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AbstractIntroductionSuboptimal male engagement in HIV programmes is a persistent challenge, leading to lower coverage of HIV testing, prevention and treatment services, and to worse outcomes for men. Differentiated service delivery models, such as peer‐led community antiretroviral refill groups (CARGs), offer the opportunity to enhance patient satisfaction, retention and treatment outcomes. We conducted an exploratory qualitative study to identify facilitators and barriers to CARG participation by HIV‐positive men, with inputs from recipients of HIV care, community members, healthcare workers (HCWs), donors and policymakers.MethodsBetween July and October 2017, we conducted 20 focus group discussions (FGDs) with 147 adults living with HIV, including men and women enrolled in CARGs and men not enrolled in CARGs, and 46 key informant interviews (KIIs) with policymakers, donors, HCWs and community members. FGDs and KIIs were recorded, transcribed and translated. A constant comparison approach was used to triangulate findings and identify themes related to male engagement in CARGs in rural Zimbabwe.ResultsCARG participants, policymakers, donors, HCWs, and community members noted many advantages to CARG participation, including convenience, efficiency, solidarity and mutual psychosocial support. Although those familiar with CARGs reported that these groups decreased HIV‐related stigma, concerns about stigma and privacy were perceived to be the primary reason for men's non‐participation. Other important barriers to male enrolment included lack of awareness of CARGs, misunderstanding of how CARGs operate, few perceived benefits and lack of flexibility in CARG implementation.ConclusionsMore effective educational and awareness campaigns, community‐based anti‐stigma campaigns, more flexible CARG designs, and provision of financial and/or in‐kind support to CARG members could mitigate many of the barriers to male enrolment in CARGs. Men may also prefer alternative differentiated service delivery models that are facility‐based and/or do not require group participation.

Abstract Background HIV incidence is a useful tool for improving the targeting of populations for interventions and assessing the effectiveness of prevention strategies. A study in Harare, Zimbabwe reported cumulative incidences of 3.4% (3.0-3.8) and 6.5% (5.7-7.4) among post-partum women followed for 12 and 24 months respectively between 1997 and 2001. According to a Government report on HIV the prevalence of HIV fell from about 30% in 1999 to 14% in 2008. The purpose of this study was to determine the incidence of HIV-1 among women enrolled during late pregnancy and followed for six years after childbirth and to identify risk factors associated with acquisition of HIV. Methods HIV-uninfected pregnant women around 36 weeks gestation were enrolled from primary health care clinics in peri-urban settlements around Harare and followed-up for up to six years after childbirth. At every visit a questionnaire was interview-administered to obtain socio-demographic data and sexual history since the previous visit. A genital examination was performed followed by the collection of biological samples. Results Of the 552 HIV-uninfected women 444 (80.4%) were seen at least twice during the six years follow-up and 39 acquired HIV, resulting in an incidence (95% CI) of 2.3/100 woman-years-at-risk (wyar) (1.1-4.1). The incidence over the first nine months post-partum was 5.7/100 wyar (3.3-8.1). A greater proportion of teenagers (15.3%) contributed to a high incidence rate of 2.9/100 (0.6-8.7) wyar. In multivariate analysis lower education of participant, RR 2.1 (1.1-4.3) remained significantly associated with HIV acquisition. Other risk factors associated with acquisition of HIV-1 in univariate analysis were young age at sexual debut, RR 2.3, (1.0-5.6) and having children with different fathers, RR 2.7(1.3-5.8). Women that knew that their partners had other sexual partners were about four times more likely to acquire HIV, RR 3.8 (1.3-11.2). Conclusion The incidence of HIV was high during the first nine months after childbirth. Time of seroconversion, age and educational level of seroconverter are important factors that must be considered when designing HIV intervention strategies.

Background HIV incidence is a useful tool for improving the targeting of populations for interventions and assessing the effectiveness of prevention strategies. A study in Harare, Zimbabwe reported cumulative incidences of 3.4% (3.0-3.8) and 6.5% (5.7-7.4) among post-partum women followed for 12 and 24 months respectively between 1997 and 2001. According to a Government report on HIV the prevalence of HIV fell from about 30% in 1999 to 14% in 2008. The purpose of this study was to determine the incidence of HIV-1 among women enrolled during late pregnancy and followed for six years after childbirth and to identify risk factors associated with acquisition of HIV. Methods HIV-uninfected pregnant women around 36 weeks gestation were enrolled from primary health care clinics in peri-urban settlements around Harare and followed-up for up to six years after childbirth. At every visit a questionnaire was interview-administered to obtain socio-demographic data and sexual history since the previous visit. A genital examination was performed followed by the collection of biological samples. Results Of the 552 HIV-uninfected women 444 (80.4%) were seen at least twice during the six years follow-up and 39 acquired HIV, resulting in an incidence (95% CI) of 2.3/100 woman-years-at-risk (wyar) (1.1-4.1). The incidence over the first nine months post-partum was 5.7/100 wyar (3.3-8.1). A greater proportion of teenagers (15.3%) contributed to a high incidence rate of 2.9/100 (0.6-8.7) wyar. In multivariate analysis lower education of participant, RR 2.1 (1.1-4.3) remained significantly associated with HIV acquisition. Other risk factors associated with acquisition of HIV-1 in univariate analysis were young age at sexual debut, RR 2.3, (1.0-5.6) and having children with different fathers, RR 2.7(1.3-5.8). Women that knew that their partners had other sexual partners were about four times more likely to acquire HIV, RR 3.8 (1.3-11.2). Conclusion The incidence of HIV was high during the first nine months after childbirth. Time of seroconversion, age and educational level of seroconverter are important factors that must be considered when designing HIV intervention strategies.

AbstractIntroductionWe 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.MethodsA 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.ResultsAmong 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).ConclusionsFindings 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.

AbstractIntroductionTuberculosis (TB) causes one‐third of HIV‐related deaths worldwide, making TB preventive treatment (TPT) a critical element of HIV programmes. Approximately 16% of people living with HIV (PLHIV) on antiretrovirals in Zimbabwe are enrolled in the Fast Track (FT) differentiated service delivery model, which includes multi‐month dispensing of antiretrovirals and quarterly health facility (HF) visits. We assessed the feasibility and acceptability of utilizing FT to deliver 3HP (3 months of once‐weekly rifapentine and isoniazid) for TPT by aligning TPT and HIV visits, providing multi‐month dispensing of 3HP, and using phone‐based monitoring and adherence support.MethodsWe recruited a purposive sample of 50 PLHIV enrolled in FT at a high‐volume HF in urban Zimbabwe. At enrolment, participants provided written informed consent, completed a baseline survey, and received counselling, education and a 3‐month supply of 3HP. A study nurse mentor called participants at weeks 2, 4 and 8 to monitor and support adherence and side effects. When participants returned for their routine 3‐month FT visit, they completed another survey, and study staff conducted a structured medical record review. In‐depth interviews were conducted with providers who participated in the pilot.ResultsParticipants were enrolled between April and June 2021 and followed through September 2021. Median age = 32 years (IQR 24,41), 50% female, median time in FT 1.8 years (IQR 0.8,2.7). Forty‐eight participants (96%) completed 3HP in 13 weeks; one completed in 16 weeks, and one stopped due to jaundice. Most participants (94%) reported "always" or "almost always" taking 3HP correctly. All reported they were very satisfied with the counselling, education, support and quality of care they received from providers and FT service efficiency. Almost all (98%) said they would recommend it to other PLHIV. Challenges reported included pill burden (12%) and tolerability (24%), but none had difficulty with phone‐based counselling or wished for additional HF‐based visits.DiscussionUsing FT to deliver 3HP was feasible and acceptable. Some reported tolerability challenges but 98% completed 3HP, and all appreciated the efficiency of aligning TPT and HIV HF visits, multi‐month dispensing and phone‐based counselling.ConclusionsScaling up this approach could expand TPT coverage in Zimbabwe.

AbstractIntroductionZimbabwe 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.MethodsRespondent‐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.ResultsAmong 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).ConclusionsFindings 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.

BackgroundSubstantial heterogeneity in HIV prevalence has been observed within sub‐Saharan Africa. It is not clear which factors can explain these differences. Our aim was to identify risk factors that could explain the large differences in HIV‐1 prevalence among pregnant women in Harare, Zimbabwe, and Moshi, Tanzania.MethodsCross‐sectional data from a two‐centre study that enrolled pregnant women in Harare (N = 691) and Moshi (N = 2654) was used. Consenting women were interviewed about their socio‐demographic background and sexual behaviour, and tested for presence of sexually transmitted infections and reproductive tract infections. Prevalence distribution of risk factors for HIV acquisition and spread were compared between the two areas.ResultsThe prevalence of HIV‐1 among pregnant women was 26% in Zimbabwe and 7% in Tanzania. The HIV prevalence in both countries rises constantly with age up to the 25‐30 year age group. After that, it continues to rise among Zimbabwean women, while it drops for Tanzanian women. Risky sexual behaviour was more prominent among Tanzanians than Zimbabweans. Mobility and such infections as HSV‐2, trichomoniasis and bacterial vaginosis were more prevalent among Zimbabweans than Tanzanians. Reported male partner circumcision rates between the two countries were widely different, but the effect of male circumcision on HIV prevalence was not apparent within the populations.ConclusionsThe higher HIV‐1 prevalence among pregnant women in Zimbabwe compared with Tanzania cannot be explained by differences in risky sexual behaviour: all risk factors tested for in our study were higher for Tanzania than Zimbabwe. Non‐sexual transmission of HIV might have played an important role in variation of HIV prevalence. Male circumcision rates and mobility could contribute to the rate and extent of spread of HIV in the two countries.