Introduction: The traditional “one-size-fits-all” model of HIV care whereby people living with HIV (PLWH) have regular individual clinical visits does not reflect the various preferences and needs of PLWH and stretches the capacity of health facilities (HFs). Little is known about the availability and the experience of differentiated HIV care delivery in the rural areas of Zimbabwe.Methods: We used a mixed-method approach to collect data from clients and providers at 26 HFs in Zimbabwe in 2019. We collected quantitative data about antiretroviral therapy (ART) delivery and time spent at the HF during a visit from one representative healthcare providers (HCP) and a stratified sample of PLWH at each HF. We performed semi-structured interviews among HCPs and focus group discussions (FGDs) among PLWH to collect information about the implementation of differentiated ART delivery (DART) models and their experience. We performed linear regression models to assess factors associated with the time spent in the HFs. We analyzed the interviews using an inductive approach. Transcripts were coded and constricted down to themes significant to the research objectives.Results: The majority (77%) of participating HFs offered at least one of the five DART models recommended in Zimbabwe: 13 (50%) offered community ART refill group (CARG), 1 (4%) club refill, 6 (23%) family refill, and 8 (31%) fast-track refill models. Mobile outreach was not available at any participating HF. In an unadjusted linear model, PLWH enrolled in the fast-track refill model spent 0.40 (95% confidence interval (CI): 0.15-0.56) less time at the HF than PLWH on routine care, whereas PLWH in the family refill model and delegated to go to the HF spent 2.63 (95% CI 1.42-4.88) more time at the HF during visit. Confidentiality and disclosure concerns were highlighted as the major barriers affecting the implementation of DART models, together with travel costs and waiting times. HCPs reported on the challenge of excessive workloads. Fast-track refill was perceived as the most adapted DART model to meet clients’ needs, followed by CARG and family refill.Conclusions: Confidentiality, travel costs and waiting times are key elements to consider in the implementation of differentiated care in rural Zimbabwe. More implementation research is needed to support the roll-out of differentiated HIV services in that region, especially DART models addressing the needs of PLWH. Our study supports the call for personalized care at ART programs in rural Africa.

ObjectivesTo examine the proportion of people living with HIV who screen positive for common mental disorders (CMD) and the associations between CMD and self-reported adherence to antiretroviral therapy (ART).SettingSixteen government-funded health facilities in the rural Bikita district of Zimbabwe.DesignCross-sectional study.ParticipantsHIV-positive non-pregnant adults, aged 18 years or older, who lived in Bikita district and had received ART for at least 6 months.Outcome measuresThe primary outcome was the proportion of participants screening positive for CMD defined as a Shona Symptoms Questionnaire score of 9 or greater. Secondary outcomes were the proportion of participants reporting suicidal ideation, perceptual symptoms and suboptimal ART adherence and adjusted prevalence ratios (aPR) for factors associated with CMD, suicidal ideation, perceptual symptoms and suboptimal ART adherence.ResultsOut of 3480 adults, 18.8% (95% CI 14.8% to 23.7%) screened positive for CMD, 2.7% (95% CI 1.5% to 4.7%) reported suicidal ideations, and 1.5% (95% CI 0.9% to 2.6%) reported perceptual symptoms. Positive CMD screens were more common in women (aPR 1.67, 95% CI 1.19 to 2.35) than in men and were more common in adults aged 40–49 years (aPR 1.47, 95% CI 1.16 to 1.85) or aged 50–59 years (aPR 1.51, 95% CI 1.05 to 2.17) than in those 60 years or older. Positive CMD screen was associated with suboptimal adherence (aPR 1.53; 95% CI 1.37 to 1.70).ConclusionsA substantial proportion of people living with HIV in rural Zimbabwe are affected by CMD. There is a need to integrate mental health services and HIV programmes in rural Zimbabwe.Trial registration numberNCT03704805.

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Introduction Zimbabwe adopted differentiated HIV care policies in 2015 to promote client‐centred care and relieve strain on health facilities. We examined the availability, experiences and perceptions of differentiated antiretroviral therapy (ART) delivery in rural Zimbabwe following the policy adoption. Methods We undertook a cross‐sectional mixed methods study in all the 26 facilities providing HIV care in a rural district in Zimbabwe. We collected quantitative data about ART delivery and visit durations from 31 healthcare providers and a purposive stratified sample of 378 clients obtaining ART either through routine care or differentiated ART delivery models. We performed 26 semi‐structured interviews among healthcare providers and seven focus group discussions (FGDs) among clients to elicit their perceptions and experiences of ART delivery. Data were collected in 2019, with one follow‐up FGD in 2021. We analysed the transcripts thematically, with inductive coding, to identify emerging themes. Results Twenty facilities (77%) offered at least one differentiated ART delivery models, including community ART refill groups (CARGs; 13 facilities, 50%), fast‐track refill (8, 31%), family refill (6, 23%) or club refill (1, 4%). Thirteen facilities (50%) offered only one model. The median visit duration was 28 minutes (interquartile range [IQR]: 16–62). Participants in fast‐track had the shortest visit durations (18 minutes, IQR: 11–24). Confidentiality and disclosure of HIV status, travelling long distances, travel costs and waiting times were the main issues influencing clients’ views on differentiated ART delivery. Fast‐track refill was perceived as the preferred model of clients for its limited involuntary disclosure and efficiency. In contrast, group‐ and community‐based refill models reduced travel costs but were felt to be associated with involuntary disclosure of HIV status, which could discourage clients. Healthcare providers also experienced an additional workload when offering facility‐based group models, such as CARGs. Conclusions Differentiated ART delivery models were widely available in this rural setting, but most facilities did not offer a choice of models to address clients’ diverse preferences. A minority offered fast‐track refills, although this model was often mentioned as desirable. Confidentiality, travel expenses and client waiting times are key elements to consider when planning and rolling out differentiated HIV care.

Background: WHO recommends differentiated antiretroviral therapy (ART) delivery with longer visit intervals for clinically stable patients. We examined time trends in visit frequency and associations between criteria for clinical stability and visit frequency in ART programs in Southern Africa. Methods:We included adults on ART from four programs with viral-load monitoring, two programs with CD4 monitoring, and four programs with clinical monitoring of ART. We classified patients as clinically stable based on virological (viral load <1000 copies/mL), immunological (CD4 >200 cells/µL), or clinical (no current tuberculosis) criteria. We used Poisson regression and survival models to examine associations between criteria for clinical stability and the rate of clinic visits. Results:We included 180,837 patients. There were trends towards fewer visits in more recent years and with longer ART duration. In all ART programs, clinically stable patients were seen less frequently than patients receiving failing ART, but the strengths of the association varied. Adjusted incidencerate ratios (IRRs) comparing visit rates for stable patients with patients on failing ART were 0.82 (95% CI 0.73-0.90) for patients classified based on the virological criterion, 0.81 (0.69-0.93) for patients classified based on the clinical criterion, and 0.90 (0.85-0.96) for patients classified based on the immunological criterion for stability. Conclusion: Differences in visit rates between stable patients and patients failing ART were variableand modest overall. Larger differences were seen in programs using virological criteria for clinical stability than in programs using immunological criteria. Greater access to routine viral-load monitoring may increase scale-up of differentiated ART delivery.

Introduction Dolutegravir is being scaled up globally as part of antiretroviral therapy (ART), but for people with HIV and tuberculosis co‐infection, its use is complicated by a drug–drug interaction with rifampicin requiring an additional daily dose of dolutegravir. This represents a disadvantage over efavirenz, which does not have a major drug–drug interaction with rifampicin. We sought to describe HIV clinic practices for prescribing concomitant dolutegravir and rifampicin, and characterize virologic outcomes among patients with tuberculosis co‐infection receiving dolutegravir or efavirenz. Methods Within the four sub‐Saharan Africa regions of the International epidemiology Databases to Evaluate AIDS consortium, we conducted a site survey (2021) and a cohort study (2015–2021). The cohort study used routine clinical data and included patients newly initiating or already receiving dolutegravir or efavirenz at the time of tuberculosis diagnosis. Patients were followed from tuberculosis diagnosis until viral suppression (<1000 copies/ml), a competing event (switching ART regimen; loss to program/death) or administrative censoring at 12 months. Results In the survey, 86 of 90 (96%) HIV clinics in 18 countries reported prescribing dolutegravir to patients who were receiving rifampicin as part of tuberculosis treatment, with 77 (90%) reporting that they use twice‐daily dosing of dolutegravir, of which 74 (96%) reported having 50 mg tablets available to accommodate twice‐daily dosing. The cohort study included 3563 patients in 11 countries, with 67% newly or recently initiating ART. Among patients receiving dolutegravir ( n = 465), the cumulative incidence of viral suppression was 58.9% (95% confidence interval [CI]: 54.3–63.3%), switching ART regimen was 4.1% (95% CI: 2.6–6.2%) and loss to program/death was 23.4% (95% CI: 19.7–27.4%). Patients receiving dolutegravir had improved viral suppression compared with patients receiving efavirenz who had a tuberculosis diagnosis before site dolutegravir availability (adjusted subdistribution hazard ratio [aSHR]: 1.47, 95% CI: 1.28–1.68) and after site dolutegravir availability (aSHR 1.28, 95% CI: 1.08–1.51). Conclusions At a programmatic level, dolutegravir was being widely prescribed in sub‐Saharan Africa for people with HIV and tuberculosis co‐infection with a dose adjustment for the drug–drug interaction with rifampicin. Despite this more complex regimen, our cohort study revealed that dolutegravir did not negatively impact viral suppression.

Importance Common mental disorders (CMD) are prevalent in people living with HIV and associated with suboptimal antiretroviral therapy (ART) adherence. Objective To assess the effect of a lay health worker-led psychological intervention on adherence to ART, virologic suppression and mental health symptoms. Design Pragmatic cluster trial with block randomization of health facilities. Treatment assignment was known to participants, providers, evaluators, and data analysts. Recruitment started in October 2018 and the last follow-up visit was done in December 2020. Participants were followed up for 12 months. Setting Sixteen public health care facilities in Bikita, a rural district in Masvingo Province, about 300 km south of Harare. Participants Men and non-pregnant women aged 18 years or older who spoke English or Shona, screened positive for CMD (Shona Symptoms Questionnaire [SSQ]-14 score ≥9), had received first-line ART for at least six months, had no WHO clinical stage 4 disease, no psychotic symptoms, and gave informed consent. Intervention The Friendship Bench, a lay health worker-led intervention consisting of six weekly individual counselling sessions of problem-solving therapy and optional peer-led group support. Main Outcomes and Measures The primary outcome was Medication Event Monitoring System (MEMS) mean adherence between 2-6 months of follow-up. Secondary outcomes included mean adherence between 1-12 months, change from baseline SSQ-14 and Patient Health Questionnaire (PHQ-9) score at 3, 6, 9, and 12 months and change in viral load suppression (viral load <1000 copies per mL) at months 6 and 12. Results We recruited 516 participants, 244 in Friendship bench and 272 in standard care facilities. The mean age was 45.6 years (SD 10.9), and most participants were women (84.9%). In the Friendship Bench group, 88.1% of participants attended all six individual counselling sessions. Rates of adherence (>85%) and virologic suppression (>90%) were high in both groups. The intervention had no statistically significant effect on adherence or viral suppression. Declines in SSQ-14 scores from baseline to 3 months (-1.65, 95% CI -3.07 to -0.24), 6 months (-1.57, 95% CI -2.98 to -0.15), and 9 months (-1.63, 95% CI -3.05 to -0.22) were greater in the Friendship Bench than the standard care group (p<0.05). There were no differences in the decline in the SSQ-14 scores from baseline to 12 months and in declines in PHQ-9 scores from baseline to 3, 6, 9, and 12 months. Conclusions and Relevance The Friendship Bench intervention is a feasible and acceptable approach to closing the treatment gap in mental health care in rural Zimbabwe. The intervention improved CMD symptoms but the intervention effect was smaller than previously shown in an urban setting. The intervention had no effect on adherence and viral suppression, possibly due to the absence of skill-based adherence training and ceiling effect. Trial registration ClinicalTrials.gov Identifier:NCT03704805

Objectives: To examine the proportion of people living with HIV who screen positive for common mental disorders (CMD) and the associations between CMD and self-reported adherence to antiretroviral therapy (ART). Setting: Sixteen government-funded health facilities in the rural Bikita district of Zimbabwe. Design: Cross-sectional study. Participants: HIV-positive non-pregnant adults, aged 18 years or older, who lived in Bikita district and had received ART for at least six months. Outcome measures: The primary outcome was the proportion of participants screening positive for CMD defined as a Shona Symptoms Questionnaire (SSQ-14) score of 9 or greater. Secondary outcomes were the proportion of participants reporting suicidal ideation, perceptual symptoms, and suboptimal ART adherence and adjusted prevalence ratios (aPR) for factors associated with CMD, suicidal ideation, perceptual symptoms, and suboptimal ART adherence. Results: Out of 3,480 adults, 18.8% (95% confidence interval [CI] 14.8-23.7) screened positive for CMD, 2.7% (95% CI 1.5-4.7) reported suicidal ideations, and 1.5% (95% 0.9-2.6) reported perceptual symptoms. Positive CMD screens were more common in women (adjusted prevalence ratio [aPR] 1.67, 95% CI 1.19-2.35) than in men and were more common in adults aged 40-49 years (aPR 1.47 95% CI 1.16-1.85) or aged 50-59 years (20.3%; aPR 1.51 95% CI 1.05-2.17) than in those 60 years or older. Positive CMD screen was associated with suboptimal adherence (aPR 1.53; 95% CI 1.37-1.70). Conclusions: A substantial proportion of people living with HIV in rural Zimbabwe are affected by CMD. There is a need to integrate mental health services and HIV programs in rural Zimbabwe.