Elizabeth Fearon

Engagement with HIV prevention treatment and care among female sex workers in Zimbabwe: a respondent driven sampling survey.

Objective(S) To determine the HIV prevalence and extent of engagement with HIV prevention and care among a representative sample of Zimbabwean sex workers working in Victoria Falls, Hwange and Mutare. Design Respondent driven sampling (RDS) surveys conducted at each site. Methods Sex workers were recruited using respondent driven sampling with each respondent limited to recruiting 2 peers. Participants completed an interviewer-administered questionnaire and provided a finger prick blood sample for HIV antibody testing. Statistical analysis took account of sampling method. Results 870 women were recruited from the three sites. HIV prevalence was between 50 and 70%. Around half of those confirmed HIV positive were aware of their HIV status and of those 50-70% reported being enrolled in HIV care programmes. Overall only 25-35% of those with laboratory-confirmed HIV were accessing antiretroviral therapy. Among those reporting they were HIV negative, 21-28% reported having an HIV test in the last 6 months. Of those tested HIV negative, most (65-82%) were unaware of their status. Around two-thirds of sex workers reported consistent condom use with their clients. As in other settings, sex workers reported high rates of gender based violence and police harassment. Conclusions This survey suggests that prevalence of HIV is high among sex workers in Zimbabwe and that their engagement with prevention, treatment and care is sub-optimal. Intensifying prevention and care interventions for sex workers has the potential to markedly reduce HIV and social risks for sex workers, their clients and the general population in Zimbabwe and elsewhere in the region.

The HIV care cascade among female sex workers in Zimbabwe: results of a population-based survey from the Sisters Antiretroviral therapy Programme for Prevention of HIV, an Integrated Response (SAPPH-IRe) Trial.

Introduction: Female sex workers (FSW) in sub-Saharan Africa have a higher prevalence of HIV than other women of reproductive age. Social, legal, and structural barriers influence their access to care. Little is known about the HIV diagnosis and care cascade in most countries in Southern Africa. We aimed to describe the HIV diagnosis and care cascade among FSW in Zimbabwe. Methods: We conducted cross-sectional respondent driven sampling (RDS) surveys of FSW in 14 sites across Zimbabwe as the baseline for a cluster-randomised controlled trial investigating a combination HIV prevention and care package. We administered a questionnaire, tested women for HIV and measured viral load. We report the mean, minimum, and maximum respondent-driven sampling-2 weighted site values. Results: The survey included 2722 women, approximately 200 per site. The mean HIV prevalence was 57.5% (42.8–79.2 site minimum and maximum). Of HIV-positive women, 64.0% (51.6–73.7) were aware of their status, 67.7% (53.4–84.1) of these reported taking antiretroviral therapy, and 77.8% (64.4–90.8) of these had a suppressed HIV viral load (<1000 copies/mL). Among all HIV-positive women, 49.5% had a viral load < 1000 copies/mL. Conclusions: Although most HIV-positive women aware of their status are accessing antiretroviral therapy, 36.0% of HIV-positive women are unaware of their status and 29.3% of all FSW have an unsuppressed HIV viral load. Investigation and investment into models of testing, treatment, and care are necessary to reach UNAIDS targets for HIV elimination.

Changes over time in sexual behaviour among young people with different levels of educational attainment in Tanzania

HIV prevalence trends in Tanzania differ between socioeconomic groups. While HIV prevalence was initially higher among those with higher levels of educational attainment, it has fallen fastest among these groups. Among those with lower levels of education HIV prevalence has been stable. The behavioural dynamics underlying this phenomenon remain unclear, and a theory to guide interpretation of these trends and enable predictions of future patterns has not emerged.

Trends in socioeconomic inequalities in HIV prevalence among young people in seven countries in eastern and southern Africa.

Background In Eastern and Southern Africa, HIV prevalence was highest among higher socioeconomic groups during the 1990s. It has been suggested that this is changing, with HIV prevalence falling among higher-educated groups while stable among lower-educated groups. A multi-country analysis has not been undertaken. Methods We analysed data on socio-demographic factors and HIV infection from 14 nationally representative surveys of adults aged 15-24 (seven countries, two surveys each, 4-8 years apart). Sample sizes ranged from 2,408-12,082 (72,135 total). We used logistic regression to assess gender-stratified associations between highest educational level attended and HIV status in each survey, adjusting for age and urban/rural setting. We tested for interactions with urban/rural setting and age. Our primary hypothesis was that higher education became less of a risk factor for HIV over time. We tested for interaction between survey-year and the education-HIV association in each country and all countries pooled. Findings In Ethiopia and Malawi, HIV prevalence was higher in more educated women in both surveys. In Lesotho, Kenya and Zimbabwe, HIV prevalence was lower in higher educated women in both surveys. In Ethiopia, HIV prevalence fell among no and secondary educated women only (interaction p<0·01). Only among young men in Tanzania there was some evidence that the association between education and HIV changed over time (p=0·07). Pooled analysis found little evidence for an interaction between survey year and the education-HIV association among men (p=0·60) or women (p=0·37). Interpretation The pattern of prevalent HIV infection among young adults by level of education in different sub-Saharan African countries was heterogeneous. There was little statistical evidence that this pattern changed between 2003-5 and 2008-12. Explanations for the social epidemiology of HIV in Africa will need to account for time-trends and inter-country differences.

Overlapping HIV and sex-work stigma among female sex workers recruited to 14 respondent-driven sampling surveys across Zimbabwe, 2013.

ABSTRACT HIV stigma can inhibit uptake of HIV testing and antiretroviral therapy as well as negatively affect mental health. Efforts to reduce discrimination against people living with HIV (LWH) have contributed to greater acceptance of the infection. Female sex workers (FSW) LWH may experience overlapping stigma due to both their work and HIV status, although this is poorly understood. We examined HIV and sex-work stigma experienced by FSW LWH in Zimbabwe. Using the SAPPH-IRe cluster-randomised trial baseline survey, we analysed the data from 1039 FSW self-reporting HIV. The women were recruited in 14 sites using respondent-driven sampling. We asked five questions to assess internalised and experienced stigma related to working as a sex worker, and the same questions were asked in reference to HIV. Among all FSW, 91% reported some form of sex-work stigma. This was not associated with sociodemographic or sex-work characteristics. Rates of sex-work stigma were higher than those of HIV-related stigma. For example, 38% reported being “talked badly about” for LWH compared with 77% for their involvement in sex work. Those who reported any sex-work stigma also reported experiencing more HIV stigma compared to those who did not report sex-work stigma, suggesting a layering effect. FSW in Zimbabwe experience stigma for their role as “immoral” women and this appears more prevalent than HIV stigma. As HIV stigma attenuates, other forms of social stigma associated with the disease may persist and continue to pose barriers to effective care.

Strengthening Routine Data Systems to Track the HIV Epidemic and Guide the Response in Sub-Saharan Africa

The global HIV response has entered a new phase with the recommendation of treating all persons living with HIV with antiretroviral therapy, and with the goals of reducing new infections and AIDS-related deaths to fewer than 500,000 by 2020. This new phase has intensive data requirements that will need to utilize routine data collected through service delivery platforms to monitor progress toward these goals. With a focus on sub-Saharan African, we present the following priorities to improve the demand, supply, and use of routine HIV data: (1) strengthening patient-level HIV data systems that support continuity of clinical care and document sentinel events; (2) leveraging data from HIV testing programs; (3) using targeting data collection in communities and among clients; and (4) building capacity and promoting a culture of HIV data quality assessment and use. When fully leveraged, routine data can efficiently provide timely information at a local level to inform action, as well as provide information at scale with wide geographic coverage to strengthen estimation efforts.

Statistical design and analysis plan for an impact evaluation of an HIV treatment and prevention intervention for female sex workers in Zimbabwe: a study protocol for a cluster randomised controlled trial

BackgroundPragmatic cluster-randomised trials should seek to make unbiased estimates of effect and be reported according to CONSORT principles, and the study population should be representative of the target population. This is challenging when conducting trials amongst ‘hidden’ populations without a sample frame. We describe a pair-matched cluster-randomised trial of a combination HIV-prevention intervention to reduce the proportion of female sex workers (FSW) with a detectable HIV viral load in Zimbabwe, recruiting via respondent driven sampling (RDS).MethodsWe will cross-sectionally survey approximately 200 FSW at baseline and at endline to characterise each of 14 sites. RDS is a variant of chain referral sampling and has been adapted to approximate random sampling. Primary analysis will use the ‘RDS-2’ method to estimate cluster summaries and will adapt Hayes and Moulton’s ‘2-step’ method to adjust effect estimates for individual-level confounders and further adjust for cluster baseline prevalence. We will adapt CONSORT to accommodate RDS. In the absence of observable refusal rates, we will compare the recruitment process between matched pairs. We will need to investigate whether cluster-specific recruitment or the intervention itself affects the accuracy of the RDS estimation process, potentially causing differential biases. To do this, we will calculate RDS-diagnostic statistics for each cluster at each time point and compare these statistics within matched pairs and time points. Sensitivity analyses will assess the impact of potential biases arising from assumptions made by the RDS-2 estimation.DiscussionWe are not aware of any other completed pragmatic cluster RCTs that are recruiting participants using RDS. Our statistical design and analysis approach seeks to transparently document participant recruitment and allow an assessment of the representativeness of the study to the target population, a key aspect of pragmatic trials. The challenges we have faced in the design of this trial are likely to be shared in other contexts aiming to serve the needs of legally and/or socially marginalised populations for which no sampling frame exists and especially when the social networks of participants are both the target of intervention and the means of recruitment.The trial was registered at Pan African Clinical Trials Registry (PACTR201312000722390) on 9 December 2013.

Changes in HIV prevalence among socioeconomic groups in eight African countries: analysis of sequential cross-sectional surveys

Abstract Background Across sub-Saharan Africa, HIV prevalence was highest among higher socioeconomic groups during the 1990s. Population-based data from Tanzania from 2003 to 2007 suggested that this pattern is changing, with HIV prevalence falling among higher-educated groups but remaining stable among those with lower levels of education, suggesting lower incidence in higher-educated groups over this period. A multi-country analysis has not previously been undertaken. Methods We collated data on sociodemographic factors and HIV infection from 16 nationally representative surveys of adults (aged 15–49 years) from Burkina Faso, Ethiopia, Malawi, Lesotho, Kenya, Rwanda, Tanzania, and Zimbabwe. Surveys were conducted 4–6 years apart; sample sizes ranged from 5357 to 29 812 (188 315 individuals total). We used logistic regression to assess gender-stratified associations between highest educational level attained and HIV status in each survey. We adjusted for age and urban/rural setting, and tested for interactions between education level, urban/rural setting, and age. Our primary hypothesis is that higher education level becomes less of a risk for HIV, or protective, over time; we report p values for the statistical interaction between education and survey year. Findings In Ethiopia, there is evidence that the association between HIV prevalence and higher education level was weaker and/or more protective in the second survey in young women (p=0·14) and all men (p=0·11). Similar patterns were observed in Malawian urban women (p=0·03) and rural men (p=0·02), Rwandan older men (p=0·16), Tanzanian men (p=0·07), and rural Zimbabwean women (p=0·07). In Burkina Faso, the risk associated with higher education levels increased (p=0·01) in older men. We found no other changes in association between education and prevalent HIV. Interpretation Changes in the social epidemiology of HIV across sub-Saharan Africa appear heterogeneous. In most cases, where there is evidence of changing association between education and HIV, education has become less risky, or protective, over time. We continue to explore the hypothesis that patterns may depend upon identifiable characteristics of a countrys HIV epidemic. Funding The study was supported through the STRIVE consortium by UKaid from the Department for International Development. However, the views expressed do not necessarily reflect the departments official policies.

Targeted combination prevention to support female sex workers in Zimbabwe accessing and adhering to antiretrovirals for treatment and prevention of HIV (SAPPH-IRe): a cluster-randomised trial.

BACKGROUND 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. METHODS 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. RESULTS 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. INTERPRETATION 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. FUNDING UN Population Fund (through Zimbabwes Integrated Support Fund funded by UK Department for International Development, Irish Aid, and Swedish International Development Cooperation Agency).

Changes in engagement in HIV prevention and care services among female sex workers during intensified community mobilization in 3 sites in Zimbabwe, 2011 to 2015

‘Sisters with a Voice’, Zimbabwes nationally scaled comprehensive programme for female sex workers (FSWs), intensified community mobilization activities in three sites to increase protective behaviours and utilization of clinical services. We compare indicators among FSWs at the beginning and after implementation.