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Introduction: Young women who sell sex (YWSS) are at disproportionate risk of HIV. Reducing YWSS' vulnerability requires engaging their male sexual partners. To achieve this, we need to understand the characteristics and dynamics of their sexual partnerships to inform effective interventions. Methods: We conducted a mixed-methods study to compare YWSS' qualitative descriptions of male partners with categories reported in a behavioral survey. Data were drawn from enrollment into an evaluation of the DREAMS initiative in Zimbabwe in 2017. As part of a respondent-driven sampling survey, we recruited 40 seed participants from 2 intervention and 4 comparison sites. We conducted semistructured interviews with 19 "seeds," followed by a behavioral survey with 2387 YWSS. We interpreted quantitative and qualitative data together to understand how YWSS perceived male sexual partners, assess how well survey variables related to narrative descriptions, and describe patterns of risk behavior within partnerships. Results: Qualitative data suggest survey categories "husband" and "client" reflect YWSS' perceptions but "regular partner/boyfriend" and "casual partner" do not. In interviews, use of the term "boyfriend" was common, describing diverse relationships with mixed emotional and financial benefits. More than 85% of male partners provided money to YWSS, but women were less likely to report condomless sex with clients than regular partners (11% vs 37%) and more likely to report condomless sex with partners who ever forced them to have sex (37% vs 21%). Conclusions: Reducing HIV risk among YWSS requires prevention messages and tools that recognize diverse and changing vulnerability within and between sexual relationships with different male partners. [ABSTRACT FROM AUTHOR]

Introduction: Adolescent girls and young women (AGYW), including those who sell sex in sub‐Saharan Africa, are especially vulnerable to HIV. Reaching them with effective prevention is a programmatic priority. The HIV prevention cascade can be used to track intervention coverage, and identify gaps and opportunities for programme strengthening. The aim of this study was to characterise gaps in condom use and identify reasons underlying these gaps among young women who sell sex (YWSS) in Zimbabwe using data from enrolment into an impact evaluation of the DREAMS programme. DREAMS provided a package of biomedical, social and economic interventions to AGYW aged 10 to 24 with the aim of reducing HIV incidence. Methods: In 2017, we recruited YWSS aged 18 to 24 using respondent‐driven sampling in six sites across Zimbabwe. We measured knowledge about efficacy of, access to, and effective (consistent) use of condoms with the most recent three sexual partners, separately by whether YWSS self‐identified as female sex workers (FSW) or not. Among YWSS without knowledge about efficacy of, not having access to, and not effectively using condoms, we described the potential reasons underlying the gaps in the condom cascade. To identify socio‐demographic characteristics associated with effective condom use, we used logistic regression modelling. All analyses were RDS‐II weighted and restricted to YWSS testing HIV‐negative at enrolment. Results: We enrolled 2431 YWSS. Among 1842 (76%) YWSS testing HIV‐negative, 66% (n = 1221) self‐identified as FSW. 89% of HIV‐negative YWSS demonstrated knowledge about efficacy of condoms, 80% reported access to condoms and 58% reported using condoms consistently with the three most recent sexual partners. Knowledge about efficacy of and effective use of condoms was similar regardless of whether or not YWSS self‐identified as FSW, but YWSS self‐identifying as FSW reported better access to condoms compared to those who did not (87% vs 68%; age‐ and site‐adjusted (adjOR) = 2.69; 95% CI: 2.01 to 3.60; p < 0.001). Women who reported experiencing sexual violence in the past year and common mental disorder in the past week were less likely to use condoms consistently (43% vs. 60%; adjOR = 0.49; 95% CI: 0.35 to 0.68; p < 0.001) and (51% vs. 61%; adjOR = 0.76; 95% CI: 0.60 to 0.97; p = 0.029), respectively. Conclusions: Despite high knowledge about efficacy of and access to condoms, there remain large gaps in self‐reported consistent condom use among YWSS. Addressing the structural determinants of YWSS' inconsistent condom use, including violence, could reduce this gap. YWSS who do not self‐identify as FSW have less access to condoms and may require additional programmatic intervention. [ABSTRACT FROM AUTHOR]

Background: "Determined, Resilient, AIDS-free, Mentored and Safe" (DREAMS) is a package of biomedical, social and economic interventions offered to adolescent girls and young women aged 10-24 years with the aim of reducing HIV incidence. In four of the six DREAMS districts in Zimbabwe, DREAMS includes an offer of oral pre-exposure prophylaxis (DREAMS+PrEP), alongside interventions to support demand and adherence, to women aged 18-24 who are at highest risk of HIV infection, including young women who sell sex (YWSS). This evaluation study addresses the question: does the delivery of DREAMS+PrEP through various providers reduce HIV incidence among YWSS Zimbabwe? We describe our approach to designing a rigorous study to assess whether DREAMS+PrEP had an impact on HIV incidence.Methods: The study design needed to account for the fact that: 1) DREAMS+PrEP was non-randomly allocated; 2) there is no sampling frame for the target population for the evaluation; 3) there are a small number of DREAMS districts (N = 6), and 4) DREAMS+PrEP is being implemented by various providers. The study will use a cohort analysis approach to compare HIV incidence among YWSS in two DREAMS+PrEP districts to HIV incidence among YWSS in non-DREAMS comparison sites. YWSS will be referred to services and recruited into the cohort through a network-based (respondent-driven) recruitment strategy, and followed-up 12- and 24-months after enrolment. Women will be asked to complete a questionnaire and offered HIV testing. Additional complications of this study include identifying comparable populations of YWSS in the DREAMS+PrEP and non-DREAMS comparison sites, and retention of YWSS over the 24-month period. The primary outcome is HIV incidence among YWSS HIV-negative at study enrolment measured by repeat, rapid HIV testing over 24-months. Inference will be based on plausibility that DREAMS+PrEP had an impact on HIV incidence. A process evaluation will be conducted to understand intervention implementation, and document any contextual factors determining the success or failure of intervention delivery.Discussion: HIV prevention products of known efficacy are available. Innovative studies are needed to provide evidence of how to optimise product use through combination interventions to achieve population impact within different contexts. We describe the design of such a study. [ABSTRACT FROM AUTHOR]

Introduction: Across sub‐Saharan Africa, selling sex puts young women at high risk of HIV. Some young women who sell sex (YWSS) may self‐identify as sex workers, while others may not, having implications for how to reach them with HIV prevention. We describe characteristics, sexual behaviours and health service use of YWSS in Zimbabwe, comparing women who identified as female sex workers (FSW) and women who did not (non‐identifying‐YWSS), and explore factors associated with HIV infection. Methods: We analysed data from respondent‐driven sampling (RDS) surveys among YWSS aged 18 to 24 implemented in six sites in Zimbabwe from April to July 2017. RDS was used to enrol YWSS into an impact evaluation of the multi‐country DREAMS (Determined, Resilient, Empowered, AIDS‐free, Mentored and Safe) Partnership, which provides comprehensive HIV prevention programming to adolescent girls and young women. Women completed an interviewer‐administered questionnaire and were offered HIV testing services. We used logistic regression (RDS‐II‐weighted, normalized by site) to identify factors associated with prevalent HIV infection. Results: Forty‐four seeds recruited 2387 YWSS. RDS‐adjusted HIV prevalence was 24%; 67% of women identified as FSW. FSW were older and had lower educational attainment than non‐identifying‐YWSS. While 40% of FSW reported 10+ clients in the previous month, 9% of non‐identifying‐YWSS did so. FSW were more likely to have accessed HIV‐related services, including HIV testing in the last six months (FSW: 70%; non‐identifying‐YWSS: 60%). Over half of all YWSS described selling sex as their main financial support (FSW: 88%; non‐identifying YWSS: 54%). Increasing age, lower educational attainment, younger age of first selling sex and higher number of clients in the previous month were associated with prevalent HIV. Conclusions: YWSS in Zimbabwe have a high prevalence of HIV, reported high numbers of sexual partners and depend financially on selling sex. Non‐identifying‐YWSS differed socio‐demographically to FSW, yet factors associated with HIV risk were similar for all women. Women not identifying as FSW were less likely to access services, suggesting they should be prioritized for HIV prevention. Network‐based recruitment may enhance their inclusion in programmes, like DREAMS, which aim to reach young women at highest‐risk with comprehensive health, HIV prevention and social protection services. [ABSTRACT FROM AUTHOR]

Background: "HIV prevention cascades" have been proposed to support programs by identifying gaps in demand for, access to, and capability to adhere to HIV prevention tools, but there are few empirical examples to guide development. We apply a prevention cascade framework to examine prevention coverage and factors associated with condoms and/or PrEP adherence among female sex workers. Setting: Seven sites across Zimbabwe. Methods: Seven respondent-driven sampling surveys from the intervention sites of a pragmatic cluster-randomized trial in Zimbabwe in 2016 were analyzed, and 611/1439 women testing HIV-negative included. We operationalized key components of an HIV prevention cascade including demand, supply, and capability to adhere to 2 tools for HIV prevention: condoms and pre-exposure prophylaxis (PrEP). We used adjusted logistic regression to identify determinants of adherence to condoms and PrEP in turn, examining the effect of adherence to one tool on adherence to the other. Results: There were 343/611, 54.7%, women reporting adherence to condoms and/or PrEP, leaving almost half uncovered. Although women were aware that condoms prevented HIV and reported good access to them, only 45[middle dot]5% reported full adherence to condom use. For PrEP, a new technology, there were gaps along all 3 domains of demand, supply, and adherence. Alcohol use decreased adherence to PrEP and condoms. Younger and newer entrants to sex work were less likely to take PrEP every day. Conclusions: HIV prevention programming among female sex workers in Zimbabwe could consider increasing awareness of PrEP alongside supply, alcohol use interventions, and approaches to engaging younger women. [ABSTRACT FROM AUTHOR]