UN Population Fund (through Zimbabwe's Integrated Support Fund funded by UK Department for International Development, Irish Aid, and Swedish International Development Cooperation Agency).
Background“Determined, Resilient, AIDS-free, Mentored and Safe” (DREAMS) is a package of biomedical, social and economic interventions offered to adolescent girls and young women aged 10–24 years with the aim of reducing HIV incidence. In four of the six DREAMS districts in Zimbabwe, DREAMS includes an offer of oral pre-exposure prophylaxis (DREAMS+PrEP), alongside interventions to support demand and adherence, to women aged 18–24 who are at highest risk of HIV infection, including young women who sell sex (YWSS). This evaluation study addresses the question: does the delivery of DREAMS+PrEP through various providers reduce HIV incidence among YWSS Zimbabwe? We describe our approach to designing a rigorous study to assess whether DREAMS+PrEP had an impact on HIV incidence.MethodsThe study design needed to account for the fact that: 1) DREAMS+PrEP was non-randomly allocated; 2) there is no sampling frame for the target population for the evaluation; 3) there are a small number of DREAMS districts (N = 6), and 4) DREAMS+PrEP is being implemented by various providers. The study will use a cohort analysis approach to compare HIV incidence among YWSS in two DREAMS+PrEP districts to HIV incidence among YWSS in non-DREAMS comparison sites. YWSS will be referred to services and recruited into the cohort through a network-based (respondent-driven) recruitment strategy, and followed-up 12- and 24-months after enrolment. Women will be asked to complete a questionnaire and offered HIV testing. Additional complications of this study include identifying comparable populations of YWSS in the DREAMS+PrEP and non-DREAMS comparison sites, and retention of YWSS over the 24-month period. The primary outcome is HIV incidence among YWSS HIV-negative at study enrolment measured by repeat, rapid HIV testing over 24-months. Inference will be based on plausibility that DREAMS+PrEP had an impact on HIV incidence. A process evaluation will be conducted to understand intervention implementation, and document any contextual factors determining the success or failure of intervention delivery.DiscussionHIV prevention products of known efficacy are available. Innovative studies are needed to provide evidence of how to optimise product use through combination interventions to achieve population impact within different contexts. We describe the design of such a study.
Young women (aged 15–24) who exchange sex for money or other support are among the highest risk groups for HIV acquisition, particularly in high prevalence settings. To prepare for introduction and evaluation of the DREAMS programme in Zimbabwe, which provides biomedical and social interventions to reduce adolescent girls’ and young women’s HIV vulnerability, we conducted a rapid needs assessment in 6 towns using a “social mapping” approach. In each site, we talked to adult sex workers and other key informants to identify locations where young women sell sex, followed by direct observation, group discussions and interviews. We collected data on socio-demographic characteristics of young women who sell sex, the structure and organisation of their sexual exchanges, interactions with each other and adult sex workers, and engagement with health services. Over a two-week period, we developed a “social map” for each study site, identifying similarities and differences across contexts and their implications for programming and research. Similarities include the concentration of younger women in street-based venues in town centres, their conflict with older sex workers due to competition for clients and acceptance of lower payments, and reluctance to attend existing services. Key differences were found in the 4 university towns included in our sample, where female students participate in diverse forms of sexual exchange but do not identify themselves as selling sex. In smaller towns where illegal gold panning or trucking routes were found, young women migrated in from surrounding rural areas specifically to sell sex. Young women who sell sex are different from each other, and do not work with or attend the same services as adult sex workers. Our findings are being used to inform appropriate intervention activities targeting these vulnerable young women, and to identify effective strategies for recruiting them into the DREAMS process and impact evaluations.
The high proportion of FSWs initiating sex work before the age of 25 years and their lower engagement in HIV services highlights the importance of considering this vulnerable population in HIV programming. Implementing targeted services tailored to the unique needs of young FSWs is a public health imperative.
Introduction UNAIDS ’ goal of ending AIDS by 2030 is unreachable without better targeting of testing, prevention and care. Female sex workers ( FSW ) in Zimbabwe are at high risk of HIV acquisition and transmission. Here, we report on collated programme and research data from Zimbabwe's national sex work programme. We also assess the potential for wider population impact of FSW programmes by modelling the impact on HIV incidence of eliminating transmission through FSW (i.e. calculate the population attributable fraction of incidence attributable to sex work). Methods Descriptive analyses of individual‐level programme data collected from FSW between 2009 and June 2018 are triangulated with data collected through 37 respondent driven sampling surveys from 19 sites in Zimbabwe 2011 to 2017. We describe programme coverage, uptake, retention and patterns of sex work behaviour and gaps in service provision. An individual‐level stochastic simulation model is used to reconstruct the epidemic and then the incidence compared with the counter‐factual trend in incidence from 2010 had transmission through sex work been eliminated from that date. Results Sisters has reached >67,000 FSW since 2009, increasing attendance as number of sites, programme staff and peer educators were increased. Over 57% of all FSW estimated to be working in Zimbabwe in 2017 (n = 40,000) attended the programme at least once. The proportion of young FSW reached has increased with introduction of the “Young Sisters programme.” There are no clear differences in pattern of sex work across settings. Almost all women report condom use with clients at last sex (95%); however, consistent condom use with clients in the last month varies from 52% to 95% by site. Knowledge of HIV ‐positive status has increased from 48 to 78% between 2011 and 2016, as has prevalence of ART use among diagnosed women (29 to 67%). Although subject to uncertainty, modelling suggests that 70% (90% range: 32%, 93%) of all new infections in Zimbabwe from 2010 are directly or indirectly attributable to transmission via sex work. Conclusions It is feasible to increase coverage and impact of sex work programming through community‐led scale‐up of evidence‐based interventions. Eliminating transmission through commercial sex would likely have a substantial impact on new infections occurring more widely across Zimbabwe.
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