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: Introduction: We used a Programme Science platform, to generate evidence to support the implementation of programmes for sex workers in Africa. Female sex workers are estimated to make up 1.6% (1.3%–1.8%) of the population of women aged 15−49 years in Zimbabwe. We highlight how programme science can be used to help distinguish between when, where and with whom programmes need to be implemented and discuss two case studies that exemplify implementing better (Case study 1 (1 June 2019−30 June 2021) Optimizing implementation of a risk differentiated microplanning intervention) and implementing differently (Case study 2 (1 October 2016−30 September 2022) Reorientating implementation of DREAMS for young women selling sex). Methods: Zimbabwe's nationally scaled programme for sex workers was established in 2009 in partnership with sex workers to provide comprehensive services for sex workers and generate evidence for programme design, implementation and scale up. Since inception, comprehensive data have been collected from all sex workers seeking services. As the scope of service provision has expanded so has the scope of data collection and analysis. At enrolment, sex workers are assigned an alphanumeric unique identifier which links consultations within and across programme sites. We conduct descriptive analyses of the Key Population (KP) programme data to guide programme implementation and redesign, embedding programmatic qualitative enquiry as required. Results: Two case studies describing different approaches to programme optimization are presented. In the first, an optimization exercise was used to strengthen programme implementation ensuring that the KP programme got back on track after SARS‐COV‐2. In the second, an in‐depth review of research and programme data led to a re‐orientation of the DREAMS programme to ensure that young women at the highest risk of HIV acquisition were enrolled and had access to DREAMS social support interventions in turn strengthening their uptake of HIV prevention. Conclusions: Optimizing and sustaining HIV care and treatment programmes requires effective delivery with sufficient scale and intensity for population impact. Our programme science approach guided the scale up of the KP programme in Zimbabwe, providing evidence to support strategy, implementation and ongoing management, and importantly helping us distinguish between when we needed to just implement, implement better or implement differently., INTRODUCTION Early in the HIV epidemic, programming and research involving female sex workers (FSW) was central to the African response. In the 2000s, the focus shifted to the general population, [...]

Introduction: In the context of key population HIV testing programmes, identifying new HIV acquisitions, tracking incidence, and responding with prevention and treatment interventions will be critical for achieving HIV epidemic control. Laboratory tests for recently acquired HIV used as part of a "recent infection testing algorithm" (RITA), offer a potential tool to support this work. We implemented a RITA for female sex workers (FSWs) in Zimbabwe to explore opportunities and programmatic benefits. Methods: Between October 2021 and January 2023, recency testing was offered to FSWs attending the Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe's key populations programme. Dried blood spot (DBS) samples were taken at 86 clinic sites across 10 provinces and Laboratory LAg Avidity and viral load testing conducted. RITA results were analysed and linked to programme data to explore geographical differences and calculate HIV incidence. We describe concurrent efforts in HIV testing for social (social network testing [SNT]) and sexual (index case testing [ICT]) contacts of those testing HIV positive. Results: Among 24,976 FSWs tested at programme sites, 9.5% (2363/24,976) were confirmed HIV positive. We enrolled 55.5% (1311/2363) of eligible HIV‐positive FSWs to our study, of whom 11.7% (153/1311) were identified as having recently acquired HIV. It took a median of 37 days (IQR 20–67) for samples to be processed. Enrolment rates varied between provinces but the proportion of recently acquired HIV was similar (range: 18.4% to 4.0%). Overall HIV incidence was 3.4 (95% CI 2.7−4.0) per 100py. Where results could be linked to routinely collected data, we found no evidence of a difference in test‐positivity between the ICT and SNT contacts of those with recently acquired compared to those with long‐term HIV. Conclusions: Implementation of a RITA was possible within a nationally scaled sex worker programme, and while challenging to implement, can provide an understanding of transmission dynamics and HIV incidence in this context. Sub‐optimal recruitment and data linkage limited the interpretation of our findings and opportunities for strategic gains though focusing on HIV prevention efforts. [ABSTRACT FROM AUTHOR]

Crowdsourcing strategies are useful in the development of public health interventions. Crowdsourcing engages end users in a co-creation process through challenge contests, designathons or online collaborations. Drawing on our experience of crowdsourcing in four African countries, we provide guidance on designing crowdsourcing strategies across seven steps: deciding on the type of crowdsourcing strategy, convening a steering committee, developing the content of the call for ideas, promotion, evaluation, recognizing finalists and sharing back ideas or implementing the solutions. [ABSTRACT FROM AUTHOR]

Introduction: The HPTN 071 (PopART) trialdemonstrated that universalHIV testing-and-treatment reduced community-level HIV incidence. Door-to-door delivery of HIV testing services (HTS) was one of the main components of the intervention. From an early stage, men were less likely to know their HIV status than women, primarily because they were not home during service delivery. To reach more men, different strategies were implemented during the trial. We present the relative contribution of these strategies to coverage of HTS and the impact of community hubs implemented after completion of the trial among men. Methods: Between 2013 and 2017, three intervention rounds (IRs) of door-to-door HTS delivery were conducted in eight PopART communities in Zambia. Additionalstrategies implemented in parallel, included: community-wide 'Man-up' campaigns (IR1), smaller HTS campaigns at work/socialplaces (IR2) and revisits to households with the option of HIV self-testing (HIVST) (IR3). In 2018, community 'hubs' offering HTS were implemented for 7 months in alleight communities. Population enumeration data for each round of HTS provided the denominator, allowing for calculation of the proportion of men tested as a result of each strategy during different time periods. Results: By the end of the three IRs, 65-75% of men were reached with HTS, primarily through door-to-door service delivery. In IR1 and IR2, 'Man-up' and work/socialplace campaigns accounted for ~1 percentage point each and in IR3, revisits with the option of self-testing for ~15 percentage points of this totalcoverage per IR. The yield of newly diagnosed HIV-positive men ranged from 2.2% for HIVST revisits to 9.9% in work/socialplaces. At community hubs, the majority of visitors accepting services were men (62.8%). In total, we estimated that ~36% (2.2% tested HIV positive) of men resident but not found at their household during IR3 of PopART accessed HTS provided at the hubs after trial completion. Conclusions: Achieving high coverage of HTS among men requires universal, home-based service delivery combined with an option of HIVST and delivery of HTS through community-based hubs. When men are reached, they are willing to test for HIV Reaching men thus requires implementers to adapt their HTS delivery strategies to meet men's needs. Clinical Trial Number: NCT01900977 Keywords: men; HIV testing; Zambia; sub-Saharan Africa; community-based, 1 | INTRODUCTION Data from sub-Saharan African countries consistently show that men are less likely than women to test for HIV [1-3]. In Zambia, the 2013-14 Demographic and Health Survey [...]

Background The growing population of adolescents and young people (AYP) aged 15 to 24 in sub-Saharan Africa face a high burden of HIV in many settings. Unintended pregnancies among adolescent girls in the region remain high. Nonetheless, the sexual and reproductive health (SRH) service needs of AYP have remained underserved. We conducted a cluster-randomised trial (CRT) to estimate the impact of community-based, peer-led SRH service provision on knowledge of HIV status and other SRH outcomes, including met need for contraceptives. Methods and findings Yathu Yathu was a cluster-randomised trial (CRT) conducted from 2019 to 2021 in 2 urban communities in Lusaka, Zambia. The communities were divided into 20 zones (approximately 2,350 AYP/zone) that were randomly allocated to the Yathu Yathu intervention or control arm. In each intervention zone, a community-based hub, staffed by peer support workers, was established to provide SRH services. In 2019, a census was conducted in all zones; all consenting AYP aged 15 to 24 were given a Yathu Yathu card, which allowed them to accrue points for accessing SRH services at the hub and health facility (intervention arm) or the health facility only (control arm). Points could be exchanged for rewards, thus acting as an incentive to use SRH services in both arms. We conducted a cross-sectional survey in 2021 to estimate the impact of Yathu Yathu on the primary outcome: knowledge of HIV status (self-reporting living with HIV or HIV testing in the last 12 months) and secondary outcomes, including use of pre-exposure prophylaxis (PrEP) in the last 12 months, current use of antiretroviral therapy (ART), and met need for contraceptive services. The sampling was stratified on sex and age group, and we analysed data at cluster-level using a two-stage process recommended for CRTs with Conclusions Delivering community-based, peer-led SRH services increased knowledge of HIV status among AYP, both males and females, compared with the control arm. Scaling up the highly effective Yathu Yathu strategy has the potential to make a substantial contribution to increasing access to HIV prevention and care services for young people. However, additional implementation research is needed to understand how to improve uptake of broader SRH services, beyond uptake of HIV testing. Trial registration ISRCTN75609016, clinicaltrials.gov number NCT04060420, Author(s): Bernadette Hensen 1,2,*, Sian Floyd 3, Mwelwa M. Phiri 4, Ab Schaap 3,4, Lucheka Sigande 4, Melvin Simuyaba 4, Lawrence Mwenge 4, Rosemary Zulu-Phiri 4, Louis Mwape 4, Sarah [...]

: Introduction: Early diagnosis of HIV is critical for epidemic control. To achieve this, successful testing programmes are essential and test positivity is often used as a marker of their performance. The aim of this study was to analyse trends and predictors of HIV test positivity over time and explore how an understanding of seroconversion rates could build on our interpretation of this indicator among female sex workers in Zimbabwe. Methods: We analysed HIV test data from Zimbabwe's nationally scaled sex work programme between 2009 and 2019. We defined test positivity as the proportion of all tests that were HIV positive and measured new diagnoses by estimating seroconversion rates among women with repeat tests, defined as an HIV‐positive test after at least one HIV‐negative test in the programme. We used logistic regression to analyse test positivity over three time‐periods: 2009–2013, 2014–2017 and 2018–2019, adjusting for potential confounding by demographic factors and the mediating effects of time since last HIV test. We calculated the seroconversion rates for the same time‐periods. Results: During the 10‐year study period, 54,503 tests were recorded in 39,462 women. Between 2009 and 2013, 18% of tests were among women who reported testing in the previous 6 months. By 2018–2019, this had increased to 57%. Between 2018 and 2019, test positivity was 9.6%, compared to 47.9% for 2009–2013 (aOR 6.08 95% CI 5.52–6.70) and 18.8% for 2014–2017 (aOR 2.17 95% CI 2.06–2.28). Adjusting for time since last test reduced effect estimates for 2009–2013 (aOR 4.03 95% CI 3.64–4.45) and 2014–2017 (aOR 1.97 95% CI 1.86–2.09) compared to 2018–2019. Among 7573 women with an initial HIV‐negative test in the programme and at least one subsequent test, 464 tested HIV positive at a rate of 3.9 per 100 pyar (95% CI 3.5–4.2). Conclusions: Test positivity decreased among women testing through the programme over time, while seroconversion rates remained high. These declines were partly driven by changes in individual testing history, reflecting comprehensive coverage of testing services and greater knowledge of HIV status, but not necessarily declining rates of seroconversion. Understanding testing history and monitoring new HIV infections from repeat tests could strengthen the interpretation of test positivity and provide a better understanding of programme performance., INTRODUCTION Early diagnosis of HIV is critical for epidemic control. Female sex workers (FSW) in sub‐Saharan Africa are at greater risk of HIV infection than other women of reproductive age, [...]

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. Keywords: female sex worker; adolescents and young women; HIV infection; HIV prevention; Zimbabwe; Sub-Saharan Africa, 1 | INTRODUCTION In sub-Saharan Africa, adolescent girls and young women aged 15 to 24 are more vulnerable to HIV infection than their male peers and older women [1]. At [...]

It is heartening to learn from recent data in multiple settings that decreasing community viral load through “universal test and treat” (UTT) programmes is having a significant impact on HIV [...]

: 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., INTRODUCTION Although HIV incidence is decreasing in sub‐Saharan Africa, it remains high among adolescent girls and young women (AGYW) aged 15 to 24 [1]. Among AGYW, young women who sell [...]