and duration of time since HIV diagnosis were attenuated when the average daily intake of fruits and vegetables or physical activity were included in our models. Diet and self-perceived quality of life measures modified the relationship between CD4+ T cell counts at participant enrollment and Hannum EAA. CONCLUSIONS: Epigenetic age is more advanced in OPLHIV in Eswatini in those diagnosed with HIV at an older age and slowed in those who have lived for a longer time with diagnosed HIV. Lifestyle and quality of life factors may differentially affect epigenetic aging in OPLHIV. To our knowledge, this is the first study to assess epigenetic aging in OPLHIV in Eswatini and one of the few in sub-Saharan Africa.

Hepatitis B virus infection (HBV) and HIV-HBV coinfection among men who have sex with men, transgender women, and genderqueer individuals in Harare and Bulawayo Zimbabwe, 2019.

Objectives: To measure HIV and Hepatitis B virus (HBV) prevalence and associated risk behaviors among men who have sex with men (MSM) and transgender women/genderqueer individuals (TGW/GQ) in Zimbabwe. Methods: We conducted a biobehavioral survey using respondent-driven sampling (RDS) among adult MSM and TGW/GQ in Harare and Bulawayo, Zimbabwe in 2019. Participants completed a questionnaire and underwent testing for HIV and HBV. Results: Overall, 1,510 (Harare: 694, Bulawayo 816) participants were enrolled and consented to testing; 3.8 % (58) tested positive for HBV, 22.5 % (339) tested positive for HIV, and 2.2 % (33) tested positive for both HIV and HBV. HBV prevalence was higher among participants with HIV compared to HIV-negative participants (9.7 % vs. 2.1 %, p < 0.0001). Overall, HBV prevalence was not statistically different between MSM and TGW/GQ (3.7 % vs 4.5 %, p = 0.49) nor between Harare and Bulawayo (3.3 % vs 4.3 %, p = 0.33). Conclusions: Our survey demonstrates the prevalence of HBV among MSM and TGW/GQ is lower than other estimates of HBV among MSM in Africa but remains high among our survey population living with HIV highlighting the need to expand HBV testing and treatment services, especially among people with HIV in Zimbabwe.

Factors Associated with Having both Male and Female Recent Sexual Partnerships Among Men Who Have Sex with Men in Harare and Bulawayo, Zimbabwe.

To better understand male and female sexual partnerships among men who have sex with men (MSM), we used data from a 2019 biobehavioral survey among MSM in Harare and Bulawayo, Zimbabwe to conduct bivariate analyses and multivariable logistic regression to determine whether sociodemographic characteristics and HIV-related factors were associated with having both male and female sexual partnerships within the last 6 months. Of included MSM (N = 1143), 31% reported both male and female partnerships in the last 6 months. Being married/cohabiting (adjusted odds ratio (aOR) = 8.58, 95% confidence interval (CI) = 4.92-14.95) or separated/divorced/widowed (aOR = 1.96, 95% CI = 1.24-3.08) vs. being single, and hazardous alcohol consumption (aOR = 1.58, 95% CI 1.19-2.09) were associated with higher odds of having both male and female recent partnerships. Being aged 35 + vs. 18-24 (aOR = 0.50, 95% CI = 0.31-0.81), condomless receptive anal intercourse at last sex with the main male partner (aOR = 0.43, 95% CI = 0.26-0.74), and positive HIV status (aOR = 0.46, 95% CI = 0.31-0.67) were associated with lower odds of recent male and female partnerships. MSM in Harare who reported harassment/abuse (aOR = 3.16, 95% CI = 1.72-5.79) had higher odds of both male and female partnerships than MSM in Bulawayo reporting harassment/abuse. The prevalence of both male and female recent partnerships (31%) was lower among MSM in this survey than in other biobehavioral surveys of MSM in sub-Saharan Africa. Findings suggest that MSM with recent male and female partnerships compared to MSM with only male recent partners have lower odds of positive HIV status and participate in behaviors that lower HIV risk; however, the direction of these relationships cannot be determined due to the cross-sectional nature of the data. The findings also suggest a possible connection between experiences of stigma of MSM behavior and not having both male and female partnerships that warrants further exploration. Accessible, stigma-free HIV testing and education programming that considers the potential overlap between the MSM and general populations via both male and female partnerships and the associated behaviors could be a key component of HIV elimination in Zimbabwe.

Epigenetic aging in older people living with HIV in Eswatini: a pilot study of HIV and lifestyle factors and epigenetic aging.

Background: People living with HIV (PLHIV) on effective antiretroviral therapy (ART) are living near-normal lives. Although they are less susceptible to AIDS-related complications, they remain highly vulnerable to non-communicable diseases (NCD). In this exploratory study of older PLHIV (OPLHIV) in Eswatini, we investigated whether biological aging (i.e., the difference between epigenetic age and chronological age, termed 'epigenetic age acceleration [EAA]') was associated with HIV-related parameters, and whether lifestyle factors modified these relationships. We calculated EAA focusing on the second-generation epigenetic clocks, PhenoAge and GrimAge, and a pace of aging biomarker (DunedinPACE) among 44 OPLHIV in Eswatini. Results: Among participants, the PhenoAge clock showed older epigenetic age (68 years old [63, 77]) but a younger GrimAge epigenetic age (median=56 years old [interquartile range=50, 61]) compared to the chronological age (59 years old [54, 66]). Participants diagnosed with HIV at an older age showed slower DunedinPACE (ß-coefficient [95% Confidence Interval]; -0.02 [-0.04, -0.01], p=0.002) and longer duration since HIV diagnosis was associated with faster DunedinPACE (0.02 [0.01, 0.04], p=0.002). The average daily dietary intake of fruits and vegetables was associated with faster DunedinPACE (0.12 [0.03, 0.22], p=0.01) and modified the relationship between HIV status variables (number of years living with HIV since diagnosis, age at HIV diagnosis, CD4+ T cell counts) and PhenoAge EAA, and DunedinPACE. Conclusions: Biological age is accelerated in OPLHIV in Eswatini, with those living with HIV for a longer duration at risk for faster biological aging. Lifestyle factors, especially healthier diets, may attenuate biological aging in OPLHIV. To our knowledge, this is the first study to assess biological aging in Eswatini and one of the few in sub-Saharan Africa.

An Evaluation of an Enhanced Model of Integrating Family Planning Into HIV Treatment Services in Zambia, April 2018-June 2019.

BACKGROUND: We designed and implemented an enhanced model of integrating family planning (FP) into existing HIV treatment services at 6 health facilities in Lusaka, Zambia. METHODS: The enhanced model included improving FP documentation within HIV monitoring systems, training HIV providers in FP services, offering contraceptives within the HIV clinic, and facilitated referral to community-based distributors. Independent samples of women living with HIV (WLHIV) aged ≥16 years were interviewed before and after intervention and their clinical data abstracted from medical charts. Logistic regression models were used to assess differences in key outcomes between the 2 periods. RESULTS: A total of 629 WLHIV were interviewed preintervention and 684 postintervention. Current FP use increased from 35% to 49% comparing the pre- and postintervention periods ( P = 0.0025). Increased use was seen for injectables (15% vs. 25%, P < 0.0001) and implants (5% vs. 8%, P > 0.05) but not for pills (10% vs. 8%, P < 0.05) or intrauterine devices (1% vs. 1%, P > 0.05). Dual method use (contraceptive + barrier method) increased from 8% to 18% ( P = 0.0003), whereas unmet need for FP decreased from 59% to 46% ( P = 0.0003). Receipt of safer conception counseling increased from 27% to 39% ( P < 0.0001). The estimated total intervention cost was $83,293 (2018 USD). CONCLUSIONS: Our model of FP/HIV integration significantly increased the number of WLHIV reporting current FP and dual method use, a met need for FP, and safer conception counseling. These results support continued efforts to integrate FP and HIV services to improve women's access to sexual and reproductive health services.

Progress towards the UNAIDS 90-90-90 targets among persons aged 50 and older living with HIV in 13 African countries.

INTRODUCTION: Achieving optimal HIV outcomes, as measured by global 90-90-90 targets, that is awareness of HIV-positive status, receipt of antiretroviral (ARV) therapy among aware and viral load (VL) suppression among those on ARVs, respectively, is critical. However, few data from sub-Saharan Africa (SSA) are available on older people (50+) living with HIV (OPLWH). We examined 90-90-90 progress by age, 15-49 (as a comparison) and 50+ years, with further analyses among 50+ (55-59, 60-64, 65+ vs. 50-54), in 13 countries (Cameroon, Cote d'Ivoire, Eswatini, Ethiopia, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe). METHODS: Using data from nationally representative Population-based HIV Impact Assessments, conducted between 2015and 2019, participants from randomly selected households provided demographic and clinical information and whole blood specimens for HIV serology, VL and ARV testing. Survey weighted outcomes were estimated for 90-90-90 targets. Country-specific Poisson regression models examined 90-90-90 variation among OPLWH age strata. RESULTS: Analyses included 24,826 HIV-positive individuals (15-49 years: 20,170; 50+ years: 4656). The first, second and third 90 outcomes were achieved in 1, 10 and 5 countries, respectively, by those aged 15-49, while OPLWH achieved outcomes in 3, 13 and 12 countries, respectively. Among those aged 15-49, women were more likely to achieve 90-90-90 targets than men; however, among OPLWH, men were more likely to achieve first and third 90 targets than women, with second 90 achievement being equivalent. Country-specific 90-90-90 regression models among OPLWH demonstrated minimal variation by age stratum across 13 countries. Among OLPWH, no first 90 target differences were noted by age strata; three countries varied in the second 90 by older age strata but not in a consistent direction; one country showed higher achievement of the third 90 in an older age stratum. CONCLUSIONS: While OPLWH in these 13 countries were slightly more likely than younger people to be aware of their HIV-positive status (first 90), this target was not achieved in most countries. However, OPLWH achieved treatment (second 90) and VL suppression (third 90) targets in more countries than PLWH <50. Findings support expanded HIV testing, prevention and treatment services to meet ongoing OPLWH health needs in SSA.

Recent HIV Infection Among Men Who Have Sex with Men, Transgender Women, and Genderqueer Individuals with Newly Diagnosed HIV Infection in Zimbabwe: Results from a Respondent-Driven Sampling Survey.

In Africa, rapid testing for recent HIV infection (RTRI) is being scaled up; however, use of the recent infection testing algorithm (RITA), which uses viral load (VL) to confirm RTRI-recent infections, is not a widespread practice. We present results of recently acquired HIV infections among men who have sex with men (MSM), transgender women, and genderqueer (TGW/GQ) individuals with newly diagnosed HIV infection in Zimbabwe as per the national approach (RTRI) and applying a RITA. In 2019, 1,538 MSM and TGW/GQ in Harare and Bulawayo, Zimbabwe were recruited to participate in a biobehavioral survey using respondent-driven sampling. Consenting participants received HIV testing and all HIV-positive specimens were tested with the RTRI Asanté HIV-1 Rapid Recency Assay, and for VL and CD4 count. RTRI-recent participants with unsuppressed VL (≥1,000 copies/mL) were classified as RITA-recent. Descriptive statistics were used to summarize results among RTRI-recent and RITA-recent participants. Among those tested for HIV (1,511/1,538), 22.5% (340/1,511) tested positive and of those, 55.0% (187/340) self-reported an HIV-negative or unknown status. Among these, 8.6% (16/187) were classified as RTRI-recent and 91.4% (171/187) were classified as RTRI-long term. After accounting for VL, RITA-recency was 1.1% (2/187). Two of 16 (12.5%) RTRI-recent infections were RITA-recent. VL among RITA-recent cases were 9,052 copies/mL and 40,694 copies/mL and both had CD4 counts <500. Data highlight misclassification of recent infections among MSM and TGW/GQ with newly diagnosed HIV infection using RTRI. With the incorporation of VL, >85% of RTRI-recent cases were reclassified as RITA-long term. True characterization of recent infections may not be possible without VL testing, which remains challenging in resource-limited settings.

Stigma, Social Cohesion, and HIV Risk Among Sexual and Gender Minorities in Two Cities in Zimbabwe.

Though stigma is a recognized contributor to the disproportionate HIV burden among sexual and gender minorities (SGM) in sub-Saharan Africa, data describing this association among Zimbabwean SGM are limited. We examined relationships between SGM stigma and HIV and the potential for social cohesion to moderate the association among Zimbabwean men who have sex with men, transgender women, and genderqueer individuals. Consenting participants (n = 1511) recruited through respondent-driven sampling for a biobehavioral survey in Harare and Bulawayo completed structured interviews and received HIV testing. Reported SGM stigma was common (68.9% in Harare and 65.3% in Bulawayo) and associated with HIV infection in Harare (adjusted prevalence ratio [aPR] = 1.82, 95% confidence interval [CI] = 1.27-2.62) and Bulawayo (aPR = 1.51, 95% CI = 1.15-2.00) in relative risk regression. Social cohesion did not moderate these relationships. Findings demonstrate stigma's association with HIV vulnerability among Zimbabwean SGM, highlighting the need for stigma-mitigation to reduce HIV transmission in this population.

Engagement in the pre-exposure prophylaxis (PrEP) cascade among a respondent-driven sample of sexually active men who have sex with men and transgender women during early PrEP implementation in Zimbabwe.

INTRODUCTION: Zimbabwe is scaling up pre-exposure prophylaxis (PrEP) for key populations, including men who have sex with men (MSM) and transgender women (TGW). To assess implementation and inform HIV programming, we evaluated gaps in PrEP awareness, uptake and use, and correlates of awareness and uptake among a sample of MSM, TGW and genderqueer individuals (GQ) in Harare and Bulawayo, Zimbabwe. METHODS: Respondent-driven sampling was used to recruit 1194 MSM and 344 TGW/GQ aged ≥18 to participate in a cross-sectional survey assessing HIV-related outcomes in 2019. Consenting participants completed a questionnaire on socio-demographic information, sexual risk practices and engagement in HIV services and underwent HIV testing. Descriptive statistics were used to assess the PrEP cascade. Multiple logistic regression models were used to identify factors associated with PrEP awareness and uptake among HIV-negative participants. Data were unweighted as the sample did not reach convergence on key estimates. RESULTS: Among the 1167 HIV-negative participants, most (79.2%) were MSM compared to TGW/GQ (20.8%). Median age was 24 years. Overall, 45.8% were aware of PrEP and of those, 31.3% had ever taken PrEP. Most (71.1%) reporting never taking PrEP were willing to start PrEP; the main reasons for never starting PrEP included not knowing where to access it (24.8%) and fearing side effects (20.4%). Among those who had ever taken PrEP, 74.9% had taken PrEP in the last 6 months; of these, 42.4% had taken PrEP the day of or day preceding the survey. Side effects represented the most common (59.5%) reason for discontinuing PrEP. MSM (adjusted odds ratio [aOR]: 2.5, 95% confidence interval [CI]: 1.8-3.6) and TGW/GQ in Harare (aOR: 3.1, 95% CI: 2.1-4.7), and TGW/GQ in Bulawayo (aOR: 2.4, 95% CI: 1.1-5.3) had higher awareness of PrEP than MSM in Bulawayo. Overall, TGW/GQ were more likely to have ever taken PrEP compared to MSM (aOR: 1.6, 95% CI: 1.01-2.4). CONCLUSIONS: Findings emphasize the need for tailored interventions to promote PrEP among key populations. As HIV programs in Zimbabwe continue to expand PrEP services, these data, including barriers to starting and continuing PrEP, can inform strategies to address gaps along the PrEP cascade.

HIV care cascade and associated factors among men who have sex with men, transgender women, and genderqueer individuals in Zimbabwe: findings from a biobehavioural survey using respondent-driven sampling.

BACKGROUND: Globally, men who have sex with men (MSM), transgender women, and genderqueer individuals are at greater risk for HIV than the general population although little data are available from these groups in Zimbabwe, a country with a national adult HIV prevalence of 12·9%. We aimed to examine progress towards the UNAIDS 90-90-90 treatment targets and factors associated with meeting the targets among a sample of MSM, transgender women, and genderqueer individuals in Zimbabwe. METHODS: In this cross-sectional survey in 2019, we used respondent-driven sampling to identify MSM, transgender women, and genderqueer individuals aged at least 18 years to participate in a biobehavioural survey in Harare and Bulawayo, Zimbabwe. Participants were eligible to participate if they were assigned male at birth; had engaged in anal or oral sex with a man in the past 12 months; resided in Harare or Bulawayo for at least 1 month; spoke English, Shona, or Ndebele; provided written informed consent; and were in possession of a valid recruitment coupon if applicable. Enrolled participants completed a questionnaire and underwent HIV testing, and off-site viral load testing was done on all HIV-positive samples. Unweighted bivariate analyses and multivariable logistic regression models were used to evaluate the association of sociodemographic, behavioural, and other factors with HIV-positive status awareness among MSM, transgender women, and genderqueer individuals, and with viral load suppression among MSM. Analyses were done firstly using self-reported information and then by classifying those with a viral load of less than 200 copies per mL as being aware of their status and on treatment (viral load recategorisation). FINDINGS: Among MSM, 248 (21%; 95% CI 19-24) of 1176 tested positive for HIV. Of those who tested positive, based on self-report, 119 (48%; 95% CI 42-54) reported knowing their HIV status, of whom 112 (94%; 88-98) reported using antiretroviral therapy (ART), of whom 89 (79%; 71-87) had viral load suppression. Based on viral load recategorisation, 180 (73%; 67-78) of 248 MSM testing HIV positive reported knowing their HIV status, of whom 174 (97%; 93-99) reported using ART, of whom 151 (87%; 81-91) had viral load suppression. 92 (28%; 23-33) of 335 transgender women and genderqueer individuals tested positive for HIV. Based on self-reports from these individuals 34 (37%; 27-48) of 92 participants reported knowing their HIV status, of whom 31 (91%; 76-98) reported using ART, of whom 27 (87%; 70-96%) had viral load suppression. Based on viral load recategorisation of data from transgender women and genderqueer participants, 53 (58%; 47-58) of 92 reported awareness of their HIV status, of whom 50 (94%; 84-99) reported using ART, of whom 46 (92%; 81-98) had viral load suppression. HIV-positive MSM aged 18-24 years had lower odds of being aware of their status than those aged at least 35 years (adjusted odds ratio [aOR] 0·34; 95% CI 0·13-0·92), as did HIV-positive MSM aged 25-34 years (aOR 0·26; 0·12-0·56). HIV-positive MSM aged 18-24 years also had a lower odds of having viral load suppression than those aged 35 years and older (aOR 0·35; 0·16-0·78), as did those aged 25-34 years (aOR 0·36; 0·19-0·67). No factors were significantly associated with awareness among transgender women and genderqueer individuals in multivariable models. INTERPRETATION: Our survey showed that HIV prevalence was high and the largest difference between our results and the 90-90-90 treatment targets was in HIV status awareness, indicating the need for improvements in engaging MSM (especially young MSM), transgender women, and genderqueer individuals in HIV testing services. FUNDING: US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.

High Burden of Active Syphilis and Human Immunodeficiency Virus/Syphilis Coinfection Among Men Who Have Sex With Men, Transwomen, and Genderqueer Individuals in Zimbabwe.

BACKGROUND: Syphilis increases human immunodeficiency virus (HIV) acquisition risk and impacts the immunologic and virologic response among people living with HIV (PLHIV). We assessed the prevalence of active or current syphilis and HIV/syphilis and their correlates among men who have sex with men (MSM), transwomen, and genderqueer (TGW/GQ) individuals in Zimbabwe. METHODS: Among a respondent-driven sample of MSM and TGW/GQ who were tested for HIV and syphilis in Harare and Bulawayo, Zimbabwe in 2019 (n = 1511), multiple logistic regression was used to assess correlates of active syphilis. Unadjusted logistic regression was used among PLHIV (n = 340) due to small sample size. All analyses were unweighted as data did not reach convergence for HIV. RESULTS: Prevalence of active syphilis overall and among PLHIV was 5.5% and 10.1%, respectively, in Harare, and 5.6% and 11.0%, respectively, in Bulawayo. Participants were more likely to have active syphilis if they were PLHIV (adjusted odds ratio [aOR], 2.2; 95% confidence interval [CI], 1.4-3.6), aged 25-34 years (aOR, 2.2 years; 95% CI, 1.3-3.8 years; reference, 18-24 years), or self-report sexually transmitted infection symptoms (aOR, 1.8; 95% CI, 1.1-3.0). Compared with Bulawayo TGW/GQ, MSM in Harare (aOR, 0.2; 95% CI, 0.1-0.5) and Bulawayo (aOR, 0.2; 95% CI, 0.1-0.4), and TGW/GQ in Harare (aOR, 0.2; 95% CI, 0.1-0.6) were less likely to have active syphilis. Among PLHIV, coinfection was 13.0% among TGW/GQ and 9.7% among MSM. Odds of coinfection were higher for those aged 25 to 34 years (OR, 3.7 years; 95% CI, 1.2-11.1 years) and lower among Harare MSM (OR, 0.2; 95% CI, 0.1-0.7), Bulawayo MSM (OR, 0.1; 95% CI, 0.0-0.4), and Harare TGW/GQ (OR, 0.1; 95% CI, 0.0-0.4) compared with Bulawayo TGW/GQ. CONCLUSIONS: Findings highlight a high burden of syphilis among MSM and TGW/GQ and underscore the importance of HIV/syphilis detection and improved service delivery for these groups.

Association of sociodemographic factors with needle sharing and number of sex partners among people who inject drugs in Egypt.

People who inject drugs (PWID) are at a high risk for HIV. We conducted an evaluation of socio-demographic factors associated with injecting and sexual behaviour among PWID who had two or more visits at a drug outreach clinic in Cairo, Egypt from 2013 to 2017. Routinely collected information on socio-demographics and HIV risk behaviours were abstracted from client records. Bivariate analysis and logistic regression were conducted to evaluate associations between socio-demographics and HIV risk factors. All PWID who tested HIV-positive at the initial visit were excluded from analyses. PWID who were married were more likely to share needles or syringes in the last month of their baseline visit [adjusted odds ratio (aOR) = 4.3, 95% confidence interval (CI) = 1.4-13.1] as were unemployed PWID [aOR = 3.9, 95% CI = 1.5-10.3]. Married PWID were less likely to discontinue sharing needles/syringes [aOR = 0.4, 95% CI = 0.2-0.8] as were those living outside of the Shobra, downtown, and Imbabah districts within Greater Cairo [aOR = 0.2, 95% CI = 0.1-0.5]. No significant associations were found between socio-demographics and number of sex partners in the six months prior to the initial visit. At follow-up visit, 4.4% tested HIV-positive for an incidence rate of 3.9 per 100 person years. Sociodemographic factors should be considered when designing preventive services for PWID.

Effects of the Coronavirus Disease 2019 Pandemic on Human Immunodeficiency Virus Services: Findings from 11 Sub-Saharan African Countries.

BACKGROUND: Due to concerns about the effects of the coronavirus disease 2019 (COVID-19 pandemic on health services, we examined its effects on human immunodeficiency virus (HIV) services in sub-Saharan Africa. METHODS: Quarterly data (Q1, 10/2019-12/2019; Q2, 1/2020-3/2020; Q3, 4/2020-6/2020; Q4, 7/2020-9/2020) from 1059 health facilities in 11 countries were analyzed and categorized by stringency of pandemic measures. We conducted a difference-in-differences assessment of HIV service changes from Q1-Q2 to Q3-Q4 by higher vs lower stringency. RESULTS: There was a 3.3% decrease in the number HIV tested from Q2 to Q3 (572 845 to 553 780), with the number testing HIV-positive declining by 4.9% from Q2 to Q3. From Q3 to Q4, the number tested increased by 10.6% (612 646), with an increase of 8.8% (23 457) in the number testing HIV-positive with similar yield (3.8%). New antiretroviral therapy (ART) initiations declined by 9.8% from Q2 to Q3 but increased in Q4 by 9.8%. Across all quarters, the number on ART increased (Q1, 419 028 to Q4, 476 010). The number receiving viral load (VL) testing in the prior 12 months increased (Q1, 255 290 to Q4, 312 869). No decrease was noted in VL suppression (Q1, 87.5% to Q4, 90.1%). HIV testing (P < .0001) and new ART initiations (P = .001) were inversely associated with stringency. CONCLUSIONS: After initial declines, rebound was brisk, with increases noted in the number HIV tested, newly initiated or currently on ART, VL testing, and VL suppression throughout the period, demonstrating HIV program resilience in the face of the COVID-19 crisis.

Characterizing acceptable and appropriate implementation strategies of a biobehavioral survey among men who have sex with men and others assigned male who have sex with men in Zimbabwe.

Key populations including men who have sex with men (MSM), female sex workers, people who inject drugs, transgender persons, and prisoners account for nearly 50% of new HIV infections globally. To inform the HIV response and monitor trends in HIV prevalence and incidence among key populations, countries have increased efforts to implement biobehavioral surveys (BBS) with these groups as part of routine surveillance. Yet the marginalized nature of populations participating in a BBS requires contextually acceptable and appropriate strategies for effective implementation. We conducted a formative assessment to inform the first BBS conducted with MSM and others assigned male who have sex with men (OAMSM) in Zimbabwe, where same-sex sexual behaviors are illegal and highly stigmatized and describe applications of our findings. Qualitative data were collected through four focus groups with 32 MSM/OAMSM and 25 in-depth interviews (15 MSM/OAMSM, 10 service providers/gatekeepers) from December 2018 to January 2019. Rapid assessment techniques were employed including rapid identification of themes from audio recordings and review of detailed field notes and memos to identify key themes. Findings from this assessment included contextually relevant considerations including behaviors and terminology to avoid when working with MSM/OAMSM in Zimbabwe, appropriate compensation amounts for survey participation, proposed data collection sites, and differences in sexual openness, marital status, and networks among younger and older MSM/OAMSM. Participants also reported strong network ties suggesting respondent-driven sampling-a peer chain referral approach-to be an appropriate recruitment method in this context. Taken together, these findings highlighted key considerations and strategies for implementation to ensure the subsequent BBS in Zimbabwe was both acceptable and appropriate. These results and applications of these results are important for informing surveillance efforts and broader HIV-related engagement efforts among MSM/OAMSM in Zimbabwe as well as in other contextually similar countries in Southern Africa.

Breast Cancer Early Detection in Eswatini: Evaluation of a Training Curriculum and Patient Receipt of Recommended Follow-Up Care.

[Figure: see text].

Patient costs for prevention of mother-to-child HIV transmission and antiretroviral therapy services in public health facilities in Zimbabwe.

Zimbabwe has made large strides in addressing HIV. To ensure a continued robust response, a clear understanding of costs associated with its HIV program is critical. We conducted a cross-sectional evaluation in 2017 to estimate the annual average patient cost for accessing Prevention of Mother-To-Child Transmission (PMTCT) services (through antenatal care) and Antiretroviral Treatment (ART) services in Zimbabwe. Twenty sites representing different types of public health facilities in Zimbabwe were included. Data on patient costs were collected through in-person interviews with 414 ART and 424 PMTCT adult patients and through telephone interviews with 38 ART and 47 PMTCT adult patients who had missed their last appointment. The mean and median annual patient costs were examined overall and by service type for all participants and for those who paid any cost. Potential patient costs related to time lost were calculated by multiplying the total time to access services (travel time, waiting time, and clinic visit duration) by potential earnings (US$75 per month assuming 8 hours per day and 5 days per week). Mean annual patient costs for accessing services for the participants was US$20.00 [standard deviation (SD) = US$80.42, median = US$6.00, range = US$0.00-US$12,18.00] for PMTCT and US$18.73 (SD = US$58.54, median = US$8.00, range = US$0.00-US$ 908.00) for ART patients. The mean annual direct medical costs for PMTCT and ART were US$9.78 (SD = US$78.58, median = US$0.00, range = US$0.00-US$ 90) and US$7.49 (SD = US$60.00, median = US$0.00) while mean annual direct non-medical cost for US$10.23 (SD = US$17.35, median = US$4.00) and US$11.23 (SD = US$25.22, median = US$6.00, range = US$0.00-US$ 360.00). The PMTCT and ART costs per visit based on time lost were US$3.53 (US$1.13 to US$8.69) and US$3.43 (US$1.14 to US$8.53), respectively. The mean annual patient costs per person for PMTCT and ART in this evaluation will impact household income since PMTCT and ART services in Zimbabwe are supposed to be free.

HIV and aging among adults aged 50 years and older on antiretroviral therapy in Eswatini.

Background: Antiretroviral therapy (ART) has decreased HIV-related morbidity and mortality and increased life expectancy of people living with HIV (PLHIV). Globally, the number of older PLHIV (OPLHIV; ≥50 years) is growing and predicted to increase substantially in coming years. In sub-Saharan Africa, where the majority of OPLHIV reside, there are limited data on the health and well-being of OPLHIV.Methods: We conducted an exploratory descriptive study that included structured interviews with 50 OPLHIV receiving ART at an outpatient HIV clinic in Eswatini and in-depth qualitative interviews (IDIs) with a sub-set of ten participants to elicit their experiences of living with HIV as an older adult, including quality of life, physical health, and mental health. Quantitative analyses were performed to obtain both descriptive statistics and cross-tabulations. A thematic analysis of IDI narratives was conducted based on three levels of the socio-ecological model to identify sub-themes and response patterns.Results: All study participants were virally suppressed. Self-reported non-communicable disease (NCD) risk factors and markers were common, with 40% (n = 20) reporting being current or former smokers, 0% consuming the recommended servings of fruits and vegetables per day, and 57% (n = 28 of 49 reporting screening) reporting having hypertension. However, the majority (88%; 44 of 50) had sufficient physical activity; most of the activity was in the work domain. Slightly more than one-third (38%; 13 of 34 tested) had a high random blood sugar level. Barriers to living with HIV were primarily structural (food insecurity, unemployment, access to transportation and health care).Conclusions: OPLHIV should be screened for NCDs, and services for NCDs should ideally be integrated with HIV services. While all participants had controlled HIV, this study highlights the need for strategies that facilitate OPLHIV's HIV service utilisation. With the increasing numbers of OPLHIV, these issues cannot be ignored.

Accelerometer and Survey Data on Patterns of Physical Inactivity in New York City and the United States.

OBJECTIVE: Inactive lifestyles contribute to health problems and premature death and are influenced by the physical environment. The primary objective of this study was to quantify patterns of physical inactivity in New York City and the United States by combining data from surveys and accelerometers. METHODS: We used Poisson regression models and self-reported survey data on physical activity and other demographic characteristics to predict accelerometer-measured inactivity in New York City and the United States among adults aged ≥18. National data came from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Surveys. New York City data came from the 2010-2011 New York City Physical Activity and Transit survey. RESULTS: Self-reported survey data indicated no significant differences in inactivity between New York City and the United States, but accelerometer data showed that 53.1% of persons nationally, compared with 23.4% in New York City, were inactive ( P < .001). New Yorkers reported a median of 139 weekly minutes of transportation activity, compared with 0 minutes nationally. Nationally, 50.0% of self-reported activity minutes came from recreation activity, compared with 17.5% in New York City. Regression models indicated differences in the association between self-reported minutes of transportation and recreation and accelerometer-measured inactivity in the 2 settings. CONCLUSIONS: The prevalence of physical inactivity was higher nationally than in New York City. The largest difference was in walking behavior indicated by self-reported transportation activity. The study demonstrated the feasibility of combining accelerometer and survey measurement and that walkable environments promote an active lifestyle.