Publications
261 results found
Davis K, Pickles M, Gregson S, et al., 2023, The effect of universal testing and treatment for HIV on health-related quality of life – an analysis of data from the HPTN 071 (PopART) cluster randomised trial, SSM: Population Health, Vol: 23, Pages: 1-10, ISSN: 2352-8273
BackgroundHIV treatment has clear Health-Related Quality-of-Life (HRQoL) benefits. However, little is known about how Universal Testing and Treatment (UTT) for HIV affects HRQoL. This study aimed to examine the effect of a combination prevention intervention, including UTT, on HRQoL among People Living with HIV (PLHIV).MethodsData were from HPTN 071 (PopART), a three-arm cluster randomised controlled trial in 21 communities in Zambia and South Africa (2013–2018). Arm A received the full UTT intervention of door-to-door HIV testing plus access to antiretroviral therapy (ART) regardless of CD4 count, Arm B received the intervention but followed national treatment guidelines (universal ART from 2016), and Arm C received standard care. The intervention effect was measured in a cohort of randomly selected adults, over 36 months. HRQoL scores, and the prevalence of problems in five HRQoL dimensions (mobility, self-care, performing daily activities, pain/discomfort, anxiety/depression) were assessed among all participants using the EuroQol-5-dimensions-5-levels questionnaire (EQ-5D-5L). We compared HRQoL among PLHIV with laboratory confirmed HIV status between arms, using adjusted two-stage cluster-level analyses.ResultsAt baseline, 7,856 PLHIV provided HRQoL data. At 36 months, the mean HRQoL score was 0.892 (95% confidence interval: 0.887–0.898) in Arm A, 0.886 (0.877–0.894) in Arm B and 0.888 (0.884–0.892) in Arm C. There was no evidence of a difference in HRQoL scores between arms (A vs C, adjusted mean difference: 0.003, -0.001-0.006; B vs C: -0.004, -0.014-0.005). The prevalence of problems with pain/discomfort was lower in Arm A than C (adjusted prevalence ratio: 0.37, 0.14–0.97). There was no evidence of differences for other HRQoL dimensions.ConclusionsThe intervention did not change overall HRQoL, suggesting that raising HRQoL among PLHIV might require more than improved testing and treatment. However, PLHIV had fewer problems with p
Pickles M, Gregson S, Moorhouse L, et al., 2023, Strengthening the HIV prevention cascade to maximise epidemiological impact in Eastern Zimbabwe: a modelling study, The Lancet Global Health, Vol: 11, Pages: e1105-e1113, ISSN: 2214-109X
Background HIV prevention cascades provide a systematic understanding of barriers to prevention. In this study we use mathematical modelling to understand the consequences of these barriers and how the cascade could be strengthened to maximise epidemiological impact, providing potentially important insights for programmes. Methods We use an individual-based model of HIV transmission (PopART-IBM), calibrated to cohort data from eastern Zimbabwe. HIV prevention cascade estimates from this cohort are used as probabilities for indicators in the model representing an individual’s ‘motivation’, ‘access’ and ‘capacity to use effectively’ pre-exposure prophylaxis, voluntary male medical circumcision and condom use. We examine how current barriers affect the number and distribution of HIV infections compared to a no-barrier scenario. Using assumptions about how interventions could strengthen the HIV prevention cascade, we estimate the reduction in HIV infections over a ten-year period through addressing different elements of the cascade.Findings 22,000 new potentially ‘avertable’ HIV infections will occur over the next ten years due to existing HIV prevention cascade barriers, 74·2% of the 28,000 new infections that would occur with existing barriers in a population of approximately 1·2 million adults. Removing these barriers would reduce HIV incidence below the benchmarks for epidemic elimination. Addressing all cascade steps in one priority population is much more impactful than addressing one step across all populations. Interpretation Interventions exists in eastern Zimbabwe to reduce HIV towards elimination, but barriers of motivation, access and effective use prevent their full effect being realised. Interventions need to be multi-layered, and address all steps along the HIV prevention cascade. Models incorporating the HIV prevention cascade can help identify the main barriers to greater impact.Funding
Shamsuddin S, Davis K, Moorhouse L, et al., 2023, Relationship between psychological distress, health behaviours and future reports of hypertension among adults in East Zimbabwe: a cohort study, Open Heart, Vol: 10, Pages: 1-10, ISSN: 2053-3624
Introduction:Extensive cross-sectional evidence has demonstrated an association between psychological distress (PD) and hypertension. However, evidence on the temporal relationship is limited, especially in low- and middle-income countries. The role of health risk behaviours including smoking and alcohol consumption in this relationship is also largely unknown. The aim of this study was to investigate the association between PD and later development of hypertension, and how this association may have been influenced by health risk behaviours, among adults in east Zimbabwe.Methods:The analysis included 742 adults (aged 15-54 years) recruited by the Manicaland general population cohort study, who did not have hypertension at baseline in 2012-2013, and who were followed until 2018. In 2012-2013, PD was measured using the Shona Symptom Questionnaire, a screening tool validated for use in Shona speaking countries including Zimbabwe [cut-off point: 7]. Smoking, alcohol consumption, and use of drugs (health risk behaviours) were also self-reported. In 2018, participants reported if they had diagnosed with hypertension by a doctor or nurse. Logistic regression was used to assess the association between PD and hypertension.Results:In 2012, 10.4% of the participants had PD. The odds of new reports of hypertension were 2.04 times greater (95% confidence interval=1.16-3.59) among those with PD at baseline, after adjusting for sociodemographic and health risk behaviour variables. Female gender (adjusted odds ratio, AOR=5.57, 2.82-11.02), older age (AOR=2.72,1.66-4.45), and greater wealth (AOR=2.13, 1.06-4.29 more wealthy, 2.91, 1.26-6.72 most wealthy) were significant risk factors for hypertension. The odds ratio for the relationship between PD and hypertension did not differ substantially between models with and without health risk behaviours.Conclusion:PD was associated with an increased risk of later reports of hypertension in the Manicaland cohort. Integrating mental health a
Sheppard R, Watson OJ, Pieciak R, et al., 2023, Using mortuary and burial data to place COVID-19 in Lusaka, Zambia within a global context, Nature Communications, Vol: 14, Pages: 1-15, ISSN: 2041-1723
Reported COVID-19 cases and associated mortality remain low in many sub-Saharan countries relative to global averages, but true impact is difficult to estimate given limitations around surveillance and mortality registration. In Lusaka, Zambia, burial registration and SARS-CoV-2prevalence data during 2020 allow estimation of excess mortality and transmission. Relative to pre-pandemic patterns, we estimate age-dependent mortality increases, totalling 3,212 excess deaths (95% CrI: 2,104-4,591), representing an 18.5% (95% CrI: 13.0-25.2%) increase relative to pre-pandemic levels. Using a dynamical model-based inferential framework, we find that these mortalitypatterns and SARS-CoV-2 prevalence data are in agreement with established COVID-19 severity estimates. Our results support hypotheses that COVID-19 impact in Lusaka during 2020 was consistent with COVID-19 epidemics elsewhere, without requiring exceptional explanations for low reported figures. For more equitable decision-making during future pandemics, barriers to ascertaining attributable mortality in low-income settings must be addressed and factored into discourse around reported impact differences.
Davis K, Moorhouse L, Maswera R, et al., 2023, Association between HIV status and payment for hypertension care in Manicaland, East Zimbabwe: a cross-sectional study, AIDSImpact 2023
Hall E, Davis K, Ohrnberger J, et al., 2023, PCR134 associations between HIV stigma and health-related quality of life among people living with HIV in Zambia and South Africa: a cross-sectional analysis of data from the HPTN 071 (POPART) study, ISPOR 2023, Publisher: Elsevier, Pages: S336-S337, ISSN: 1098-3015
Little is known about the relationship between HIV stigma and health-related quality of life (HRQoL) among people living with HIV (PLHIV). We aimed to explore associations between four HIV stigma outcomes and HRQoL among PLHIV and examined which HRQoL domains were most affected.
Davis K, Moorhouse L, Maswera R, et al., 2023, Association between symptoms of depression and sexual risk behaviours among young people in Manicaland, East Zimbabwe: a cohort study, AIDSImpact
Skovdal M, Sorensen O, Muchemwa D, et al., 2023, “It will not be easy to accept”: Parents conflicting attitudes towards pre-exposure prophylaxis for HIV prevention amongst adolescent girls and young women in Zimbabwe, Research in Social and Administrative Pharmacy, Vol: 19, Pages: 266-271, ISSN: 1551-7411
Background:Pre-exposure prophylaxis, or PrEP, is a pill that has been hailed as a ‘game changer’ for HIV prevention, based on the belief it provides adolescent girls and young women (AGYW) with a level of user-control. However, engagement with PrEP is often dependent on societal factors, such as social attitudes towards gender, sexuality, and PrEP. As parents' communication on sexual and reproductive health issues with AGYW are central to HIV prevention, it is critical to explore how parents talk and think about PrEP.Objective:To examine parental attitudes towards PrEP for HIV prevention amongst adolescent girls and young women in eastern Zimbabwe.Method:A qualitative interview study with 14 parents from two districts in Manicaland, eastern Zimbabwe. Interviews were transcribed, translated, and subjected to thematic network analysis. The concept of ‘attitudes’ steered the analytical work.Results:Parents' attitudes towards PrEP are conflictual, multi-layered, and contingent on the context in which they reflect and talk about PrEP. While parents aspired to be supportive of innovative HIV prevention methods and wanted to see girl-children protected from HIV, they struggled to reconcile this positive and accepting attitude towards PrEP with traditional ‘good girl’ notions, which stigmatize pre-marital sex. Although a few parents articulated an acceptance of PrEP use amongst their daughters, for many this was simply not possible. Many parents thus co-produce public gender orders that prevent adolescent girls and young women from engaging with PrEP.Conclusions:While parents’ conflicting attitudes towards PrEP may provide spaces and opportunities for change, harmful gender norms and negative attitudes towards PrEP must be addressed at a community and cultural level. Only then can parents and their children have productive conversations about sexual health.
Davis K, Moorhouse L, Maswera R, et al., 2023, Associations between HIV status and self-reported hypertension in a high HIV prevalence sub-Saharan African population: a cross-sectional study, BMJ Open, Vol: 13, ISSN: 2044-6055
Objectives: This study examined whether HIV status and antiretroviral therapy (ART)-exposure were associated with self-reported hypertension in Zimbabwe. Design: Study data were taken from a cross-sectional, general population survey, which included HIV testing (July 2018 – December 2019). Setting: The data were collected in Manicaland Province, Zimbabwe.Participants: 9,780 people aged 15 years and above were included. Outcome measure: Self-reported hypertension was the outcome measure. This was defined as reporting a previous diagnosis of hypertension by a doctor or nurse. After weighting of survey responses by age and sex using household census data, chi-squared tests and logistic regression were used to explore whether HIV status and ART-exposure were associated with self-reported hypertension.Results: The weighted prevalence of self-reported hypertension was 13.6% (95% Confidence Interval: 12.9%-14.2%) and the weighted prevalence of HIV was 11.1% (10.4%-11.7%). In univariable analyses, there was no evidence of a difference in the weighted prevalence of self-reported hypertension between people living with HIV (PLHIV) and HIV-negative people (14.1%, 11.9%-16.3% vs 13.3%, 12.6%-14.0%; p=0.503) or between ART-exposed and ART-naive PLHIV (14.8%, 12.0%-17.7% vs 12.8%, 9.1%-16.4%, p=0.388). Adjusting for socio-demographic variables in logistic regression did not alter this finding (odds ratios: HIV status: 0.88, 0.70-1.10, p=0.261; ART-exposure: 0.83, 0.53-1.30, p=0.411). Conclusions: Approximately one in seven PLHIV self-reported having hypertension, highlighting an important burden of disease. However, no associations were found between HIV status or ART-exposure and self-reported hypertension, suggesting that it will be valuable to focus on managing other risk factors for hypertension in this population. These findings should be fully accounted for as Zimbabwe re-orients its health system towards non-communicable disease control and management.
Skovdal M, Jensen FJB, Maswera R, et al., 2023, Temporal discrepancies in "rapid" HIV testing: explaining misdiagnoses at the point-of-care in Zimbabwe, BMC INFECTIOUS DISEASES, Vol: 23
Skovdal M, Maunzagona T, Dzamatira F, et al., 2023, 'Condoms are hard to get by': access to HIV prevention methods during lockdown of the COVID-19 epidemic in eastern Zimbabwe, Global Health Action, Vol: 16, Pages: 1-10, ISSN: 1654-9880
BACKGROUND: In the early phase of the coronavirus disease 2019 (COVID-19) pandemic, health services were disrupted worldwide, including HIV prevention services. While some studies have begun to document the effects of COVID-19 on HIV prevention, little has been done to qualitatively examine how lockdown measures were experienced and perceived to affect access to HIV prevention methods in sub-Saharan Africa. OBJECTIVES: To explore how the COVID-19 pandemic was perceived to affect access to HIV prevention methods in eastern Zimbabwe. METHOD: This article draws on qualitative data from the first three data collection points (involving telephone interviews, group discussions, and photography) of a telephone and WhatsApp-enabled digital ethnography. Data were collected from 11 adolescent girls and young women and five men over a 5-month period (March-July 2021). The data were analysed thematically. RESULTS: Participants reported widespread interruption to their condom supply when beerhalls were shut down as part of a nationwide lockdown. Restrictions in movement meant that participants who could afford to buy condoms from larger supermarkets or pharmacies were unable to. Additionally, the police reportedly refused to issue letters granting permission to travel for the purpose of accessing HIV prevention services. The COVID-19 pandemic was also described to obstruct the demand (fear of COVID-19, movement restrictions) and supply (de-prioritised, stock-outs) for HIV prevention services. Nonetheless, under certain formal and informal circumstances, such as accessing other and more prioritised health services, or 'knowing the right people', some participants were able to access HIV prevention methods. CONCLUSION: People at risk of HIV experienced the COVID-19 epidemic in Zimbabwe as disruptive to access to HIV prevention methods. While the disruptions were temporary, they were long enough to catalyse local responses, and to highlight the need for future pandemic response cap
Shayegh S, Andreu-Perez J, Akoth C, et al., 2023, Prioritizing COVID-19 vaccine allocation in resource poor settings: Towards an Artificial Intelligence-enabled and Geospatial-assisted decision support framework., PLoS One, Vol: 18, Pages: 1-11, ISSN: 1932-6203
OBJECTIVES: To propose a novel framework for COVID-19 vaccine allocation based on three components of Vulnerability, Vaccination, and Values (3Vs). METHODS: A combination of geospatial data analysis and artificial intelligence methods for evaluating vulnerability factors at the local level and allocate vaccines according to a dynamic mechanism for updating vulnerability and vaccine uptake. RESULTS: A novel approach is introduced including (I) Vulnerability data collection (including country-specific data on demographic, socioeconomic, epidemiological, healthcare, and environmental factors), (II) Vaccination prioritization through estimation of a unique Vulnerability Index composed of a range of factors selected and weighed through an Artificial Intelligence (AI-enabled) expert elicitation survey and scientific literature screening, and (III) Values consideration by identification of the most effective GIS-assisted allocation of vaccines at the local level, considering context-specific constraints and objectives. CONCLUSIONS: We showcase the performance of the 3Vs strategy by comparing it to the actual vaccination rollout in Kenya. We show that under the current strategy, socially vulnerable individuals comprise only 45% of all vaccinated people in Kenya while if the 3Vs strategy was implemented, this group would be the first to receive vaccines.
Beckmann N, Skovdal M, Maswera R, et al., 2022, Rituals of care: Strategies adopted by HIV testers to avoid misdiagnosis in rapid HIV testing in Zimbabwe, Global Public Health, Vol: 17, Pages: 4169-4182, ISSN: 1744-1692
A growing number of studies highlight high levels of misdiagnosis in the scale-up of HIV rapid testing programmes, which often remain invisible to individual testers. Drawing on interviews with HIV testers and observations in four health facilities in Zimbabwe, we show that testers navigated the translation of the standardised, dis-embodied norms of laboratory-based testing into the body work of point-of-care testing through ritualisation of laboratory-practices in their daily clinical work. Yet, this was interrupted through the challenging work conditions the testers face. They ritualised careful procedures, forcing themselves to focus even if queues were long, and making quality assurance procedures part of their daily routine. They actively tried to reduce their workloads and double-checked and discussed unexpected results, especially when a test result did not match their evaluation of clients’ circumstances or clinical status. This helped not only to increase confidence in the authenticity of their diagnosis, but also to share responsibility for potential errors. Existing approaches to tackle the problem of misdiagnosis through quality assurance (QA) procedures mainly focus on adjusting individual testers’ performance and ensuring that basic testing resources were present, thus falling short of creating a work environment that is conducive to high quality testing.
Rao A, Moorhouse L, Maswera R, et al., 2022, Status of the HIV epidemic in Manicaland, east Zimbabwe prior to the outbreak of the COVID-19 pandemic, PLoS One, Vol: 17, Pages: 1-19, ISSN: 1932-6203
BackgroundManicaland province in eastern Zimbabwe has a high incidence of HIV. Completion of the seventh round of the Manicaland Survey in 2018–2019 provided the opportunity to assess the state of the epidemic prior to the start of the COVID-19 pandemic. The study aims were to: a) estimate HIV seroprevalence and assess whether prevalence has declined since the last round of the survey (2012–2013), b) describe and analyse the socio-demographic and behavioural risk factors for HIV infection and c) describe the HIV treatment cascade.MethodsParticipants were administered individual questionnaires collecting data on socio-demographic characteristics, sexual relationships, HIV prevention methods and treatment access, and were tested for HIV. Descriptive analyses were followed by univariate and multivariate analyses of risk factors for HIV seropositvity using logistic regression modelling based on the proximate-determinants framework.ResultsHIV prevalence was 11.3% [95% CI; 10.6–12.0] and was higher in females than males up to 45–49 years. Since 2012–2013 HIV prevalence has significantly declined in 30–44 year-olds in males, and 20–44 year-olds in females. The HIV epidemic has aged since 2012–2013, with an increase in the mean age of HIV positive persons from 38 to 41 years. Socio-demographic determinants of HIV prevalence were church denomination in males, site-type, wealth-status, employment sector and alcohol use in females, and age and marital status in both sexes. Behavioural determinants associated with increased odds of HIV were a higher number of regular sexual partners (lifetime), non-regular sexual partners (lifetime) and condom use in both sexes, and early sexual debut and concomitant STIs in females; medical circumcision was protective in males. HIV status awareness among participants testing positive in our study was low at 66.2%. ART coverage amongst all participants testing positive for HIV in our study was 65.
Skovdal M, Clausen CL, Magoge-Mandizvidza P, et al., 2022, How gender norms and 'good girl' notions prevent adolescent girls and young women from engaging with PrEP: qualitative insights from Zimbabwe, BMC Womens Health, Vol: 22, ISSN: 1472-6874
Background:Pre-exposure prophylaxis, or PrEP, has been hailed for its promise to provide women with user-control. However, gender-specific challenges undermining PrEP use are beginning to emerge. We explore the role of gender norms in shaping adolescent girls and young women’s (AGYW) engagement with PrEP.Methods:We draw on qualitative data from 12 individual interviews and three focus group discussions with AGYW from eastern Zimbabwe. Interviews were transcribed and thematically coded in NVivo 12. Emerging themes were further investigated using Connell’s notion of ‘emphasised femininity’.Results:Participants alluded to the patriarchal society they are part of, with ‘good girl’ notions subjecting them to direct and indirect social control. These controls manifest themselves through the anticipation of intersecting sexuality- and PrEP-related stigmas, discouraging AGYW from engaging with PrEP. AGYW recounted the need for permission to engage with PrEP, forcing them to consider engaging with PrEP in secrecy. In addition, limited privacy at home, and fear of disclosure of their health clinic visits, further heightened their fear of engaging with PrEP. PrEP is not simply a user-controlled HIV prevention method, but deeply entrenched within public gender orders.Conclusion:AGYW face significant limitations in their autonomy to initiate and engage with PrEP. Those considering PrEP face the dilemma of Scylla and Charybdis: The social risks of stigmatisation or risks of HIV acquisition. Efforts to make PrEP available must form part of a combination of social and structural interventions that challenge harmful gender norms.
Davis K, Pickles M, Gregson S, et al., 2022, The effect of universal testing and treatment for HIV on health-related quality of life - data from the HPTN 071 (PopART) cluster randomised trial in Zambia and South Africa, AIDS 2022, Publisher: International AIDS Society, ISSN: 1758-2652
Gregson S, Dadirai T, Maswera R, et al., 2022, Survey measurements of community norms on adolescent girls and young women's (AGYW) sexual behaviour and use of condoms for HIV prevention in Manicaland, East Zimbabwe, 24th International AIDS Conference, Publisher: International AIDS Society, Pages: 88-88, ISSN: 1758-2652
Background: Qualitative data suggest pre-marital sex stigma presents a major obstacle to AGYW's use of HIV prevention methods. Lack of social acceptability therefore is included as a barrier to motivation to use condoms in HIV prevention cascades. Representative survey data on community norms are rare but necessary to test the validity of this assumption and measure their contributions to gaps in prevention cascades. Methods: General-population survey participants in Manicaland (ages≥15,N = 9803) were asked if they agreed/disagreed with statements on social norms. AGYW were asked whether community views are an obstacle to their using condoms. Proportions agreeing/disagreeing with these statements were calculated, variations in community members’ views were investigated in multivariable logistic-regression models, and the association between AGYW's perceiving negative community norms and condom use was measured.Results: 93.5%(95%CI,93%-94%) of respondents agreed that ‘Many young women have sex before marriage these days’. 57%(56%-59%) of men and 70%(69%-71%) of women disagreed that ‘If I have a teenage daughter and she has sex before marriage, I would be ok with this’; and 41%(40%-43%) of men and 57%(56%-59%) of women disagreed that ‘If I have a teenage daughter, I would tell her about condoms’. Fathers but not mothers were more likely to disagree with their daughters having sex before marriage (Figure). Similar proportions of parents and other community members were against telling daughters about condoms. 68%(61%-75%) of sexually-active unmarried AGYW said negative community views were unimportant in decisions to use condoms. Condom use didn't differ between those who agreed/disagreed that negative community views are important (46.9% vs. 50.0%; AOR = 0.88, 95%CI, 0.48–1.62; N = 202).Conclusions: Community resistance to condom promotion based on pre-marital sex stigma may be weakening as a barrier to AGYW's motivat
Shamsuddin S, Davis K, Moorhouse L, et al., 2022, Association between psychological distress and later reports of hypertension amongst adults in East Zimbabwe, 31st European Meeting on Hypertension and Cardiovascular Protection (ESH 2022), Publisher: Lippincott, Williams & Wilkins, Pages: e213-e213, ISSN: 0263-6352
Objective: Little is known about the temporal relationship between psychological distress (PD) and hypertension, especially in low-income countries. We assessed the association between PD and later development of hypertension among Zimbabwean adults, and the role of smoking, alcohol consumption and recreational drug use in this relationship.Design and method: Data were taken from the Manicaland Study, an open cohort study in east Zimbabwe. Participants aged 15–54 were surveyed in 2012/2013 and followed-up in 2018/19. At baseline, PD was assessed using the Shona Symptom Questionnaire, a screening tool developed and validated in Shona-speaking countries. Participants self-reported whether they were currently: smokers; took drugs for pleasure; or regularly visited bars and/or consumed over three alcoholic drinks per sitting. At baseline and follow-up, participants reported whether they had ever been diagnosed with hypertension by a doctor/nurse. We selected individuals who did not report hypertension at baseline and used logistic regression to examine associations between baseline PD and hypertension at follow-up, controlling for sociodemographic and economic confounders. We also explored the effect of including binary variables capturing smoking status, drug use and alcohol consumption in the model.Results: 742 participants who completed baseline and follow-up surveys, were not hypertensive at baseline, and had full covariate data, were included. At baseline, 10.4% of these had PD, and at follow-up 17.5% (overall) had developed hypertension. The odds of developing hypertension were 2.01 (95% Confidence Interval = 1.14–3.54) times higher among those with PD at baseline, after adjustment for sociodemographic and economic confounders (Table 1). Introducing smoking status, drug use and alcohol consumption into the model had little effect on our findings (adjusted Odds Ratio, aOR:2.04, 1.16–3.59) and we had little evidence that these behaviours were indep
Skovdal M, Magoge-Mandizvidza P, Dzamatira F, et al., 2022, Improving access to pre-exposure prophylaxis for adolescent girls and young women: recommendations from healthcare providers in eastern Zimbabwe, BMC Infectious Diseases, Vol: 22, Pages: 1-10, ISSN: 1471-2334
BackgroundIn sub-Saharan Africa, adolescent girls and young women (AGYW) are at high risk of acquiring HIV. A growing number of sub-Saharan African countries are beginning to avail pre-exposure prophylaxis, or PrEP, but with limited success. Unpacking strategies to overcome barriers to the uptake of PrEP is critical to prevent HIV amongst AGYW. This article explores health professionals’ views and recommendations on what is required to increase uptake of PrEP.MethodsThe study draws on interview data from 12 providers of HIV prevention services in eastern Zimbabwe. The healthcare providers were purposefully recruited from a mix of rural and urban health facilities offering PrEP. The interviews were transcribed and imported into NVivo 12 for thematic coding and network analysis.ResultsOur analysis revealed six broad strategies and 15 concrete recommendations which detail the range of elements healthcare providers consider central for facilitating engagement with PrEP. The healthcare providers called for: (1) PrEP marketing campaigns; (2) youth-friendly services or corners; (3) improved PrEP delivery mechanisms; (4) improvements in PrEP treatment; (5) greater engagement with key stakeholders, including with young people themselves; and (6) elimination of costs associated with PrEP use. These recommendations exemplify an awareness amongst healthcare providers that PrEP access is contingent on a range of factors both inside and outside of the clinical setting.ConclusionsHealthcare providers are at the frontline of the HIV epidemic response. Their community-embeddedness, coupled with their interactions and encounters with AGYW, make them well positioned to articulate context-specific measures for improving access to PrEP. Importantly, the breadth of their recommendations suggests recognition of PrEP use as a complex social practice that requires integration of a combination of interventions, spanning biomedical, structural, and behavioural domains.
Moorhouse L, Schaefer R, Eaton JW, et al., 2022, Male partners' influence on adolescent girls and young women's use of combination HIV prevention: insights from analysis of HIV-prevention cascade data collected in a general-population survey in Manicaland, Zimbabwe, AIDS 2022
Hall E, Davis K, Ohrnberger J, et al., 2022, Associations between HIV stigma and health-related quality of life among people living with HIV in Zambia and South Africa: Cross-sectional analysis of data from the HPTN071 (PopART) study, AIDS 2022
Skovdal M, Beckmann N, Maswera R, et al., 2022, The (in)visibility of misdiagnosis in point-of-care HIV testing in Zimbabwe, Medical Anthropology: cross-cultural studies in health and illness, Vol: 41, Pages: 404-417, ISSN: 0145-9740
There is a global trend to introduce point-of-care diagnostic tests, enabling healthcare workers at any level to test, provide results, and initiate immediate treatment if necessary. This article explores how healthcare workers conducting rapid HIV tests – in contexts of limited external quality assurance mechanisms – ascertain the accuracy of their test results. Drawing on interview data and participant observations from health facilities in Zimbabwe, we open the black box of misdiagnosis (in)visibility and reveal a range of proxies and markers that HIV testers draw on to develop certainty, or question, the reliability of their diagnostic classifications.
Goodwin T, Gregson S, Maswera R, et al., 2021, Understanding the determinants and consequences of HIV status disclosure in Manicaland, Zimbabwe: cross-sectional and prospective analyses, AIDS Care: psychological and socio-medical aspects of AIDS-HIV, Vol: 33, Pages: 1577-1594, ISSN: 0954-0121
Few longitudinal studies have measured trends and effects of disclosure over ART scale-up in general-population samples. We investigated levels, determinants and outcomes of disclosure to relatives and partners in a large general-population cohort in Zimbabwe. Trends in disclosure levels from 2003-2013 were analysed, and multivariable logistic regression was used to identify determinants. Longitudinal analyses were conducted testing associations between disclosure and prevention/treatment-related outcomes. Disclosure to anyone increased from 79% to 100% in men and from 63% to 98% in women from 2003-2008; but declined to 89% in both sexes in 2012-2013. More women than men disclosed to relatives (67.8% versus 44.4%; p<0.001) but fewer women disclosed to partners (85.3% versus 95.0%; p<0.001). In 2012-13, younger age, secondary/higher education, being single, and experience of stigma were associated with disclosure to relatives in both sexes. Partner characteristics and HIV-group attendance were associated with disclosure to partners for women. Reactions to disclosure were generally supportive but less so for females than males disclosing to partners (92.0% versus 97.4%). Partner disclosure was associated with greater social support and treatment adherence in females. To conclude, this study shows disclosure is vital to HIV prevention and treatment, and programmes to facilitate disclosure should be re-invigorated.
Chang A, Maswera R, Moorhouse L, et al., 2021, The determinants and impacts of age-disparate relationships on women in Zimbabwe: A life course perspective, Social Science and Medicine – Population Health, Vol: 16, Pages: 1-9, ISSN: 2352-8273
Age-disparate relationships (ADR) with older men have been studied mostly in the context of HIV and found to be associated with increased HIV prevalence among young women in sub-Saharan Africa. Less is known about the impact of ADR on the broader life course of women. The objectives of this study are to identify the factors associated with being in ADR and estimate the association between ADR and a set of life outcomes in Manicaland, Zimbabwe. We used data from a general population open-cohort survey from 1998 to 2013 in Manicaland. We applied binary logistic regression models to estimate the odds ratios for association between socio-demographic determinants and ADR and multinomial logistic regression models to estimate the association between ADR and women's life outcomes. We found that women with less education, younger age at first sex and first marriage were more likely to be in ADR, and women in ADR have male partners with less education and less skilled employment. In terms of life and relationship outcomes, women in ADR had mostly negative life outcomes compared to women not in ADR. Future policies and research on ADR in women should reflect these complexities and study a wider range of life outcomes, beyond the commonly studied narrower topics such as HIV.
Stapley J, Davis K, Dadirai T, et al., 2021, Impact of community-level ART coverage on HIV-related stigmatising attitude within a general population cohort in Manicaland, east Zimbabwe; a longitudinal study, 12th Annual International Conference on Stigma
Tlhajoane M, Dzamatira F, Kadzura N, et al., 2021, Incidence and predictors of attrition among patients receiving ART in eastern Zimbabwe before, and after the introduction of universal ‘treat-all’ policies: A competing risk analysis, PLOS Global Public Health, Vol: 1, Pages: 1-15
As HIV treatment is expanded, attention is focused on minimizing attrition from care. We evaluated the impact of treat-all policies on the incidence and determinants of attrition amongst clients receiving ART in eastern Zimbabwe. Data were retrospectively collected from the medical records of adult patients (aged≥18 years) enrolled into care from July 2015 to June 2016—pre-treat-all era, and July 2016 to June 2017—treat-all era, selected from 12 purposively sampled health facilities. Attrition was defined as an absence from care >90 days following ART initiation. Survival-time methods were used to derive incidence rates (IRs), and competing risk regression used in bivariate and multivariable modelling. In total, 829 patients had newly initiated ART and were included in the analysis (pre-treat-all 30.6%; treat-all 69.4%). Incidence of attrition (per 1000 person-days) increased between the two time periods (pre-treat-all IR = 1.18 (95%CI: 0.90–1.56) versus treat-all period IR = 1.62 (95%CI: 1.37–1.91)). In crude analysis, patients at increased risk of attrition were those enrolled into care during the treat-all period, <34 years of age, WHO stage I at enrolment, and had initiated ART on the same day as HIV diagnosis. After accounting for mediating clinical characteristics, the difference in attrition between the pre-treat-all, and treat-all periods ceased to be statistically significant. In a full multivariable model, attrition was significantly higher amongst same-day ART initiates (aSHR = 1.47, 95%CI:1.05–2.06). Implementation of treat-all policies was associated with an increased incidence of ART attrition, driven largely by ART initiation on the same day as HIV diagnosis which increased significantly in the treat all period. Differentiated adherence counselling for patients at increased risk of attrition, and improved access to clinical monitoring may improve retention in care.
Davis K, Perez-Guzman P, Hoyer A, et al., 2021, Correction to: Association between HIV infection and hypertension: a global systematic review and meta-analysis of cross-sectional studies., BMC Medicine, Vol: 19, Pages: 228-228, ISSN: 1741-7015
Davis K, Muzariri K, Mangenah C, et al., 2021, Modelling the interaction between depression and HIV incidence in Manicaland, East Zimbabwe, Fast Track Cities 2021
Risher K, Cori A, Reniers G, et al., 2021, Age patterns of HIV incidence in eastern and southern Africa: a collaborative analysis of observational general population cohort studies, The Lancet HIV, Vol: 8, Pages: e429-e439, ISSN: 2405-4704
Background: As the HIV epidemic in sub-Saharan Africa matures, evidence about the age distribution of new HIV infections and how this has changed over the epidemic is needed to guide HIV prevention. We assessed trends in age-specific HIV incidence in six population-based cohort studies in eastern and southern Africa, reporting changes in average age at infection, age distribution of new infections, and birth cohort cumulative incidence. Methods: We used a Bayesian model to reconstruct age-specific HIV incidence from repeated observations of individuals’ HIV serostatus and survival collected among population HIV cohorts in rural Malawi, South Africa, Tanzania, Uganda, and Zimbabwe. The HIV incidence rate by age, time and sex was modelled using smooth splines functions. Incidence trends were estimated separately by sex and study. Estimated incidence and prevalence results for 2000-2017, standardised to study population distribution, were used to estimate average age at infection and proportion of new infections by age. Findings: Age-specific incidence declined at all ages, though the timing and pattern of decline varied by study. The average age at infection was higher in men (cohort means: 27·8-34·6 years) than women (cohort means: 24·8-29·6 years). Between 2000 and 2017, the average age at infection increased slightly: cohort means 0·5-2·8 years among men and -0·2-2·5 years among women. Across studies, between 38-63%(cohort means)of women’s infections were among 15-24-year-olds and between 30-63% of men’s infections were in 20-29-year-olds. Lifetime risk of HIV declined for successive birth cohorts. Interpretation: HIV incidence declined in all age groups and shifted slightly, but not dramatically, to older ages. Disproportionate new HIV infections occur among 15-24-year-old 4women and20-29-year-oldmen, supporting focused prevention in these groups. But 40-60% of infections were outside these
Wolock T, Flaxman S, Risher K, et al., 2021, Evaluating distributional regression strategies for modelling self-reported sexual age-mixing, eLife, Vol: 10, Pages: 1-38, ISSN: 2050-084X
The age dynamics of sexual partnership formation determine patterns of sexually transmitted disease transmission and have long been a focus of researchers studying human immunodeficiency virus. Data on self-reported sexual partner age distributions are available from a variety of sources. We sought to explore statistical models that accurately predict the distribution of sexual partner ages over age and sex. We identified which probability distributions and outcome specifications best captured variation in partner age and quantified the benefits of modelling these data using distributional regression. We found that distributional regression with a sinh-arcsinh distribution replicated observed partner age distributions most accurately across three geographically diverse data sets. This framework can be extended with well-known hierarchical modelling tools and can help improve estimates of sexual age-mixing dynamics.
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