Towards ending HIV in Zimbabwe through focusing on improving targeting of HIV testing and uptake of HIV prevention in adolescent girls and young women

Lead Research Organisation: University College London
Department Name: Institute for Global Health

Abstract

In Zimbabwe HIV remains the leading cause of death. In 2016, 1 in 7 adults were living with HIV.
In order to end the HIV epidemic as a public health threat by 2030, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set the targets of: (a) 95% of people living with HIV (PLWH) being diagnosed, (b) 95% of those diagnosed on antiretroviral therapy (ART), and (c) 95% of those on ART with an undetectable viral load ("suppressed"). These targets were based on the rationale that PLWH diagnosed, on ART and suppressed have near normal life-expectancy and cannot transmit the virus to others. In Zimbabwe in 2016 these were: (a) 73%, (b) 87% and (c) 86%, respectively, despite the number of HIV tests having increased by four-fold between 2007 and 2017. This is particularly low among adolescents and young people. In addition, the proportion of all HIV tests with a positive result has been declining, with a higher cost to identify each new case. For this reason, Zimbabwe is shifting to differentiated HIV testing strategies, targeting sub-populations at higher risk of HIV and using a range of testing strategies (e.g. "index testing", whereby household, family members or partners of people diagnosed with HIV are offered an HIV test; self-testing). However, the impact of this shift is unclear, as is whether it offers value for money.
Adolescent girls and young women (AGYW; aged 15-24) are disproportionately affected by HIV. The World Health Organization (WHO) recommends Pre-Exposure Prophylaxis (PrEP; use of specific antiretrovirals in people without HIV to prevent HIV infection), as an additional choice for people at substantial risk of HIV (including AGYW). In Zimbabwe PrEP roll out has started, but only 4% of current users are AGYW (not counting those reporting as selling sex). An approach to increase PrEP use among those AGYW most at risk is required. Studies evaluating the safety and efficacy of additional PrEP formulations (long-acting injectables, implants, other antiretrovirals and in combination with contraceptives) are ongoing. However, little is known about preferences of AGYW for different PrEP attributes, nor is there information on how to ensure high uptake and sufficient support among this group.
The overall aim of this fellowship is to fill these gaps. This will be achieved by:
a. working closely with the Zimbabwe Ministry of Health and Child Care and other stakeholders to identify the optimal combination of HIV testing strategies that maximise health, within the budget available, to assess its impact (in terms of HIV infections, morbidity and mortality) and whether this combination is predicted to achieve the target of 95% of PLWH being diagnosed by 2030. This will be performed using a mathematical model informed by analysis of data already collected in Zimbabwe.
b. co-developing with AGYW a PrEP implementation intervention for AGYW who need it, that attracts them to PrEP, and supports them while taking PrEP, with the potential to offer value for money. This will be achieved using qualitative and quantitative methods (survey of AGYW) and mathematical modelling.
If the PrEP implementation intervention developed has the potential to offer value for money and being affordable, it will be then evaluated in a randomised trial in Years 5-7.

The research will be led by Dr Valentina Cambiano, Lecturer in Infectious Disease Modelling and Biostatistics at University College London (UCL) and will draw together experts from UCL, the Liverpool School of Tropical Medicine and the Centre for Sexual Health and HIV/AIDS Research Zimbabwe and Zimbabwe and international policy makers.

This research is required to address questions low- and middle- income countries with a high HIV burden are facing.

Planned Impact

The research produced through this fellowship has a number of beneficiaries. The order in which they are presented reflects when the impact will be realised.

Firstly, the academic community, including the research team and students, will benefit. This project will expand knowledge in the field of HIV testing and prevention and sexual health more broadly and be of interest for the following disciplines: public health, epidemiology, mathematical modelling for infectious diseases, health economics and social sciences. I will master my leadership skills and strengthen and widen my academic knowledge and experience to become an independent researcher leader. The researchers employed through this fellowship, who will all be based in Zimbabwe except for me (who will spend a substantial amount of time there) and my co-I Dr Copas, will have the opportunity to gain further research experience and be supervised by national and international experts so that they become highly skilled researchers for the future. University College London (UCL) will benefit, as it will allow UCL to diversify its research portfolio, strengthen collaboration with research institutions and stakeholders in Zimbabwe and produce high-quality research in a crucial area of public health. UCL students will benefit as findings from this research will be embedded into teaching, with the aim of enhancing their learning experience. This impact will be realised in the short- (during the term of the grant) and middle-term of the grant (by Years 5-7) but of course with long lasting consequences.

Secondly, the Zimbabwe Ministry of Health and Child Care (ZMoHCC), national (Zimbabwe National AIDS Council) and international health agencies (e.g. World Health Organization, Joint United Nations Programme on HIV/AIDS), donors (e.g. the Global Fund, USAID, and Bill and Melinda Gates Foundation) and implementers/research centres (Centre for Sexual Health and HIV/AIDS Research Zimbabwe) will benefit from the proposed research. This project aims to provide evidence-based answers to questions decision-makers are currently facing: which new HIV testing strategies to implement or expand and which one to scale down (if needed) and how to optimally implemented Pre-Exposure Prophylaxis (PrEP) for adolescent girl and young women in need to ensure high uptake and adherence when needed, in an affordable and cost-effective way. The involvement of the stakeholders in this project should facilitate prompt translation of this research into policies, so it is expected some of the impact on this regard will be already seen in the short-term but most will probably take place in the medium-term.

Thirdly, the communities in Zimbabwe, and in particular adolescent girls and young women, and the international society will benefit. Adolescent girls and young women will be directly involved in the research and will jointly develop with the research team a PrEP implementation intervention; therefore, some of the impact will be already realised in the short-term. Ultimately, the vision for this proposal is that the impact will be on the people whose health will be improved by utilizing health care resources in a way that maximises health. This includes people living with HIV, but also HIV negative people at risk of acquiring HIV, and in particular sexually active adolescent girls and young women, a particularly vulnerable group. This latter group will benefit if indeed the PrEP implementation intervention developed is found to offer the potential to be cost-effective and affordable and is then proven to be effective in a trial (in Year 5-7) and it is implemented. This will be in the first instance in Zimbabwe, but lessons learned could be adapted to countries in the rest of Southern Africa. The international society will benefit by the enhancement of the efficiency of UK and international aid and by gaining knowledge of these findings. This impact will be realised in the long-term.

Publications

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Modelling To Inform HIV Programmes In Sub-Saharan Africa (MIHPSA) Working Group (2022) Perspectives on the use of modelling and economic analysis to guide HIV programmes in sub-Saharan Africa. in The lancet. HIV

 
Description This project is still ongoing.
There are two main aims: first, to develop a Pre-exposure prophylaxis (PrEP) implementation intervention for adolescent girls and young women (AGYW; aged 15 to 24 years old) who need it, with the potential to offer value for money; and, second, to inform the best allocation of HIV testing resources to maximise health.

In order to achieve the first one, one of our objective was to explore awareness and views on PrEP among AGYW, better understand sexual behaviour and perceptions of risk in this population in Zimbabwe and listen to how AGYW think programs can improve PrEP uptake and continuation among AGYW. From the focus group discussions conducted, involving over 90 AGYW, we observed that there was variation in the level of PrEP awareness: most were knowledgeable about PrEP (30% had already used it), especially those involved in programmes for sex workers and tertiary education students, and recognized that PrEP was an effective tool to prevent HIV. The few not involved in any sexual and reproductive health (SRH) programs were hearing of PrEP for the first time.
In terms of sexual behaviour and perceptions of risk, most recognized their risk of contracting HIV and mentioned as particularly risky circumstances: engaging in condom-less sex with older men, having multiple and concurrent sexual partnerships or their partners engaging in them and sexual abuse by relatives and strangers. However, a few AGYW had low risk perception.
Three main categories of barriers to use PrEP were identified: the use of PrEP being socially undesirable, concerns about the PrEP product and the facilities where PrEP can be accessed. In particular, PrEP was seen as socially undesirable because of its association with being sexually active, the fear that PrEP can be misconstrued as HIV treatment or could negatively affect relationship with sexual partner and parental and partner influence. In terms of PrEP product, AGYW were concerned about the PrEP packaging, pill size and side effects. In Zimbabwe PrEP is currently mainly available as a daily pill, but vaginal ring and injectable formulations have been found to be effective and these were considered to be preferable by AGYW, as viewed as convenient and more private. Finally, AGYW reported being concerned about health care workers distributing PrEP having an unfriendly and judgmental attitude, lack of privacy and confidentiality at PrEP dispensing location and health facility consultation fees. Across all groups, unmarried AGYW mothers emerged as vulnerable. This group tended not to be part of any SRH programs, have usually no family and society support and no systems in place of reducing their vulnerability and exposure to HIV risk factors.
In summary, the factors that were identified at this stage as key to improve PrEP uptake and retention among AGYW in Zimbabwe are: education of parents and partners on sexual and reproductive health issues, provision of PrEP services free of charge, friendly attitudes of health workers, private and confidential PrEP services and availability of different products.

In order to achieve the second aim, one of our objective was to characterize those who have never tested for HIV in Zimbabwe; in particular: to estimate the prevalence of never having tested for HIV and identify factors associated with never having tested for HIV among rural communities following community-based HIV self-test kits (HIVST) distribution. The study used data from a community-led cluster randomised trial (CRT) comparing two HIV self-testing (HIVST) distribution strategies in six rural districts in Zimbabwe, between 2018 and 2019. 17% (1,822/11,076) of participants had never tested for HIV and the most cited reason for never having tested was perception of no HIV risk (50%). Of these, a third reportedly engaged in condomless sex in the past 3 months. Never testers were more likely to: be men, unmarried people, not having a religion or being of African Traditional religion, muslim or of other minority religions, those projecting HIV stigma, not reporting condomless sex in past 3 months, residing in communities with low or medium levels of treatment optimism on effectiveness of antiretroviral therapy and vulnerable groups (young people (below 35) and elderly (45 or above), unemployed, low education, non-participants in household decision-making). Interventions that focus on reaching these individuals while addressing misperceptions of HIV risk are important.
Exploitation Route The findings about the FGDs were presented at the 23rd International Union Against Sexually Transmitted Infections.
The findings about the factors associated with never testing were presented at the 22nd International Conference on AIDS and STIs in Africa (ICASA) (ICASA-2023-Programme-Booklet-26102023.pdf (saafrica.org) .
The Zimbabwe Ministry of Health HIV prevention lead was involved in the design of this project and presentation of the findings and she is best placed in making sure these findings are considered when further rolling out PrEP in this population in Zimbabwe and developing strategies to reach those who never tested for HIV.
Sectors Healthcare

URL https://www.iusti2022zimbabwe.com/wp-content/uploads/2022/09/Programme-Book.pdf
 
Description Appointment of Dr Euphemia Sibanda and Wellington Murenjekwa to Zimbabwe Ministry of Health HIV prevention technical working group and Zimbabwe HIV Prevention Partnership Forum
Geographic Reach National 
Policy Influence Type Participation in a guidance/advisory committee
 
Description Co-chair of the World Health Organization guidelines development group for HIV post-exposure prophylaxis
Geographic Reach Multiple continents/international 
Policy Influence Type Participation in a guidance/advisory committee
 
Description MATRIX BACH Advisory group on cost effectiveness modelling of future HIV and multipurpose prevention technologies (MPTs)
Geographic Reach Multiple continents/international 
Policy Influence Type Participation in a guidance/advisory committee
 
Description Membership to World Health Organization advisory group on HIV testing services
Geographic Reach Multiple continents/international 
Policy Influence Type Participation in a guidance/advisory committee
 
Description Project in Zimbabwe on self-care interventions led by young people
Amount $116,944 (USD)
Organisation Joint United Nations Programme on HIV/AIDS (UNAIDS) 
Sector Public
Country Global
Start 02/2023 
End 07/2023
 
Description R34
Amount $553,141 (USD)
Funding ID 1R34MH129220-01A1 
Organisation National Institute of Mental Health 
Sector Public
Country United States
Start 08/2022 
End 07/2024
 
Description Collaboration with University of Berkley on a PrEP implementation intervention 
Organisation University of California, Berkeley
Department School of Public Health Berkeley
Country United States 
Sector Academic/University 
PI Contribution Dr Euphemia Sibanda, co-investigator in this fellowship, is now the PI for a NIMH funded study which is aimed at developing and piloting an intervention for pharmacy PrEP distribution for sex workers in Zimbabwe. The co-PI of this study is Dr Sandie McCoy based at University of California Berkeley. As part of this collaboration Dr Euphemia Sibanda has jointly developed the proposal and will lead the piloting of the intervention.
Collaborator Contribution Dr Sandie McCoy, co-PI, has jointly developed the proposal and will together provide oversight of the project.
Impact None yet.
Start Year 2022
 
Description Collaboration with the World Health Organization on HIV testing reviews 
Organisation World Health Organization (WHO)
Country Global 
Sector Public 
PI Contribution Valentina Cambiano, the Principal investigator, collaborated with the WHO HIV testing team to co-supervise two MSc students: - Tafadzwa Kadye working on the project "Country uptake of WHO recommendations on differentiated HIV testing services approaches: a global policy review" (the paper has now been accepted by BMJ Open) - Nomenzile Mamba working on the project "HIV re-testing prevalence and motivations among people with known HIV-positive diagnosis in LMICs: a systematic literature review" (a paper is in preparation)
Collaborator Contribution The WHO HIV testing team co-supervises these two projects.
Impact Paper entitled "Country uptake of WHO recommendations on differentiated HIV testing services approaches: a global policy review" has now been accepted by BMJ Open.
Start Year 2021
 
Description MIHPSA Zimbabwe 
Organisation East Central and Southern Africa Health Community
Country Tanzania, United Republic of 
Sector Public 
PI Contribution Valentina Cambiano, Principal Investigator of this fellowship, is co-chair together with Isaac Taramusi (former Zimbabwe National AIDS Council, now UNAIDS Zimbabwe) and Ngwarai Sithole (Zimbabwe Ministry of Health and Child Care) of the MIHPSA Zimbabwe Collaboration, which is part of the wider MIHPSA collaboration, which also involves similar projects in Malawi and South Africa. As part of this collaboration Valentina Cambiano organizes regular meetings involving four other mathematical modelling groups (Goals-RSM, Optima, PopART-IBM and EMOD), ECSA-Health Community, Zimbabwe Ministry of Health and Child Care and the Zimbabwe National AIDS Council. She contributes with a mathematical model to this comparison exercise and leads the comparison and discussion of modelling projections.
Collaborator Contribution The Zimbabwe Ministry of Health and Child Care shares their knowledge on the current implementation of the HIV response in Zimbabwe, providing constructive feedback, collates data to inform the mathematical model calibration and co-leads this collaboration. The National AIDS Council shares their knowledge on modelling activities taking place in Zimbabwe and collates data to inform the mathematical models calibration. The East, Central and Southern Africa Health Community (ECSA-HC) promotes regional cooperation in health among member states. The HIV Modelling Consortium coordinates the MIHPSA research activities in the three countries: Zimbabwe, Malawi and South Africa
Impact This collaboration is multidisciplinary involving epidemiology, mathematical modelling of infectious disease science and health economics.
Start Year 2021
 
Description MIHPSA Zimbabwe 
Organisation National AIDS Council
Country Zimbabwe 
Sector Public 
PI Contribution Valentina Cambiano, Principal Investigator of this fellowship, is co-chair together with Isaac Taramusi (former Zimbabwe National AIDS Council, now UNAIDS Zimbabwe) and Ngwarai Sithole (Zimbabwe Ministry of Health and Child Care) of the MIHPSA Zimbabwe Collaboration, which is part of the wider MIHPSA collaboration, which also involves similar projects in Malawi and South Africa. As part of this collaboration Valentina Cambiano organizes regular meetings involving four other mathematical modelling groups (Goals-RSM, Optima, PopART-IBM and EMOD), ECSA-Health Community, Zimbabwe Ministry of Health and Child Care and the Zimbabwe National AIDS Council. She contributes with a mathematical model to this comparison exercise and leads the comparison and discussion of modelling projections.
Collaborator Contribution The Zimbabwe Ministry of Health and Child Care shares their knowledge on the current implementation of the HIV response in Zimbabwe, providing constructive feedback, collates data to inform the mathematical model calibration and co-leads this collaboration. The National AIDS Council shares their knowledge on modelling activities taking place in Zimbabwe and collates data to inform the mathematical models calibration. The East, Central and Southern Africa Health Community (ECSA-HC) promotes regional cooperation in health among member states. The HIV Modelling Consortium coordinates the MIHPSA research activities in the three countries: Zimbabwe, Malawi and South Africa
Impact This collaboration is multidisciplinary involving epidemiology, mathematical modelling of infectious disease science and health economics.
Start Year 2021
 
Description Meetings with national stakeholders 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact The research team held a meeting in March 2021, one in March 2022 and one in April 2023 with the Zimbabwe Ministry of Health and Child Care, the Zimbabwe National AIDS Council and the mentors to discuss the plans and progress of the research undertaken as part of this fellowship.
Year(s) Of Engagement Activity 2021,2022,2023
 
Description Podcast episode 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact The podcast episode presented the research we are conducting as part of this UKRI FLF in a podcast series named "Next Generation Research" (pod.link). Guests included: Valentina Cambiano (PI), Getrude Ncube (Head of HIV prevention at Ministry of Health and Child Care in Zimbabwe) and Kudzai Chidanguro (Social Scientist at CeSHHAR, partner organization based in Harare).
Year(s) Of Engagement Activity 2023
URL https://www.flfdevnet.com/nextgenresearch/