Owen Mugurungi

HIV decline in Zimbabwe due to reductions in risky sex? Evidence from a comprehensive epidemiological review

Background Recent data from antenatal clinic (ANC) surveillance and general population surveys suggest substantial declines in human immunodeficiency virus (HIV) prevalence in Zimbabwe. We assessed the contributions of rising mortality, falling HIV incidence and sexual behaviour change to the decline in HIV prevalence. Methods Comprehensive review and secondary analysis of national and local sources on trends in HIV prevalence, HIV incidence, mortality and sexual behaviour covering the period 1985–2007. Results HIV prevalence fell in Zimbabwe over the past decade (national estimates: from 29.3% in 1997 to 15.6% in 2007). National census and survey estimates, vital registration data from Harare and Bulawayo, and prospective local population survey data from eastern Zimbabwe showed substantial rises in mortality during the 1990s levelling off after 2000. Direct estimates of HIV incidence in male factory workers and women attending pre- and post-natal clinics, trends in HIV prevalence in 15–24-year-olds, and back-calculation estimates based on the vital registration data from Harare indicated that HIV incidence may have peaked in the early 1990s and fallen during the 1990s. Household survey data showed reductions in numbers reporting casual partners from the late 1990s and high condom use in non-regular partnerships between 1998 and 2007. Conclusions These findings provide the first convincing evidence of an HIV decline accelerated by changes in sexual behaviour in a southern African country. However, in 2007, one in every seven adults in Zimbabwe was still infected with a life-threatening virus and mortality rates remained at crisis level.

A Surprising Prevention Success: Why Did the HIV Epidemic Decline in Zimbabwe?

Daniel Halperin and colleagues examine reasons for the remarkable decline in HIV in Zimbabwe, in the context of severe social, political, and economic disruption.

Evaluation of the PIMA point-of-care CD4 analyzer in VCT clinics in Zimbabwe.

Point-of-care (POC) CD4 testing was implemented at a stand-alone HIV voluntary testing and counseling centre in Harare, Zimbabwe. To validate the use of this new technology, paired blood samples were collected from 165 patients either by a nurse or a laboratory technician and tested using POC and conventional laboratory CD4 machines. Finger prick (capillary) blood was collected directly into the PIMA POC CD4 Analyzer cartridges and tested immediately, whereas venous blood collected into evacuated tubes was used for CD4 enumeration on a Becton Dickinson FACSCalibur. There was no significant difference in mean absolute CD4 counts between the POC PIMA and Becton Dickinson FACSCalibur platforms (+7.6 cells/μL; P = 0.72). Additionally, there was no significant difference in CD4 counts between the platforms when run by either a nurse (+18.0 cells/μL; P = 0.49), or a laboratory technicians (−3.1 cells/μL; P = 0.93). This study demonstrates that POC CD4 testing can be conducted in a voluntary testing and counseling setting for staging HIV-positive clients. Both nurses and laboratory technicians performed the test accurately, thereby increasing the human resources available for POC CD4 testing. By producing same-day results, POC CD4 facilitates immediate decision-making, patient management and referral and may help improve patient care and retention. POC CD4 may also alleviate testing burdens at traditional central CD4 laboratories, hence improving test access in both rural and urban environments.

HIV prevalence and trends from data in Zimbabwe, 1997–2004

Background: This paper brings together data from a variety of reports to provide a basis for assessing future steps for responding to and monitoring the HIV epidemic in Zimbabwe. Method: Data reported from four antenatal clinic (ANC) surveys conducted between 2000 and 2004, two small local studies in Zimbabwe conducted from 1997 through 2003, four general population surveys from 1999 through 2003, and service statistics covering 1990 through 2004 were used to describe recent trends in HIV prevalence and incidence, behaviour change, and programme provision. Results: HIV prevalence among pregnant women attending ANCs declined substantially from 32.1% in 2000 to 23.9% in 2004. The local studies confirmed the decline in prevalence. However, prevalence continued to be high. Sexual behaviour data from surveys suggests a reduction in sexual experience before age 15 years among both males and females age 15–19 years, and in the proportions of males and females aged 15–29 years reporting non-regular sexual partners in the past 12 months. Reported condom use with non-regular partners has been high since 1999. Condom distribution and HIV counseling and testing increased from 2000 to 2004. Discussion: On the basis of examination of data from a variety of sources, the recent decrease in HIV prevalence may be related to recent reductions in early-age sexual activity and non-regular sexual partnerships and increases in condom use. Comparison of data from sentinel surveillance systems, population based serosurveys, local studies, and service statistics provide increased confidence that a decline in HIV prevalence in Zimbabwe is actually happening in the population.

Assessing evidence for behaviour change affecting the course of HIV epidemics: A new mathematical modelling approach and application to data from Zimbabwe

BACKGROUND Determining whether interventions to reduce HIV transmission have worked is essential, but complicated by the potential for generalised epidemics to evolve over time without individuals changing risk behaviour. We aimed to develop a method to evaluate evidence for changes in risk behaviour altering the course of an HIV epidemic. METHODS We developed a mathematical model of HIV transmission, incorporating the potential for natural changes in the epidemic as it matures and the introduction of antiretroviral treatment, and applied a Bayesian Melding framework, in which the model and observed trends in prevalence can be compared. We applied the model to Zimbabwe, using HIV prevalence estimates from antenatal clinic surveillance and house-hold based surveys, and basing model parameters on data from sexual behaviour surveys. RESULTS There was strong evidence for reductions in risk behaviour stemming HIV transmission. We estimate these changes occurred between 1999 and 2004 and averted 660,000 (95% credible interval: 460,000-860,000) infections by 2008. DISCUSSION The model and associated analysis framework provide a robust way to evaluate the evidence for changes in risk behaviour affecting the course of HIV epidemics, avoiding confounding by the natural evolution of HIV epidemics.

Barriers and Motivators to Voluntary Medical Male Circumcision Uptake among Different Age Groups of Men in Zimbabwe: Results from a Mixed Methods Study

Background We conducted quantitative and qualitative studies to explore barriers and motivating factors to VMMC for HIV prevention, and to assess utilization of existing VMMC communication channels. Methods and Findings A population-based survey was conducted with 2350 respondents aged 15–49. Analysis consisted of descriptive statistics and bivariate analysis between circumcision and selected demographics. Logistic regression was used to determine predictors of male circumcision uptake compared to intention to circumcise. Focus group discussions (FGDs) were held with men purposively selected to represent a range of ethnicities. 68% and 53% of female/male respondents, respectively, had heard about VMMC for HIV prevention, mostly through the radio (71%). Among male respondents, 11.3% reported being circumcised and 49% reported willingness to undergo VMMC. Factors which men reported motivated them to undergo VMMC included HIV/STI prevention (44%), improved hygiene (26%), enhanced sexual performance (6%) and cervical cancer prevention for partner (6%). Factors that deterred men from undergoing VMMC included fear of pain (40%), not believing that they were at risk of HIV (18%), lack of partner support (6%). Additionally, there were differences in motivators and barriers by age. FGDs suggested additional barriers including fear of HIV testing, partner refusal, reluctance to abstain from sex and myths and misconceptions. Conclusions VMMC demand-creation messages need to be specifically tailored for different ages and should emphasize non-HIV prevention benefits, such as improved hygiene and sexual appeal, and need to address mens fear of pain. Promoting VMMC among women is crucial as they appear to have considerable influence over mens decision to get circumcised.

Patient Retention, Clinical Outcomes and Attrition-Associated Factors of HIV-Infected Patients Enrolled in Zimbabwe's National Antiretroviral Therapy Programme, 2007???2010

Background Since establishment of Zimbabwes National Antiretroviral Therapy (ART) Programme in 2004, ART provision has expanded from <5,000 to 369,431 adults by 2011. However, patient outcomes are unexplored. Objective To determine improvement in health status, retention and factors associated with attrition among HIV-infected patients on ART. Methods A retrospective review of abstracted patient records of adults ≥15 years who initiated ART from 2007 to 2009 was done. Frequencies and medians were calculated for rates of retention in care and changes in key health status outcomes at 6, 12, 24 and 36 months respectively. Cox proportional hazards models were used to determine factors associated with attrition. Results Of the 3,919 patients, 64% were female, 86% were either WHO clinical stage III or IV. Rates of patient retention at 6, 12, 24 and 36 months were 90.7%, 78.1%, 68.8% and 64.4%, respectively. After ART initiation, median weight gains at 6, 12, and 24 months were 3, 4.5, and 5.0 kgs whilst median CD4+ cell count gains at 6, 12 and 24 months were 122, 157 and 279 cells/µL respectively. Factors associated with an increased risk of attrition included male gender (AHR 1.2; 95% CI, 1.1–1.4), baseline WHO stage IV (AHR 1.7; 95% CI, 1.1–2.6), lower baseline body weight (AHR 2.0; 95% CI, 1.4–2. 8) and accessing care from higher level healthcare facilities (AHR 3.5; 95% 1.1–11.2). Conclusions Our findings with regard to retention as well as clinical and immunological improvements following uptake of ART, are similar to what has been found in other settings. Factors influencing attrition also mirror those found in other parts of sub-Saharan Africa. These findings suggest the need to strengthen earlier diagnosis and treatment to further improve treatment outcomes. Whilst decentralisation improves ART coverage it should be coupled with strategies aimed at improving patient retention.

Survey of children accessing HIV services in a high prevalence setting: time for adolescents to count?

OBJECTIVE To establish the proportion of adolescents among children infected with human immunodeficiency virus (HIV) in Zimbabwe who receive HIV care and support, and what clinic staff perceives to be the main problems faced by HIV-infected children and adolescents. METHODS In July 2008, we sent a questionnaire to all 131 facilities providing HIV care in Zimbabwe. In it we requested an age breakdown of the children (aged 0-19 years) registered for care and asked what were the two major problems faced by younger children (0-5 years) and adolescents (10-19 years). FINDINGS Nationally, 115 (88%) facilities responded. In 98 (75%) that provided complete data, 196 032 patients were registered and 24 958 (13%) of them were children. Of children under HIV care, 33% were aged 0-4 years; 25%, 5-9 years; 25%, 10-14 years; and 17%, 15-19 years. Staff highlighted differences in the problems most commonly faced by younger children and adolescents. For younger children, such problems were malnutrition and lack of appropriate drugs (cited by 46% and 40% of clinics, respectively); for adolescents they concerned psychosocial issues and poor drug adherence (cited by 56% and 36%, respectively). CONCLUSION Interventions for the large cohort of adolescents who are receiving HIV care in Zimbabwe need to target the psychosocial concerns and poor drug adherence reported by staff as being the main concerns in this age group.

Do behavioural differences help to explain variations in HIV prevalence in adolescents in sub-Saharan Africa?

Objective  To compare adolescent risk factors for HIV infection in two countries with high adolescent HIV prevalence and two lower prevalence countries with the aim of identifying risk factors that may help explain differences in adolescent HIV prevalence.

Lessons learned from scale-up of voluntary medical male circumcision focusing on adolescents: benefits, challenges, and potential opportunities for linkages with adolescent HIV, sexual, and reproductive health services.

Background and Methods:By December 2013, it was estimated that close to 6 million men had been circumcised in the 14 priority countries for scaling up voluntary medical male circumcision (VMMC), the majority being adolescents (10–19 years). This article discusses why efforts to scale up VMMC should prioritize adolescent men, drawing from new evidence and experiences at the international, country, and service delivery levels. Furthermore, we review the extent to which VMMC programs have reached adolescents, addressed their specific needs, and can be linked to their sexual and reproductive health and other key services. Results and Discussion:In priority countries, adolescents represent 34%–55% of the target population to be circumcised, whereas program data from these countries show that adolescents represent between 35% and 74% of the circumcised men. VMMC for adolescents has several advantages: uptake of services among adolescents is culturally and socially more acceptable than for adults; there are fewer barriers regarding sexual abstinence during healing or female partner pressures; VMMC performed before the age of sexual debut has maximum long-term impact on reducing HIV risk at the individual level and consequently reduces the risk of transmission in the population. Offered as a comprehensive package, adolescent VMMC can potentially increase public health benefits and offers opportunities for addressing gender norms. Additional research is needed to assess whether current VMMC services address the specific needs of adolescent clients, to test adapted tools, and to assess linkages between VMMC and other adolescent-focused HIV, health, and social services.