Frances M. Cowan

Background: Community-led interventions for female sex workers (FSW) can improve HIV prevention and treatment outcomes by lowering self-stigma and strengthening social cohesion to improve service uptake. In Zimbabwe, the AMETHIST intervention trial integrated peer-led microplanning with self-help groups for FSW and demonstrated improved HIV treatment outcomes. We investigated the role of social cohesion and self-stigma in explaining these findings. Method: We conducted a mixed-method analysis of data collected during AMETHIST. We re-analysed qualitative data from interviews and group discussions to identify narratives linking self-stigma, engagement with microplanners and/or self-help groups and HIV service use. We analysed quantitative data from endline respondent-driven sampling surveys for differences in self-reported measures of social cohesion and self-stigma between trial arms, and between those who did and did not participate in intervention activities or access services. Results: In both arms, FSW self-reported engaging with peer supporters, participating in self-help groups and accessing HIV services. Qualitative narratives suggested peer support and group participation could reduce self-stigma and support service uptake. Lower levels of self-stigma were seen in the intervention arm (58.6% vs 63.2%; aOR 0.77; 95% CI 0.61-0.86). Social cohesion exceeded 50% across the whole sample, but was not associated with study arm, nor with engagement in intervention-related activities. Discussion: Although qualitative data suggested some FSW felt their uptake of services was influenced by intervention components, quantitative analyses did not suggest either variable was on the causal pathway to the outcomes of the intervention. A limitation may have been the measurement of these complex constructs and the high levels of social cohesion across both study arms. Contributions to the literature: - Community-led, empowerment-based interventions are the cornerstone of effective HIV responses for sex workers. The hypothesised mechanisms of improved social cohesion and self-efficacy through which these work to increase HIV services uptake are less well understood. - Our study contributes to evidence on the social mechanisms through which community based interventions work to improve HIV outcomes among female sex workers in Zimbabwe - Our study found that female sex workers who more frequently accessed HIV services were more likely to report higher levels of social cohesion, but was unable to establish whether this was a mechanism along the pathway between intervention engagement and improved HIV outcomes Our study indicated that reductions in self-stigma through peer-led community-based support are important for HIV programme implementation; increasing the uptake of HIV services and improving HIV outcomes

Men attending social venues face barriers to accessing HIV prevention and care services. These venues—such as bars, guesthouses, nightclubs, and transport hubs—facilitate new sexual partnerships but lack cohesive social networks, making it challenging to design and implement effective HIV prevention strategies. Men who attend social venues are more likely to pay for sex, potentially increasing their risk of acquiring or transmitting HIV. However, data on how HIV-related behaviours and service engagement differ between men who do and do not pay for sex among those attending venues remain limited. This study examines whether men who pay for sex have higher rates of HIV prevalence, lower rates of virological suppression, and poor HIV-prevention-related behaviours compared to those who do not. Using the Priorities for Local AIDS Control Efforts (PLACE) methodology, we collected cross-sectional data from April to December 2022 across 190 venues in four cities and towns in Zimbabwe. Participants underwent finger-prick HIV testing; those testing positive provided dried blood spots (DBS) for viral load measurement. We also collected sexual behaviour data, including condom use. We applied survey weights and used weighted Poisson regression models with robust standard errors to investigate factors associated with HIV status, virological suppression, and condom use among venue-going men, treating paying for sex as the primary exposure variable. All reported percentages are weighted. Among venue-going 2,827 men, 984 (40.1%) reported paying for sex in the past 12 months, and 531 (15.1%) reported consistent condom use in the past month. Overall, HIV prevalence was 10.7%. Among men living with HIV, virological suppression was 67.9%. In adjusted analyses, there were no significant associations between paying for sex and HIV status (adjusted prevalence ratio (aPR) = 1.12, 95% CI: 0.64–1.94), self-reported consistent condom use in the past month (aPR = 0.87, 95% CI: 0.57–1.34), or rates of virological suppression among men living with HIV (aPR = 0.97, 95% CI: 0.71–1.34). Findings indicate substantial HIV risk and suboptimal prevention and treatment engagement among men frequenting social venues, irrespective of paying for sex. Therefore, targeted interventions are needed for both paying and non-paying men.

Introduction: Female sex workers (FSWs) in sub-Saharan Africa are at high risk of HIV acquisition. Here we explore the values and preferences of Zimbabwean FSW for long-acting pre-exposure prophylaxis (PrEP). Methods: We employed mixed methods; focus group discussions (FGD) (n=15), a respondent-driven sampling (RDS) survey (n=4444) from 22 sites across Zimbabwe and a nested discrete choice experiment (DCE) (n=435) conducted in 4/22 sites in 2021. Purposively selected FSWs aged 18 or over who reported being HIV negative were eligible for inclusion in FGDs. Analysis of self-reported HIV negative survey participants was RDS-II weighted. DCE analysis estimated relative preferences. Qualitative and quantitative data were triangulated. Results: Median age of survey participants was 28 years with IQR of 23–34 years. There was strong concordance across methods by product, provider, service and individual characteristics. Most FSWs indicated that they preferred long-acting injectable (LAI) PrEP to either oral PrEP or dapivirine vaginal ring (DVR). Most were interested in using LAI PrEP (74.1%; n=1835/2392), a few the DVR (10.9%, n=230/2392), and 2.4% (59/2392) and 13.5% (268/2392) either or neither of the two options, respectively. There was little trust in public sector healthcare providers, with most FSWs opting to access PrEP through programmes designed for sex workers (and stating they would miss a prescription refill/repeat injection if the public sector was the only available option). Injectable PrEP addressed privacy and adherence concerns to some extent, although FSWs felt that 6-monthly would be preferable to less frequent injections. Issues of privacy (related to PrEP and being a FSW), confidentiality and respect emerged as key qualitative themes. Conclusions: FSW had a strong preference for LAI PrEP, but ensuring product choice and user privacy was key. FSW in Eastern and Southern Africa should therefore be prioritised for PrEP choices, with ongoing monitoring and evaluation of services to make sure they are acceptable, effective and evolve as products and delivery options become available.

Cervical cancer screening among Zimbabwean women is suboptimal. Integrating cervical cancer screening with HIV and sexual and reproductive health services

Female sex workers (FSW) face high HIV risk of HIV transmission and acquisition. The AMETHIST (“Adapted Microplanning: Eliminating Transmissible HIV In Sex Transactions”) trial enhanced Zimbabwe’s Key Populations (KP) programme by providing targeted, community-based support for FSW. We used the HIV Synthesis Model to assess its long-term impact and cost-effectiveness. Given USAID’s major role in funding, we also evaluated the effects of ending US support on the KP programme. We modelled a KP programme from 2010. From 2024 we compared (i) continuation of KP programme to (ii) continuation of KP programme + ‘AMETHIST’ intervention. We assessed HIV outcomes in 2030 and conducted cost-effectiveness analysis over a 50 year time horizon. Similar analyses were undertaken comparing continuation of the current KP programme to discontinuation. Here we show that AMETHIST had greater positive impact than the KP programme alone; a higher proportion of FSW tested for HIV in the past year, were diagnosed, on ART and had undetectable viral loads compared to the KP programme alone. Disability adjusted life years were averted with AMETHIST and it was cost-saving within 15 years. Continuing the current KP programme was also cost-saving compared to discontinuation of the KP programme.

Introduction: Female sex workers (FSWs) in sub-Saharan Africa are at higher risk of HIV acquisition and transmission. However, FSWs’ life experiences are heterogeneous and are important to characterise in order to tailor responses to individual needs. Peer microplanners are FSWs trained to engage other FSWs and offer each individual a tailored package of support. We sought to assess the feasibility, acceptability and fidelity of implementing peer-led assessments of risk. Methods: Between December 2020 and August 2021, we conducted a qualitative process evaluation study of the Adapted Microplanning: Eliminating Transmissible HIV In Sex Transactions (AMETHIST) trial’s peer-led assessment of FSWs’ risk of HIV acquisition and transmission. We enrolled 60 participants (30 FSW and 30 peer microplanners) for semistructured in-depth interviews at 3 of 11 intervention sites. Interview guides and analysis were underpinned by three elements adapted from the UK Medical Research Council’s process evaluation framework: (1) feasibility, (2) acceptability and (3) fidelity. Using a framework analytic approach, data were familiarised, coded with NVivo V.12 software, charted, interpreted and then deductively mapped to these three elements. Results: Peer microplanners used the risk scores to tailor their support to FSW with good fidelity. Some experienced difficulties completing assessments during the initial period of implementation. However, it was feasible for peer microplanners to establish strong relationships, and they used observational and conversational skills to elicit sensitive information from FSW to support their assessment. The assessments and tailored support offered by peer microplanners were acceptable to FSWs, although some did not appear to know they were being assessed. Conclusions: Our findings show that peer microplanners feasibly and acceptably assessed FSW for certain risk factors through a scoring tool and focused their support accordingly. This approach could be integrated into other peer-led interventions to improve prioritisation of HIV programmes.

HIV epidemic trends among female sex workers in sub-Saharan Africa are rarely known. We analysed HIV prevalence trends among 10,562 female sex workers aged 18–39 years, recruited through serial cross-sectional respondent-driven sampling surveys in 13 towns and 2 cities in Zimbabwe between 2013 and 2023. HIV prevalence remained stable from 2013 to 2016–2017 but declined significantly from 54.6% in 2016–2017 to 38.9% in 2021–2023 (cluster prevalence mean difference: 15.7%, prevalence ratio: 0.74; 95% CI: 0.68-0.79). This decline cannot be attributed to sampling bias or shifts in the characteristics of the female sex worker population. Mathematical modelling using the HIV Synthesis model and age cohort analysis also suggested lower HIV incidence in later years. While the availability of oral pre-exposure prophylaxis increased, there was little evidence of reduced risk behaviour over time. Increased treatment coverage among the male population likely contributed to the lower HIV incidence among female sex workers.

Background: Sex workers (SWs) are at risk of acquiring HIV infections. Despite this, SWs have low uptake of relevant preventive measures, such as HIV pre-exposure prophylaxis (PrEP). Community-based programs that make PrEP convenient and accessible have the potential to drive PrEP continuation and reduce HIV risk. Objective: This study aims to describe the co-development and piloting of the Together Optimizing PrEP Access in Zimbabwe (TOPAZ) intervention—where SWs have the opportunity to access PrEP refills through pharmacies in Zimbabwe. Methods: Using a participatory process, the TOPAZ intervention will be collaboratively developed with pharmacy owners and SWs. TOPAZ comprises the provision of safe and convenient spaces for PrEP refill pickups bundled with a gift voucher incentive at pharmacies. Formative research comprising focus group discussions and in-depth interviews with SWs, pharmacists, and stakeholders will inform the development of the preliminary model (aim 1). A cluster-randomized pilot trial will evaluate the impact of the PrEP-in-pharmacy intervention, compared to standard clinic-based pickup in the key populations program, on PrEP retention at 3, 6, 9, and 12 months after initiation (aim 2). The outcome of the pilot trial will be a comparison of PrEP retention at 6 months after initiation between study arms. We will also compare PrEP retention among SWs aged between 18 and 24 years at 6 months and among participants remaining active in sex work at 6 months. We will use the Generalized Estimation Equations model to generate risk differences and 95% CIs for PrEP retention in intervention versus comparison arms. Analysis will follow an intent-to-treat approach. Finally, a mixed methods study will be conducted to understand the potential for scaling TOPAZ for SWs; insights from this study will inform the design of a future effectiveness trial (aim 3). Proctor’s implementation outcomes, namely, acceptability, adoption, appropriateness, feasibility, fidelity, and penetration of the pharmacy-based PrEP refill program, will be evaluated by triangulation of program data and qualitative interviews. Results: This study began the enrollment of participants in March 2024. Data collection ended in May 2025. The final comprehensive analysis of the results will be conducted in February 2026 after all the data have been collected and reviewed comprehensively. Conclusions: This study will report on the feasibility, acceptability, and effectiveness of pharmacy-based PrEP refills to improve PrEP continuation among women who sell sex. If successful, this preliminary study will pave the way for a future effectiveness trial to evaluate this intervention more comprehensively. Trial Registration: ClinicalTrials.gov NCT06348069; https://clinicaltrials.gov/study/NCT06348069 International Registered Report Identifier (IRRID): DERR1-10.2196/74141

Accessible and timely diagnostic testing was essential during the COVID-19 pandemic to control the virus’s spread and mitigate severe outcomes. However, real-time polymerase chain reaction tests, although sensitive incur high costs and prolonged turnaround times, and face implementation challenges in many resource-constrained settings. Antigen rapid diagnostic tests (Ag-RDT), which can be administered either by providers or as self-tests, are accessible and low-cost alternatives. We conducted this study to assess the acceptability of Ag-RDT in different use cases and delivery models in Malawi, Nigeria, and Zimbabwe. We implemented a qualitative study drawing on Louart’s theoretical framework for the acceptability of technological healthcare innovations. In-depth interviews (n = 228) were conducted with community members, healthcare workers and providers to explore participants’ experiences with Ag-RDT COVID-19 testing. Data were analysed using NVivo 14 software, applying an inductive thematic approach centred on the constant comparison method across countries, participant groups, and delivery models. The study revealed that Ag-RDT COVID-19 testing was acceptable across the three settings due to speed, non-invasiveness, and simplicity in sample collection compared to the real-time polymerase chain reaction alternative. Ag-RDT was integrated into existing healthcare systems with minimal disruption and used effectively across different use cases and populations. Participants particularly valued the self-testing option for its privacy, reduced stigma and convenience. However, acceptability was somewhat affected by the timing of the intervention, as it was implemented toward the end of the COVID-19 pandemic when many individuals no longer perceived testing as a priority. COVID-19 Ag-RDT testing was an acceptable complementary methodology to PCR testing in Malawi, Nigeria and Zimbabwe. The findings emphasise the need for strategic investment in accessible diagnostic technologies that complement existing molecular diagnostics, particularly supporting decentralised testing and rapid response capabilities in resource-constrained settings while maintaining robust surveillance systems.