Search

To estimate HIV incidence among female sex workers (FSW) in Zimbabwe: using HIV prevalence by age and number of years since started selling sex (YSSS).We pooled data from FSW aged 18-39 participating in respondent-driven sampling surveys conducted in Zimbabwe between 2011 and 2017.For each year of age, we estimated: HIV prevalence ( Pt ) and the change in HIV prevalence from the previous age ( Pt - Pt -1 ). We then estimated the rate of new HIV infections during that year of age: It = Pt - Pt -1 /(1 - Pt -1 ), and calculated HIV incidence for 18-24 and 25-39 year-olds separately as the weighted average of It . We estimated HIV incidence for FSW 1-5 years and 6-15 years since first selling sex using the same approach, and compared HIV prevalence among FSW first selling sex at their current age with the general population.Among 9906 women, 50.2% were HIV positive. Based on HIV prevalence increases by age, we estimated an HIV incidence of 6.3/100 person-years at risk (pyar) (95% confidence interval [CI] 5.3, 7.6) among 18-24 year-olds, and 3.3/100 pyar (95% CI 1.3, 4.2) among 25-39 year-olds. Based on prevalence increases by YSSS, HIV incidence was 5.3/100 pyar (95% CI 4.3, 8.5) between 1 and 5 years since first selling sex, and 2.1/100 pyar (95% CI -1.3, 7.2) between 6 and 15 years.Our analysis is consistent with very high HIV incidence among FSW in Zimbabwe, especially among those who are young and recently started selling sex. There is a critical need to engage young entrants into sex work in interventions that reduce their HIV risk.

Supplemental Digital Content is Available in the Text., Background: We constructed self-reported pre-exposure prophylaxis (PrEP) cascades and explored factors associated with and barriers to PrEP use to inform efforts to support PrEP use among young women who sell sex. Methods: Using self-reported data from HIV-negative young women who sell sex enrolled into a cohort study using respondent-driven sampling in Zimbabwe, we constructed PrEP cascades assessing knowledge of, ever offered, ever used, and current PrEP use in 2017 and 2019. We used logistic regression to examine factors associated with PrEP use by 2019. Through qualitative interviews with 43 women enrolled in the cohort, we investigated barriers to PrEP use. Results: At enrollment, 50% of women had heard of PrEP, 12% had ever been offered PrEP, and 7% ever used PrEP. Over time, all cascade domains: 96% of women had heard of and 55% reported an active offer of PrEP. Among women retained in the study in 2019 (56%; n = 538), 34% ever took PrEP by 2019. PrEP use was associated with, at enrollment, reporting more clients in the past month (10+: 45% vs 1–3: 27% adjOR = 1.71 95% CI: 1.06 to 2.76), duration of selling sex (24%

Objectives: Sex work sites have been hypothesised to be at the root of the observed heterogeneity in HIV prevalence in sub-Saharan Africa. We determined if proximity to sex work sites is associated with HIV prevalence among the general population in Zimbabwe, a country with one of the highest HIV prevalence in the world. Methods: In this cross-sectional study we use a unique combination of nationally representative geolocated individual-level data from 16,121 adults (age 15–49 years) from 400 sample locations and the locations of 55 sex work sites throughout Zimbabwe; covering an estimated 95% of all female sex workers (FSWs). We calculated the shortest distance by road from each survey sample location to the nearest sex work site, for all sites and by type of sex work site, and conducted univariate and multivariate multilevel logistic regressions to determine the association between distance to sex work sites and HIV seropositivity, controlling for age, sex, male circumcision status, number of lifetime sex partners, being a FSW client or being a stable partner of an FSW client. Results: We found no significant association between HIV seroprevalence and proximity to the nearest sex work site among the general population in Zimbabwe, regardless of which type of site is closest (city site adjusted odds ratio [aOR] 1.010 [95% confidence interval {CI} 0.992–1.028]; economic growth point site aOR 0.982 [95% CI 0.962–1.002]; international site aOR 0.995 [95% CI 0.979–1.012]; seasonal site aOR 0.987 [95% CI 0.968–1.006] and transport site aOR 1.007 [95% CI 0.987–1.028]). Individual-level indicators of sex work were significantly associated with HIV seropositivity: being an FSW client (aOR 1.445 [95% CI 1.188–1.745]); nine or more partners versus having one to three lifetime partners (aOR 2.072 [95% CI 1.654–2.596]). Conclusions: Sex work sites do not seem to directly affect HIV prevalence among the general population in surrounding areas. Prevention and control interventions for HIV at these locations should primarily focus on sex workers and their clients, with special emphasis on including and retaining mobile sex workers and clients into services.

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.

ntroduction \ud 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.\ud \ud Methods \ud We conducted a mixed methods study to compare YWSS’ qualitative descriptions of male partners with categories reported in a behavioural survey. Data were drawn from enrolment 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 semi-structured interviews with 19 “seeds” followed by a behavioural 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 behaviour within partnerships.\ud \ud Results \ud 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. Over 85% of male partners provided money to YWSS, but women were less likely to report condom-less sex with clients than regular partners (11% vs 37%) and more likely to report condom-less sex with partners who ever forced them to have sex (37% vs 21%).\ud \ud Conclusions \ud Reducing HIV risk among YWSS requires prevention messages and tools that recognise diverse and changing vulnerability within and between sexual relationships with different male partners.

Background Female sex workers (FSW) in sub-Saharan Africa are disproportionately affected by HIV and are critical to engage in HIV prevention, testing and care services. We describe the design of our evaluation of the ‘AMETHIST’ intervention, nested within a nationally-scaled programme for FSW in Zimbabwe. We hypothesise that the implementation of this intervention will result in a reduction in the risk of HIV transmission within sex work. Methods The AMETHIST intervention (Adapted Microplanning to Eliminate Transmission of HIV in Sex Transactions) is a risk-differentiated intervention for FSW, centred around the implementation of microplanning and self-help groups. It is designed to support uptake of, and adherence to, HIV prevention, testing and treatment behaviours among FSW. Twenty-two towns in Zimbabwe were randomised to receive either the Sisters programme (usual care) or the Sisters programme plus AMETHIST. The composite primary outcome is defined as the proportion of all FSW who are at risk of either HIV acquisition (HIV-negative and not fully protected by prevention interventions) or of HIV transmission (HIV-positive, not virally suppressed and not practicing consistent condom use). The outcome will be assessed after 2 years of intervention delivery in a respondent-driven sampling survey (total n = 4400; n = 200 FSW recruited at each site). Primary analysis will use the ‘RDS-II’ method to estimate cluster summaries and will adapt Hayes and Moulton’s ‘2-step’ method produce adjusted effect estimates. An in-depth process evaluation guided by our project trajectory will be undertaken. Discussion Innovative pragmatic trials are needed to generate evidence on effectiveness of combination interventions in HIV prevention and treatment in different contexts. We describe the design and analysis of such a study. Trial registration Pan African Clinical Trials Registry PACTR202007818077777. Registered on 2 July 2020.

In Zimbabwe, as in other East and Southern African countries, HIV prevalence is largely geographically heterogeneous. We determined if, and to what extent, this heterogeneity is associated with proximity to sex work sites by type of site (city, economic growth point, international, seasonal, or transport), using Demographic and Health Surveys location-specific HIV prevalence data—including 16,121 individuals (aged 15-49 years) from 400 sample locations—and Centre for Sexual Health and HIV/AIDS Research data on locations of 56 sex work sites throughout Zimbabwe. We conducted univariate and multivariate multilevel logistic regression to determine the association between sex work proximity—calculated as the shortest distance by road from each survey sample location to the nearest sex work site—and HIV seropositivity. We found no association between locations of sex work and heterogeneity in HIV prevalence in the general population, possibly explained by the mobile nature of both female sex workers and their clients as individual-level indicators of sex work were still significantly associated with HIV.

IntroductionYoung women who sell sex (YWSS) in Zimbabwe remain at high risk of HIV infection. Effective HIV prevention strategies are needed. Through support to access a combination of evidence-based interventions, including oral pre-exposure prophylaxis (PrEP), the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) partnership aimed to reduce new HIV infections among adolescent girls and young women by 40% over 24 months.MethodsNon-randomised ‘plausibility’ evaluation, powered to detect a 40% HIV incidence difference between DREAMS and non-DREAMS sites. Two large cities with DREAMS funding were included, and four smaller non-DREAMS towns for comparison. In all sites, YWSS were enrolled to a cohort through peer-referral. Women were followed up for 24 months. HIV seroconversion was the primary outcome, with secondary outcomes identified through a theory of change. Outcomes were compared between YWSS recruited in DREAMS cities and non-DREAMS towns, adjusting for individual-level confounders and HIV prevalence at enrolment.ResultsFrom April to July 2017, 2431 women were enrolled, 1859 of whom were HIV negative at enrolment; 1019 of these women (54.8%) were followed up from March to May 2019 and included in endline analysis. Access to clinical services increased, but access to socioeconomic interventions promoted by DREAMS was limited. A total of 79 YWSS HIV seroconverted, with HIV incidence among YWSS in DREAMS cities lower (3.1/100 person-years) than in non-DREAMS towns (5.3/100 person-years). In prespecified adjusted analysis, HIV incidence was lower in DREAMS cities but with weak statistical evidence (adjusted rate ratio (RR)=0.68; 95% CI 0.40 to 1.19; p=0.18). Women in DREAMS cities were more likely to report ever and ongoing PrEP use, consistent condom use, fewer sexual partners and less intimate partner violence.ConclusionIt is plausible that DREAMS lowered HIV incidence among YWSS in two Zimbabwean cities, but our evaluation provides weak statistical evidence for impact and suggests any reduction in incidence was lower than the anticipated 40% decline. We identified changes to some important ‘pathways to impact’ variables, including condom use.

Background Population size estimates (PSEs) for hidden populations at increased risk of HIV, including female sex workers (FSWs), are important to inform public health policy and resource allocation. The service multiplier method (SMM) is commonly used to estimate the sizes of hidden populations. We used this method to obtain PSEs for FSWs at 9 sites in Zimbabwe and explored methods for assessing potential biases that could arise in using this approach. Objective This study aimed to guide the assessment of biases that arise when estimating the population sizes of hidden populations using the SMM combined with respondent-driven sampling (RDS) surveys. Methods We conducted RDS surveys at 9 sites in late 2013, where the Sisters with a Voice program (the program), which collects program visit data of FSWs, was also present. Using the SMM, we obtained PSEs for FSWs at each site by dividing the number of FSWs who attended the program, based on program records, by the RDS-II weighted proportion of FSWs who reported attending this program in the previous 6 months in the RDS surveys. Both the RDS weighting and SMM make a number of assumptions, potentially leading to biases if the assumptions are not met. To test these assumptions, we used convergence and bottleneck plots to assess seed dependence of RDS-II proportion estimates, chi-square tests to assess if there was an association between the characteristics of FSWs and their knowledge of program existence, and logistic regression to compare the characteristics of FSWs attending the program with those recruited to RDS surveys. Results The PSEs ranged from 194 (95% CI 62-325) to 805 (95% CI 456-1142) across 9 sites from May to November 2013. The 95% CIs for the majority of sites were wide. In some sites, the RDS-II proportion of women who reported program use in the RDS surveys may have been influenced by the characteristics of selected seeds, and we also observed bottlenecks in some sites. There was no evidence of association between characteristics of FSWs and knowledge of program existence, and in the majority of sites, there was no evidence that the characteristics of the populations differed between RDS and program data. Conclusions We used a series of rigorous methods to explore potential biases in our PSEs. We were able to identify the biases and their potential direction, but we could not determine the ultimate direction of these biases in our PSEs. We have evidence that the PSEs in most sites may be biased and a suggestion that the bias is toward underestimation, and this should be considered if the PSEs are to be used. These tests for bias should be included when undertaking population size estimation using the SMM combined with RDS surveys.

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.\ud \ud 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.\ud \ud 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.\ud \ud 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.\ud \ud Keywords: HIV prevention; HIV prevention cascade; Zimbabwe; condom cascade; female sex worker; sub-Saharan Africa; young women who sell sex.

BACKGROUND:\ud National-level population size estimates (PSEs) for hidden populations are required for HIV programming and modelling. Various estimation methods are available at the site-level, but it remains unclear which are optimal and how best to obtain national-level estimates.\ud \ud SETTING:\ud Zimbabwe METHODS:: Using 2015-2017 data from respondent-driven sampling surveys (RDS) among female sex workers (FSW) aged 18+ years, mappings, and programme records, we calculated PSEs for each of 20 sites across Zimbabwe, using up to three methods per site (service and unique object multipliers, census, and capture-recapture). We compared estimates from different methods, and calculated site medians. We estimated prevalence of sex work at each site using census data available on the number of 15-49 year-old women, generated a list of all 'hotspot' sites for sex work nationally, and matched sites into strata in which the prevalence of sex work from sites with PSEs was applied to those without. Directly and indirectly estimated PSEs for all hotspot sites were summed to provide a national-level PSE, incorporating an adjustment accounting for sex work outside hotspots.\ud \ud RESULTS:\ud Median site PSEs ranged from 12,863 in Harare to 247 in a rural growth-point. Multiplier methods produced the highest PSEs. We identified 55 hotspots estimated to include 95% of all FSW. FSW nationally were estimated to number 40,491, 1.23% of women aged 15-49 years, (plausibility bounds 28,177-58,797, 0.86-1.79%, those under 18 considered sexually exploited minors).\ud \ud CONCLUSION:\ud There are large numbers of FSW estimated in Zimbabwe. Uncertainty in population size estimation should be reflected in policy-making.

Introduction\ud Surveillance of recent HIV infections in national testing services has the potential to inform primary prevention programming activities. Focusing on procedures required to accurately determine recent infection, and the potential for recent infection surveillance to inform prevention efforts, we present the results of three independent but linked pilots of recency testing.\ud \ud Methods\ud To distinguish recently acquired HIV infection from long‐standing infection, in 2018 we applied a Recent Infection Testing Algorithm that combined a laboratory‐based Limiting Antigen Avidity Enzyme Immunoassay with clinical information (viral‐load; history of prior HIV diagnosis; antiretroviral therapy‐exposure). We explored potential misclassification of test results and analysed the characteristics of participants with recent infection. We applied the algorithm in antenatal clinics providing prevention of mother‐to‐child transmission services in Siaya County, Kenya, outreach sites serving female sex workers in Zimbabwe, and routine HIV testing and counselling facilities in Nairobi, Kenya. In Nairobi, we also conducted recency testing among partners of HIV‐positive participants.\ud \ud Results\ud In Siaya County, 2.3% (10/426) of HIV‐positive pregnant women were classified as recent. A risk factor analysis comparing women testing recent with those testing HIV‐negative found women in their first trimester were significantly more likely to test recent than those in their second or third trimester. In Zimbabwe, 10.5% (33/313) of female sex workers testing HIV‐positive through the outreach programme were classified recent. A risk factor analysis of women testing recent versus those testing HIV‐negative, found no strong evidence of an association with recent infection. In Nairobi, among 532 HIV‐positive women and men, 8.6% (46) were classified recent. Among partners of participants, almost a quarter of those who tested HIV‐positive were classified as recent (23.8%; 5/21). In all three settings, the inclusion of clinical information helped improve the positive predictive value of recent infection testing by removing cases that were likely misclassified.\ud \ud Conclusions\ud We successfully identified recently acquired infections among persons testing HIV‐positive in routine testing settings and highlight the importance of incorporating additional information to accurately classify recent infection. We identified a number of groups with a significantly higher proportion of recent infection, suggesting recent infection surveillance, when rolled‐out nationally, may help in further targeting primary prevention efforts.

Introduction\ud \ud 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.\ud \ud Methods\ud \ud 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.\ud \ud Results\ud \ud 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.\ud \ud Conclusions\ud \ud 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.

Female sex workers’ livelihoods in Zimbabwe have been severely impacted by the coronavirus disease 2019 pandemic due to closure of entertainment venues. Competition over fewer clients has reduced ability to negotiate condom use. At the same time as partner numbers have decreased, frequency of reported condomless sex has not increased, suggesting potential reduction in overall HIV and sexually transmitted infection risk and an opportunity for programmes to reach sex workers with holistic social and economic support and prevention services.

IntroductionReaching men aged 20–35 years, the group at greatest risk of HIV, with voluntary medical male circumcision (VMMC) remains a challenge. We assessed the impact of two VMMC demand creation approaches targeting this age group in a randomised controlled trial (RCT).MethodsWe conducted a 2×2 factorial RCT comparing arms with and without two interventions: (1) standard demand creation augmented by human-centred design (HCD)-informed approach; (2) standard demand creation plus offer of HIV self-testing (HIVST). Interpersonal communication (IPC) agents were the unit of randomisation. We observed implementation of demand creation over 6 months (1 May to 31 October 2018), with number of men circumcised assessed over 7 months. The primary outcome was the number of men circumcised per IPC agent using the as-treated population of actual number of months each IPC agent worked. We conducted a mixed-methods process evaluation within the RCT.ResultsWe randomised 140 IPC agents, 35 in each arm. 132/140 (94.3%) attended study training and 105/132 (79.5%) reached at least one client during the trial period and were included in final analysis. There was no evidence that the HCD-informed intervention increased VMMC uptake versus no HCD-informed intervention (incident rate ratio (IRR) 0.87, 95% CI 0.38 to 2.02; p=0.75). Nor did offering men a HIVST kit at time of VMMC mobilisation (IRR 0.65, 95% CI 0.28 to 1.50; p=0.31). Among IPC agents that reported reaching at least one man with demand creation, both the HCD-informed intervention and HIVST were deemed useful. There were some challenges with trial implementation; ConclusionThis RCT did not show evidence of an effect of HCD-informed demand intervention or HIVST on VMMC uptake. Findings will inform future design and implementation of demand creation evaluations.Trial registration numberPACTR201804003064160.

Introduction UNAIDS’ goal of ending AIDS by 2030 is unreachable without better targeting of testing, prevention and care. Female sex workers (FSW) in Zimbabwe are at high risk of HIV acquisition and transmission. Here, we report on collated programme and research data from Zimbabwe's national sex work programme. We also assess the potential for wider population impact of FSW programmes by modelling the impact on HIV incidence of eliminating transmission through FSW (i.e. calculate the population attributable fraction of incidence attributable to sex work). Methods Descriptive analyses of individual‐level programme data collected from FSW between 2009 and June 2018 are triangulated with data collected through 37 respondent driven sampling surveys from 19 sites in Zimbabwe 2011 to 2017. We describe programme coverage, uptake, retention and patterns of sex work behaviour and gaps in service provision. An individual‐level stochastic simulation model is used to reconstruct the epidemic and then the incidence compared with the counter‐factual trend in incidence from 2010 had transmission through sex work been eliminated from that date. Results Sisters has reached >67,000 FSW since 2009, increasing attendance as number of sites, programme staff and peer educators were increased. Over 57% of all FSW estimated to be working in Zimbabwe in 2017 (n = 40,000) attended the programme at least once. The proportion of young FSW reached has increased with introduction of the “Young Sisters programme.” There are no clear differences in pattern of sex work across settings. Almost all women report condom use with clients at last sex (95%); however, consistent condom use with clients in the last month varies from 52% to 95% by site. Knowledge of HIV‐positive status has increased from 48 to 78% between 2011 and 2016, as has prevalence of ART use among diagnosed women (29 to 67%). Although subject to uncertainty, modelling suggests that 70% (90% range: 32%, 93%) of all new infections in Zimbabwe from 2010 are directly or indirectly attributable to transmission via sex work. Conclusions It is feasible to increase coverage and impact of sex work programming through community‐led scale‐up of evidence‐based interventions. Eliminating transmission through commercial sex would likely have a substantial impact on new infections occurring more widely across Zimbabwe.

BACKGROUND Population size estimates (PSEs) for hidden populations at increased risk of HIV, including female sex workers (FSWs), are important to inform public health policy and resource allocation. The service multiplier method (SMM) is commonly used to estimate the sizes of hidden populations. We used this method to obtain PSEs for FSWs at 9 sites in Zimbabwe and explored methods for assessing potential biases that could arise in using this approach. OBJECTIVE This study aimed to guide the assessment of biases that arise when estimating the population sizes of hidden populations using the SMM combined with respondent-driven sampling (RDS) surveys. METHODS We conducted RDS surveys at 9 sites in late 2013, where the Sisters with a Voice program (the program), which collects program visit data of FSWs, was also present. Using the SMM, we obtained PSEs for FSWs at each site by dividing the number of FSWs who attended the program, based on program records, by the RDS-II weighted proportion of FSWs who reported attending this program in the previous 6 months in the RDS surveys. Both the RDS weighting and SMM make a number of assumptions, potentially leading to biases if the assumptions are not met. To test these assumptions, we used convergence and bottleneck plots to assess seed dependence of RDS-II proportion estimates, chi-square tests to assess if there was an association between the characteristics of FSWs and their knowledge of program existence, and logistic regression to compare the characteristics of FSWs attending the program with those recruited to RDS surveys. RESULTS The PSEs ranged from 194 (95% CI 62-325) to 805 (95% CI 456-1142) across 9 sites from May to November 2013. The 95% CIs for the majority of sites were wide. In some sites, the RDS-II proportion of women who reported program use in the RDS surveys may have been influenced by the characteristics of selected seeds, and we also observed bottlenecks in some sites. There was no evidence of association between characteristics of FSWs and knowledge of program existence, and in the majority of sites, there was no evidence that the characteristics of the populations differed between RDS and program data. CONCLUSIONS We used a series of rigorous methods to explore potential biases in our PSEs. We were able to identify the biases and their potential direction, but we could not determine the ultimate direction of these biases in our PSEs. We have evidence that the PSEs in most sites may be biased and a suggestion that the bias is toward underestimation, and this should be considered if the PSEs are to be used. These tests for bias should be included when undertaking population size estimation using the SMM combined with RDS surveys.

Supplemental Digital Content is Available in the Text., 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 45·5% 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.

Targeted HIV interventions for female sex workers (FSW) combine biomedical technologies, behavioural change and community mobilization with the aim of empowering FSW and improving prevention and treatment. Understanding how to deliver combined interventions most effectively in sub-Saharan Africa is critical to the HIV response. The Sisters’ Antiretroviral Programme for Prevention of HIV: an Integrated Response (SAPPH-Ire) randomized controlled trial in Zimbabwe tested an intervention to improve FSW engagement with HIV services. After 2 years, results of the trial showed no significant difference between study arms in proportion of FSW with HIV viral load ≥1000 copies/ml as steep declines occurred in both. We present the results of a process evaluation aiming to track the intervention’s implementation, assess its feasibility and accessibility, and situate trial results within the national HIV policy context. We conducted a mixed methods study using data from routine programme statistics, qualitative interviews with participants and respondent driven surveys. The intervention proved feasible to deliver and was acceptable to FSW and providers. Intervention clinics saw more new FSW (4082 vs 2754), performed over twice as many HIV tests (2606 vs 1151) and nearly double the number of women were diagnosed with HIV (1042 vs 546). Community mobilization meetings in intervention sites also attracted higher numbers. We identified some gaps in programme fidelity: offering pre-exposure prophylaxis took time to engage FSW, viral load monitoring was not performed, and ratio of peer educators to FSW was lower than intended. During the trial, reaching FSW with HIV testing and treatment became a national priority, leading to increasing attendance at both intervention and control clinics. Throughout Zimbabwe, antiretroviral therapy coverage improved and HIV-stigma declined. Zimbabwe’s changing HIV policy context appeared to contribute to positive improvements across the HIV care continuum for all FSW over the course of the trial. More intense community-based interventions for FSW may be needed to make further gains.

Young female sex-workers (FSW) aged 18–24 are at high risk of HIV due to high numbers of sexual partners, difficulty negotiating condom use, increased risk of gender-based violence, and limited access to services. Here we describe changes in sexual behaviours among young FSW across Zimbabwe between 2013 and 2016, and risk factors for prevalent HIV in 2013 and 2016. FSW ≥ 18 years were recruited using respondent-driven sampling in 14 sites across Zimbabwe in 2013 and 2016 as part of the SAPPH-IRe trial. We collected data on socio-demographics and sexual behaviour and offered HIV testing. Statistical analyses were RDS-II weighted. Characteristics of young FSW aged 18–24 were described, stratified by age. Logistic regression was used to assess difference in sexual behaviours by reported HIV status between 2013 and 2016, and to explore associations with prevalent HIV in 2013 and 2016. 656 young FSW were recruited in 2013 and 503 in 2016. Characteristics of young FSW were similar across both surveys. HIV prevalence was similar at both time points (35% vs 36%) and rose steeply with age. Compared to young FSW in 2013, reported condom-less sex with a steady partner and condom-less sex with clients was higher in 2016 among women self-reporting HIV negative status (OR = 6.41; 95%CI: 3.40-12.09; P

INTRODUCTION: Young female sex workers (FSWs) are at greater HIV risk than their older counterparts. Yet, the extent of their engagement with HIV services is largely unknown. We compared engagement among FSWs aged 18-24 years with those 25 years and older. METHODS: We used respondent-driven sampling to recruit FSWs from 14 communities in Zimbabwe from November to December 2013. We collected data on demographics, behavior, service uptake, and HIV and viral load testing. Data were pooled and weighted using respondent-driven sampling-2 estimation. We analyzed HIV care cascade variables by age group. To identify potential drivers of younger FSW service use, we explored factors associated with knowing one's HIV status. RESULTS: Among 2617 participants, mean age was 31 years and 26% were 18-24 years. Over half of FSWs initiated sex work before the age of 25 years. Overall HIV prevalence was 59% but was lower among younger FSWs (35% vs 67%, P < 0.01). Younger HIV-infected FSWs were significantly less engaged at each step of the care cascade. Among younger FSWs reporting antiretroviral therapy use, 62% had an undetectable viral load compared with 79% in older FSWs. In multivariable regression, young FSWs encouraged to have an HIV test by another FSW (adjusted odds ratio = 2.54; 95% confidence interval: 1.44 to 4.50), and those with no recent clients (adjusted odds ratio = 4.31; 95% confidence interval: 1.30 to 14.33) were more likely to report knowing their status. CONCLUSIONS: The high proportion of FSWs initiating sex work before the age of 25 years and their lower engagement in HIV services highlights the importance of considering this vulnerable population in HIV programming. Implementing targeted services tailored to the unique needs of young FSWs is a public health imperative.

BACKGROUND\ud Strengthening engagement of female sex workers with health services is needed to eliminate HIV. We assessed the efficacy of a targeted combination intervention for female sex workers in Zimbabwe.\ud \ud METHODS\ud We did a cluster-randomised trial from 2014 to 2016. Clusters were areas surrounding female sex worker clinics and were enrolled in matched pairs. Sites were randomly assigned (1:1) to receive usual care (free sexual-health services supported by peer educators, including HIV testing on demand, referral for antiretroviral therapy [ART], and health education) or an intervention that supported additional regular HIV testing, on-site initiation of ART, pre-exposure prophylaxis, adherence, and intensified community mobilisation. The primary outcome was the proportion of all female sex workers with HIV viral load 1000 copies per mL or greater, assessed through respondent-driven sampling surveys. We used an adapted cluster-summary approach to estimate risk differences. This trial is registered with Pan African Clinical Trials Registry, number PACTR201312000722390.\ud \ud RESULTS\ud We randomly assigned 14 clusters to usual care or the intervention (seven in each group). 3612 female sex workers attended clinics in the usual-care clusters and 4619 in the intervention clusters during the study. Half as many were tested (1151 vs 2606) and diagnosed as being HIV positive (546 vs 1052) in the usual-care clusters. The proportion of all female sex workers with viral loads of 1000 copies per mL or greater fell in both study groups (from 421 [30%] of 1363 to 279 [19%] of 1443 in the usual-care group and from 399 [30%] of 1303 to 240 [16%] of 1439 in the intervention group), but with a risk difference at the end of the assessment period of only -2·8% (95% CI -8·1 to 2·5, p=0·23). Among HIV-positive women, the proportions with viral loads less than 1000 copies per mL were 590 (68%) of 869 in the usual-care group and 588 (72%) of 828 in the intervention group at the end of the assessment period, adjusted risk difference of 5·3% (95% CI -4·0 to 14·6, p=0·20). There were no adverse events.\ud \ud INTERPRETATION\ud Our intervention of a dedicated programme for female sex workers led to high levels of HIV diagnosis and treatment. Further research is needed to optimise programme content and intensity for the broader population.\ud \ud FUNDING\ud UN Population Fund (through Zimbabwe's Integrated Support Fund funded by UK Department for International Development, Irish Aid, and Swedish International Development Cooperation Agency).