Search

Abstract Background In 2013, the World Health Organisation (WHO) recommended Option B+ as a strategy to prevent mother-to-child transmission (PMTCT) of HIV. In option B+ , lifelong antiretroviral therapy (ART) is offered to all HIV positive pregnant and breastfeeding women to reduce MTCT rate to less than or equal to 5%. Its success depends on retaining women on ART during pregnancy, delivery and breast-feeding period. There is limited data on early retention on ART among pregnant women in Zimbabwe. We therefore assessed early retention among women on Option B + from antenatal care (ANC) until 6 months post ANC booking and at delivery in Bulawayo city and Mazowe rural district of Zimbabwe. Methods We collected data for pregnant women booking for ANC between January and March 2018, comparing early retention among ART naïve women and those already on ART. The two cohorts were followed up for 6 months post ANC booking, and this was done in two districts. Data were collected from routine tools used at facility level which include ANC, delivery and ART registers. The Kaplan-Meier survival analysis was used to estimate retention probabilities at 1, 3 and 6 months post-delivery and for retention at delivery proportions were used. Poisson regression was used to investigate factors associated with non-retention at 6 months post ANC booking. Results A total of 388 women were included in the study with median age of 29 years (IQR: 25–34). Two-thirds booked in their second trimester. Retention at 3 and 6 months post ANC booking was 84% (95% CI 80–88) and 73% (95% CI 69–78) respectively. At delivery 81% (95% CI 76–84) were retained in care, 18% lost-to-follow-up and 1% transferred out. In this study we did not find marital status, gestation age, facility location, ART status at ANC booking, to be associated with loss to follow-up. Conclusion In this study, we found low retention at 3, 6 months and delivery, a threat to elimination of Mother-to-child Transmission of HIV in Zimbabwe. Our findings emphasize the need for enhanced interventions to improve early retention such as post-test counselling, patient tracing and visit reminders.

IntroductionThe COVID-19 pandemic has caused widespread disruptions including to health services. In the early response to the pandemic many countries restricted population movements and some health services were suspended or limited. In late 2020 and early 2021 some countries re-imposed restrictions. Health authorities need to balance the potential harms of additional SARS-CoV-2 transmission due to contacts associated with health services against the benefits of those services, including fewer new HIV infections and deaths. This paper examines these trade-offs for select HIV services.MethodsWe used four HIV simulation models (Goals, HIV Synthesis, Optima HIV and EMOD) to estimate the benefits of continuing HIV services in terms of fewer new HIV infections and deaths. We used three COVID-19 transmission models (Covasim, Cooper/Smith and a simple contact model) to estimate the additional deaths due to SARS-CoV-2 transmission among health workers and clients. We examined four HIV services: voluntary medical male circumcision, HIV diagnostic testing, viral load testing and programs to prevent mother-to-child transmission. We compared COVID-19 deaths in 2020 and 2021 with HIV deaths occurring now and over the next 50 years discounted to present value. The models were applied to countries with a range of HIV and COVID-19 epidemics.ResultsMaintaining these HIV services could lead to additional COVID-19 deaths of 0.002 to 0.15 per 10,000 clients. HIV-related deaths averted are estimated to be much larger, 19-146 discounted deaths per 10,000 clients.DiscussionWhile there is some additional short-term risk of SARS-CoV-2 transmission associated with providing HIV services, the risk of additional COVID-19 deaths is at least 100 times less than the HIV deaths averted by those services. Ministries of Health need to take into account many factors in deciding when and how to offer essential health services during the COVID-19 pandemic. This work shows that the benefits of continuing key HIV services are far larger than the risks of additional SARS-CoV-2 transmission.

BackgroundZimbabwe adopted voluntary medical male circumcision (VMMC) as a priority HIV prevention strategy in 2007 and began implementation in 2009. We evaluated the costs and impact of this VMMC program to date and in future.MethodsThree mathematical models describing Zimbabwe's HIV epidemic and program evolution were calibrated to household survey data on prevalence and risk behaviors, with circumcision coverage calibrated to program-reported VMMCs. We compared trends in new infections and costs to a counterfactual without VMMC. Input assumptions were agreed in workshops with national stakeholders in 2015 and 2017.ResultsThe VMMC program averted 2,600-12,200 infections (among men and women combined) by the end of 2016. This impact will grow as circumcised men are protected lifelong, and onward dynamic transmission effects, which protect women via reduced incidence and prevalence in their male partners, increase over time. If other prevention interventions remain at 2016 coverages, the VMMCs already performed will avert 24,400-69,800 infections (2.3-5% of all new infections) through 2030. If coverage targets are achieved by 2021 and maintained, the program will avert 108,000-171,000 infections (10-13% of all new infections) by 2030, costing $2,100-3,250 per infection averted relative to no VMMC. Annual savings from averted treatment needs will outweigh VMMC maintenance costs once coverage targets are reached. If Zimbabwe also achieves ambitious UNAIDS targets for scaling up treatment and prevention efforts, VMMC will reduce the HIV incidence remaining at 2030 by one-third, critically contributing to the UNAIDS goal of 90% incidence reduction.ConclusionsVMMC can substantially impact Zimbabwe's HIV epidemic in the coming years; this investment will save costs in the longer term.

Understanding the economic implications of COVID-19 for the HIV epidemic and response is critical for designing policies and strategies to effectively sustain past gains and accelerate progress to end these colliding pandemics. While considerable cross-national empirical evidence exists at the global level, there is a paucity of such deep-dive evidence at national level. This article addresses this gap. While Zimbabwe experienced fewer COVID-19 cases and deaths than most countries, the pandemic has had profound economic effects, reducing gross domestic product by nearly 7% in 2020. This exacerbates the long-term economic crisis that began in 1998. This has left many households vulnerable to the economic fallout from COVID-19, with the number of the extreme poor having increased to 49% of the population in 2020 (up from 38% in 2019). The national HIV response, largely financed externally, has been one of the few bright spots. Overall, macro-economic and social conditions heavily affected the capacity of Zimbabwe to respond to COVID-19. Few options were available for borrowing the needed sums of money. National outlays for COVID-19 mitigation and vaccination amounted to 2% of GDP, with one-third funded by external donors. Service delivery innovations helped sustain access to HIV treatment during national lockdowns. As a result of reduced access to HIV testing, the number of people initiating HIV treatment declined. In the short term, there are likely to be few immediate health care consequences of the slowdown in treatment initiation due to the country's already high level of HIV treatment coverage. However, a longer-lasting slowdown could impede national progress towards ending HIV and AIDS. The findings suggest a need to finance the global commons, specifically recognising that investing in health care is investing in economic recovery. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: The COVID-19 pandemic has caused widespread disruptions including to health services. In the early response to the pandemic many countries restricted population movements and some health services were suspended or limited. In late 2020 and early 2021 some countries re-imposed restrictions. Health authorities need to balance the potential harms of additional SARS-CoV-2 transmission due to contacts associated with health services against the benefits of those services, including fewer new HIV infections and deaths. This paper examines these trade-offs for select HIV services. Methods: We used four HIV simulation models (Goals, HIV Synthesis, Optima HIV and EMOD) to estimate the benefits of continuing HIV services in terms of fewer new HIV infections and deaths. We used three COVID-19 transmission models (Covasim, Cooper/Smith and a simple contact model) to estimate the additional deaths due to SARS-CoV-2 transmission among health workers and clients. We examined four HIV services: voluntary medical male circumcision, HIV diagnostic testing, viral load testing and programs to prevent mother-to-child transmission. We compared COVID-19 deaths in 2020 and 2021 with HIV deaths occurring now and over the next 50 years discounted to present value. The models were applied to countries with a range of HIV and COVID-19 epidemics. Results: Maintaining these HIV services could lead to additional COVID-19 deaths of 0.002 to 0.15 per 10,000 clients. HIV-related deaths averted are estimated to be much larger, 19–146 discounted deaths per 10,000 clients. Discussion: While there is some additional short-term risk of SARS-CoV-2 transmission associated with providing HIV services, the risk of additional COVID-19 deaths is at least 100 times less than the HIV deaths averted by those services. Ministries of Health need to take into account many factors in deciding when and how to offer essential health services during the COVID-19 pandemic. This work shows that the benefits of continuing key HIV services are far larger than the risks of additional SARS-CoV-2 transmission. [ABSTRACT FROM AUTHOR]

Background: In 2013, the World Health Organisation (WHO) recommended Option B+ as a strategy to prevent mother-to-child transmission (PMTCT) of HIV. In option B+ , lifelong antiretroviral therapy (ART) is offered to all HIV positive pregnant and breastfeeding women to reduce MTCT rate to less than or equal to 5%. Its success depends on retaining women on ART during pregnancy, delivery and breast-feeding period. There is limited data on early retention on ART among pregnant women in Zimbabwe. We therefore assessed early retention among women on Option B + from antenatal care (ANC) until 6 months post ANC booking and at delivery in Bulawayo city and Mazowe rural district of Zimbabwe. Methods: We collected data for pregnant women booking for ANC between January and March 2018, comparing early retention among ART naïve women and those already on ART. The two cohorts were followed up for 6 months post ANC booking, and this was done in two districts. Data were collected from routine tools used at facility level which include ANC, delivery and ART registers. The Kaplan-Meier survival analysis was used to estimate retention probabilities at 1, 3 and 6 months post-delivery and for retention at delivery proportions were used. Poisson regression was used to investigate factors associated with non-retention at 6 months post ANC booking. Results: A total of 388 women were included in the study with median age of 29 years (IQR: 25–34). Two-thirds booked in their second trimester. Retention at 3 and 6 months post ANC booking was 84% (95% CI 80–88) and 73% (95% CI 69–78) respectively. At delivery 81% (95% CI 76–84) were retained in care, 18% lost-to-follow-up and 1% transferred out. In this study we did not find marital status, gestation age, facility location, ART status at ANC booking, to be associated with loss to follow-up. Conclusion: In this study, we found low retention at 3, 6 months and delivery, a threat to elimination of Mother-to-child Transmission of HIV in Zimbabwe. Our findings emphasize the need for enhanced interventions to improve early retention such as post-test counselling, patient tracing and visit reminders. [ABSTRACT FROM AUTHOR]

Introduction: Despite improvements in prevention of mother‐to‐child transmission (PMTCT) of HIV outcomes, there remain unacceptably high numbers of mother‐to‐child transmissions (MTCT) of HIV. Programmes and research collect multiple sources of PMTCT data, yet this data is rarely integrated in a systematic way. We conducted a data integration exercise to evaluate the Zimbabwe national PMTCT programme and derive lessons for strengthening implementation and documentation. Methods: We used data from four sources: research, Ministry of Health and Child Care (MOHCC) programme, Implementer – Organization for Public Health Interventions and Development, and modelling. Research data came from serial population representative cross‐sectional surveys that evaluated the national PMTCT programme in 2012, 2014 and 2017/2018. MOHCC and Organization for Public Health Interventions and Development collected data with similar indicators for the period 2018 to 2019. Modelling data from 2017/18 UNAIDS Spectrum was used. We systematically integrated data from the different sources to explore PMTCT programme performance at each step of the cascade. We also conducted spatial analysis to identify hotspots of MTCT. Results: We developed cascades for HIV‐positive and negative‐mothers, and HIV exposed and infected infants to 24 months post‐partum. Most data were available on HIV positive mothers. Few data were available 6‐8 weeks post‐delivery for HIV exposed/infected infants and none were available post‐delivery for HIV‐negative mothers. The different data sources largely concurred. Antenatal care (ANC) registration was high, although women often presented late. There was variable implementation of PMTCT services, MTCT hotspots were identified. Factors positively associated with MTCT included delayed ANC registration and mobility (use of more than one health facility) during pregnancy/breastfeeding. There was reduced MTCT among women whose partners accompanied them to ANC, and infants receiving antiretroviral prophylaxis. Notably, the largest contribution to MTCT was from postnatal women who had previously tested negative (12/25 in survey data, 17.6% estimated by Spectrum modelling). Data integration enabled formulation of interventions to improve programmes. Conclusions: Data integration was feasible and identified gaps in programme implementation/documentation leading to corrective interventions. Incident infections among mothers are the largest contributors to MTCT: there is need to strengthen the prevention cascade among HIV‐negative women. [ABSTRACT FROM AUTHOR]

Background: The last evaluation to assess outcomes for patients receiving antiretroviral therapy (ART) through the Zimbabwe public sector was conducted in 2011, covering the 2007–2010 cohorts. The reported retention at 6, 12, 24 and 36 months were 90.7%, 78.1%, 68.8% and 64.4%, respectively. We report findings of a follow-up evaluation for the 2012–2015 cohorts to assess the implementation and impact of recommendations from this prior evaluation. Methods: A nationwide retrospective study was conducted in 2016. Multi-stage proportional sampling was used to select health facilities and study participants records. The data extracted from patient manual records included demographic, baseline clinical characteristics and patient outcomes (active on treatment, died, transferred out, stopped ART and lost to follow-up (LTFU)) at 6, 12, 24 and 36 months. The data were analysed using Stata/IC 14.2. Retention was estimated using survival analysis. The predictors associated with attrition were determined using a multivariate Cox regression model. Results: A total of 3,810 participants were recruited in the study. The median age in years was 35 (IQR: 28–42). Overall, retention increased to 92.4% (p-value = 0.060), 86.5% (p-value<0.001), 79.2% (p-value<0.001) and 74.4% (p-value<0.001) at 6, 12, 24 and 36 months respectively. LTFU accounted for 98% of attrition. Being an adolescent or a young adult (15–24 years) (vs adult;1.41; 95% CI:1.14–1.74), children (<15years) (vs adults; aHR 0.64; 95% CI:0.46–0.91), receiving care at primary health care facility (vs central and provincial facility; aHR 1.23; 95% CI:1.01–1.49), having initiated ART between 2014–2015 (vs 2012–2013; aHR1.45; 95%CI:1.24–1.69), having WHO Stage IV (vs Stage I-III; aHR2.06; 95%CI:1.51–2.81) and impaired functional status (vs normal status; aHR1.25; 95%CI:1.04–1.49) predicted attrition. Conclusion: The overall retention was higher in comparison to the previous 2007–2010 evaluation. Further studies to understand why attrition was found to be higher at primary health care facilities are warranted. Implementation of strategies for managing patients with advanced HIV disease, differentiated care for adolescents and young adults and tracking of LTFU clients should be prioritised to further improve retention. [ABSTRACT FROM AUTHOR]

Background: Zimbabwe adopted voluntary medical male circumcision (VMMC) as a priority HIV prevention strategy in 2007 and began implementation in 2009. We evaluated the costs and impact of this VMMC program to date and in future. Methods: Three mathematical models describing Zimbabwe’s HIV epidemic and program evolution were calibrated to household survey data on prevalence and risk behaviors, with circumcision coverage calibrated to program-reported VMMCs. We compared trends in new infections and costs to a counterfactual without VMMC. Input assumptions were agreed in workshops with national stakeholders in 2015 and 2017. Results: The VMMC program averted 2,600–12,200 infections (among men and women combined) by the end of 2016. This impact will grow as circumcised men are protected lifelong, and onward dynamic transmission effects, which protect women via reduced incidence and prevalence in their male partners, increase over time. If other prevention interventions remain at 2016 coverages, the VMMCs already performed will avert 24,400–69,800 infections (2.3–5% of all new infections) through 2030. If coverage targets are achieved by 2021 and maintained, the program will avert 108,000–171,000 infections (10–13% of all new infections) by 2030, costing $2,100–3,250 per infection averted relative to no VMMC. Annual savings from averted treatment needs will outweigh VMMC maintenance costs once coverage targets are reached. If Zimbabwe also achieves ambitious UNAIDS targets for scaling up treatment and prevention efforts, VMMC will reduce the HIV incidence remaining at 2030 by one-third, critically contributing to the UNAIDS goal of 90% incidence reduction. Conclusions: VMMC can substantially impact Zimbabwe’s HIV epidemic in the coming years; this investment will save costs in the longer term. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the author discusses articles within the issue on topics including global response to human immunodeficiency virus (HIV) prevention in the context of human capital development, community mobilisation and coercive public health measures for HIV and COVID control, and inequalities driving HIV.

Competing Interests: JWI-E's institution receives funding from the Bill & Melinda Gates Foundation (BMGF), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the US National Institutes of Health (NIH) and has received consulting fees from BAO Systems and support to attend meetings from UNAIDS, BMGF, the International AIDS Society, and the South African Centre for Epidemiological Modelling and Analysis (SACEMA). CF's institution receives funding from BMGF for the PANGEA2-HIV consortium and received support from UNAIDS to attend meetings in Boston and Botswana related to this work. HA received support from UNAIDS and BMGF to attend a meeting in Botswana related to this work. JSt's institution receives funding from UNAIDS and received support from UNAIDS and BMGF to attend a meeting in Botswana related to this work. PG-F received support from Imperial College London to support this work and to attend the meeting in Botswana and has received consultancy contracts from UNAIDS for other projects. LA-D, OE, and SMi received support from UNAIDS to attend meetings in Boston and Botswana related to this work. RA, SMa, SLB, and WLK received support from UNAIDS to attend a meeting in Botswana related to this work. RG's institution receives funding from UNAIDS and BMGF. MKG's institution receives funding from BMGF. AA, MRM, and GPG are employees of BMGF. AB's institution receives funding from NIH, BMGF, the New York City Department of Health and Mental Hygiene, and the Foundation for Innovative New Diagnostics (FIND) and has received consulting fees from Gates Ventures. HM received support from BMGF for work presented at meetings related to this Comment. JRH receives funding from BMGF and was partly supported by the MeSH Consortium, based at the London School of Hygiene & Tropical Medicine with a grant funded by BMGF (INV-007055). GM-R's institution receives funding from BMGF, FIND, and the United States Agency for International Development (USAID). WJMP received consulting fees from WHO. ANP's institution receives funding from BMGF, the Wellcome Trust, the European Union (EU), NIH, and the National Institute for Health and Care Research (NIHR). VC's institution receives funding from BMGF, NIHR, USAID, Unitaid, UK Research and Innovation (UKRI), and the Medical Research Council (MRC) and has received consulting fees from WHO. DK has received consulting fees from University College London and Massachusetts General Hospital. MREHP has received consulting fees from the HIV Modelling Consortium. LB-M's institution receives funding from BMGF. SPR is an employee of Airfinity Ltd. LKW's institution receives funding from Wellcome Trust, NIHR, has received consulting fees from WHO and Pacific Life Re and has received honoraria from The Lancet Infectious Diseases and Luxembourg National Research Fund and has participated on a Research Steering Group for the Wellcome Trust. All the other authors declare no competing interests. The members of the The Post-2030 HIV Response Working Group are Adam Akullian, Ruth Akulu, Gambo Aliyu, Florence Anam, Anne-Claire Guichard, Helen Ayles, Rachel Baggaley, Loveleen Bansi-Matharu, Solange L Baptiste, Anna Bershteyn, Valentina Cambiano, Austin Carter, Nafiisah Chotun, Daniel T Citron, Siobhan Crowley, Shona Dalal, Olanrewaju Edun, Christophe Fraser, Alison P Galvani, Geoffrey P Garnett, Robert Glaubius, Peter Godfrey-Faussett, M Kate Grabowski, Glenda E Gray, James R Hargreaves, Jeffrey W Imai-Eaton, Leigh F Johnson, David Kaftan, Joseph Kagaayi, Edward Kataika, Nduku Kilonzo, Wilford L Kirungi, Eline L Korenromp, Mach-Houd Kouton, Lucie Abeler-Dörner, Mary Mahy, Tara D Mangal, Rowan Martin-Hughes, Samuel Matsikure, Gesine Meyer-Rath, Sharmistha Mishra, Mpho Mmelesi, Abdulaziz Mohammed, Haroon Moolla, Michelle R Morrison, Sikhulile Moyo, Edinah Mudimu, Mbulawa Mugabe, Maurine Murenga, Joyce Ng'ang'a, Yewande Olaifa, Andrew N Phillips, Michael R E H Pickles, William J M Probert, Dinah Ramaabya, Stefan P Rautenbach, Paul Revill, Ani Shakarishvili, Robert Sheneberger, Jennifer Smith, Christine Stegling, John Stover, Frank Tanser, Isaac Taramusi, Debra ten Brink, Lilith K Whittles, and Irum Zaidi. The affiliations of the group members are listed in the appendix.