Tiffany G. Harris

Objective: To characterize nursing home (NH) resident hand hygiene knowledge, hand hygiene habits, and bathing practices to inform intervention strategies. Design: Cross-sectional survey. Setting: Twenty geographically diverse NHs between December 2023 and July 2024. Participants: NH residents. Methods: The survey was administered verbally to NH residents and consisted of 22 questions pertaining to residents’ hand hygiene knowledge, hand hygiene habits at their previous residence and at the NH, and bathing practices at the NH. Results: Among the 495 NH residents who completed the survey, 54% were short-stay/temporary residents, 65% were female, and 79% were aged 70 years or older. Less than a third (29%) of the residents answered all three hand hygiene knowledge-based questions correctly. Residents washed their hands less often at the NH compared to their previous residence. Residents also washed their hands with running water less frequently at the NH (81% vs. 98%). Thirty percent of residents reported facing challenges with hand hygiene at the NH with 53% of the responses mentioning mobility impairments as the main reason why. Additionally, residents facing challenges with hand hygiene had a lower frequency of hand hygiene at the NH. Half (51%) of the residents reported bathing less at the NH compared to their previous residence with NH policy being the most commonly reported reason encompassing 54% of the responses. Conclusions: NH residents perform hand hygiene and bathe less frequently at the NH. Our multi-site study identified multiple barriers to resident hand hygiene and bathing that can be modifiable through practice or policy changes.

Young adults with HIV (YAHIV) may be particularly vulnerable to the impact of the COVID-19 pandemic. In this context, associated mitigation measures among YAHIV can adversely impact fragile social and economic systems. We examined the impact of the pandemic and related government-mandated restrictions among YAHIV in Kisumu, Kenya. Between April-May 2021, a cross-sectional survey was conducted among a convenience sample of YAHIV 18–25 years receiving HIV care in Kisumu, Kenya. The information collected included demographics, COVID-19 knowledge, protective measures, and the impact of the pandemic and related restrictions on their daily lives and well-being since the start of the pandemic (i.e., curfews, lockdowns, school/workplace closures). Responses were analyzed using descriptive statistics. Of 275 YAHIV: median age 22 years (IQR: 19–24 years); 178 (65%) female; 222 (81%) completed some secondary education or higher; 108 (39%) lived in an informal housing area. Awareness of COVID-19 was high (99%), mean knowledge score was 4.32 (SD: 0.93; range 1–5) and most reported taking protective measures. Overall, 193 (70%) reported they were affected by COVID-19 and associated restrictions. Almost half (49%) reported changes in a living situation; 24% living with different people, 11% had moved/relocated, and 5% were newly living on the street. Additionally, respondents reported increased verbal arguments (30%) and physical conflict (16%) at home with 8% reporting someone having used/threatened them with a weapon, 12% experiencing physical abuse, 7% being touched in a sexual way without permission, and 5% had forced sex. Impacts of the pandemic and related restrictions were felt across various aspects of YAHIV’s lives, including disrupted living situations and increased exposure to verbal and physical conflict, including sexual violence. Interventions are needed to address the impact and potential negative long-term effects of the pandemic on YAHIV health and well-being.

Introduction: We sought to characterize social and structural drivers of HIV vulnerability for transgender women (TGW) in Zimbabwe, where TGW are not legally recognized, and explore differences in vulnerability by feminine presentation.Methods: A secondary analysis was conducted with a sub‐sample of participants recruited from a 2019 respondent‐driven sampling survey that comprised men who have sex with men, TGW and genderqueer individuals assigned male sex at birth, from two cities in Zimbabwe. Survey questionnaires captured information related to socio‐demographics, sexual and substance use behaviours, and social and structural barriers to HIV services. Secondary analyses were restricted to participants who identified as female, transfemale or transwomen (236/1538) and were unweighted. Descriptive statistics were used to calculate sample estimates and chi‐square and Fisher's exact tests were used to assess differences in vulnerability by feminine presentation.Results: Among 236 TGW, almost half (45.3%) presented as feminine in the 6 months preceding the survey and 8.5% had ever used hormones to affirm their gender identities. Median age among TGW was 23 years (interquartile range: 20–26). Feminine presenting TGW in our sample had higher prevalence of arrest (15.9% vs. 3.9%), rejection by family/friends (38.3% vs. 14.0%), employment termination (11.2% vs. 3.9%), employment refusal (14.0% vs. 3.9%), denial of healthcare (16.8% vs. 2.3%), physical, sexual or verbal harassment or abuse (59.8% vs. 34.1%), alcohol dependence (32.7% vs. 12.4%), recent transactional sex with a male or TGW partner (30.8% vs. 13.3%) and recent non‐injection drug use (38.3% vs. 20.2%) than non‐feminine presenting TGW (all p‐value <0.05).Conclusions: Findings suggest that TGW, particularly feminine presenting TGW, experience social and structural inequities which may contribute to HIV vulnerability. Interventions aimed at addressing inequities, including trans competency training for providers and gender‐affirming, psychosocial and legal support services for TGW, might mitigate risk.

To better understand male and female sexual partnerships among men who have sex with men (MSM), we used data from a 2019 biobehavioral survey among MSM in Harare and Bulawayo, Zimbabwe to conduct bivariate analyses and multivariable logistic regression to determine whether sociodemographic characteristics and HIV-related factors were associated with having both male and female sexual partnerships within the last 6 months. Of included MSM (N = 1143), 31% reported both male and female partnerships in the last 6 months. Being married/cohabiting (adjusted odds ratio (aOR) = 8.58, 95% confidence interval (CI) = 4.92–14.95) or separated/divorced/widowed (aOR = 1.96, 95% CI = 1.24–3.08) vs. being single, and hazardous alcohol consumption (aOR = 1.58, 95% CI 1.19–2.09) were associated with higher odds of having both male and female recent partnerships. Being aged 35 + vs. 18–24 (aOR = 0.50, 95% CI = 0.31–0.81), condomless receptive anal intercourse at last sex with the main male partner (aOR = 0.43, 95% CI = 0.26–0.74), and positive HIV status (aOR = 0.46, 95% CI = 0.31–0.67) were associated with lower odds of recent male and female partnerships. MSM in Harare who reported harassment/abuse (aOR = 3.16, 95% CI = 1.72–5.79) had higher odds of both male and female partnerships than MSM in Bulawayo reporting harassment/abuse. The prevalence of both male and female recent partnerships (31%) was lower among MSM in this survey than in other biobehavioral surveys of MSM in sub-Saharan Africa. Findings suggest that MSM with recent male and female partnerships compared to MSM with only male recent partners have lower odds of positive HIV status and participate in behaviors that lower HIV risk; however, the direction of these relationships cannot be determined due to the cross-sectional nature of the data. The findings also suggest a possible connection between experiences of stigma of MSM behavior and not having both male and female partnerships that warrants further exploration. Accessible, stigma-free HIV testing and education programming that considers the potential overlap between the MSM and general populations via both male and female partnerships and the associated behaviors could be a key component of HIV elimination in Zimbabwe.

Introduction: Achieving optimal HIV outcomes, as measured by global 90‐90‐90 targets, that is awareness of HIV‐positive status, receipt of antiretroviral (ARV) therapy among aware and viral load (VL) suppression among those on ARVs, respectively, is critical. However, few data from sub‐Saharan Africa (SSA) are available on older people (50+) living with HIV (OPLWH). We examined 90‐90‐90 progress by age, 15–49 (as a comparison) and 50+ years, with further analyses among 50+ (55–59, 60–64, 65+ vs. 50–54), in 13 countries (Cameroon, Cote d'Ivoire, Eswatini, Ethiopia, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe).Methods: Using data from nationally representative Population‐based HIV Impact Assessments, conducted between 2015and 2019, participants from randomly selected households provided demographic and clinical information and whole blood specimens for HIV serology, VL and ARV testing. Survey weighted outcomes were estimated for 90‐90‐90 targets. Country‐specific Poisson regression models examined 90‐90‐90 variation among OPLWH age strata.Results: Analyses included 24,826 HIV‐positive individuals (15–49 years: 20,170; 50+ years: 4656). The first, second and third 90 outcomes were achieved in 1, 10 and 5 countries, respectively, by those aged 15–49, while OPLWH achieved outcomes in 3, 13 and 12 countries, respectively. Among those aged 15–49, women were more likely to achieve 90‐90‐90 targets than men; however, among OPLWH, men were more likely to achieve first and third 90 targets than women, with second 90 achievement being equivalent. Country‐specific 90‐90‐90 regression models among OPLWH demonstrated minimal variation by age stratum across 13 countries. Among OLPWH, no first 90 target differences were noted by age strata; three countries varied in the second 90 by older age strata but not in a consistent direction; one country showed higher achievement of the third 90 in an older age stratum.Conclusions: While OPLWH in these 13 countries were slightly more likely than younger people to be aware of their HIV‐positive status (first 90), this target was not achieved in most countries. However, OPLWH achieved treatment (second 90) and VL suppression (third 90) targets in more countries than PLWH <50. Findings support expanded HIV testing, prevention and treatment services to meet ongoing OPLWH health needs in SSA.

Introduction: Zimbabwe is scaling up pre‐exposure prophylaxis (PrEP) for key populations, including men who have sex with men (MSM) and transgender women (TGW). To assess implementation and inform HIV programming, we evaluated gaps in PrEP awareness, uptake and use, and correlates of awareness and uptake among a sample of MSM, TGW and genderqueer individuals (GQ) in Harare and Bulawayo, Zimbabwe.Methods: Respondent‐driven sampling was used to recruit 1194 MSM and 344 TGW/GQ aged ≥18 to participate in a cross‐sectional survey assessing HIV‐related outcomes in 2019. Consenting participants completed a questionnaire on socio‐demographic information, sexual risk practices and engagement in HIV services and underwent HIV testing. Descriptive statistics were used to assess the PrEP cascade. Multiple logistic regression models were used to identify factors associated with PrEP awareness and uptake among HIV‐negative participants. Data were unweighted as the sample did not reach convergence on key estimates.Results: Among the 1167 HIV‐negative participants, most (79.2%) were MSM compared to TGW/GQ (20.8%). Median age was 24 years. Overall, 45.8% were aware of PrEP and of those, 31.3% had ever taken PrEP. Most (71.1%) reporting never taking PrEP were willing to start PrEP; the main reasons for never starting PrEP included not knowing where to access it (24.8%) and fearing side effects (20.4%). Among those who had ever taken PrEP, 74.9% had taken PrEP in the last 6 months; of these, 42.4% had taken PrEP the day of or day preceding the survey. Side effects represented the most common (59.5%) reason for discontinuing PrEP. MSM (adjusted odds ratio [aOR]: 2.5, 95% confidence interval [CI]: 1.8–3.6) and TGW/GQ in Harare (aOR: 3.1, 95% CI: 2.1–4.7), and TGW/GQ in Bulawayo (aOR: 2.4, 95% CI: 1.1–5.3) had higher awareness of PrEP than MSM in Bulawayo. Overall, TGW/GQ were more likely to have ever taken PrEP compared to MSM (aOR: 1.6, 95% CI: 1.01–2.4).Conclusions: Findings emphasize the need for tailored interventions to promote PrEP among key populations. As HIV programs in Zimbabwe continue to expand PrEP services, these data, including barriers to starting and continuing PrEP, can inform strategies to address gaps along the PrEP cascade.

PURPOSE: Breast cancer (BC) is detected at late stages in sub-Saharan Africa. We piloted a BC early-detection program in Eswatini aimed at increasing breast health knowledge and clinical skills. We also aimed to determine the proportion of patients with breast abnormalities who completed referral to breast specialty clinics.METHODS: Nurses and counselors from five human immunodeficiency virus and/or antiretroviral therapy clinics underwent training in BC and clinical breast examination (CBE). We compared knowledge and skill examinations completed before, immediately after, and 90 days after training. Nurses then screened female clinic patients ≥ 18 years for breast symptoms, examined those with symptoms, and referred women with CBE abnormalities to a surgeon or the national breast clinic. Consenting women were contacted at 30 and 60 days after screening to determine if they had completed referral.RESULTS: In 2019, 44 nurses underwent training. Median scores (interquartile range) on pretraining, immediate post-training, and 90-day post-training knowledge examinations were 17.5 (16-19), 20 (19-21), and 20 (19-21), respectively. Median scores (interquartile range) on pretraining, immediate post-training, and 90-day post-training skills examinations were 10 (7-11), 23 (21.5-25), and 23 (22-24), respectively. Compared with pretraining scores, post-training scores were significantly improved ( P < .0001 for all comparisons). From June 2019 to April 2020, a total of 9,502 clinic patients were screened for breast symptoms: 150 (2%) underwent CBE, 93 (62%) were referred for further evaluation, and 88 (97%) were included in the study. Of those, 54 (61%) completed referral. Referral completion was not associated with age, employment, relationship status, or prior experiences related to BC.CONCLUSION: The program's training curriculum improved breast health knowledge and clinical skills. Efforts are needed to improve patients' receipt of recommended evaluation for breast abnormalities.

Due to concerns about the effects of the coronavirus disease 2019 (COVID-19 pandemic on health services, we examined its effects on human immunodeficiency virus (HIV) services in sub-Saharan Africa. Quarterly data (Q1, 10/2019–12/2019; Q2, 1/2020–3/2020; Q3, 4/2020–6/2020; Q4, 7/2020–9/2020) from 1059 health facilities in 11 countries were analyzed and categorized by stringency of pandemic measures. We conducted a difference-in-differences assessment of HIV service changes from Q1–Q2 to Q3–Q4 by higher vs lower stringency. There was a 3.3% decrease in the number HIV tested from Q2 to Q3 (572 845 to 553 780), with the number testing HIV-positive declining by 4.9% from Q2 to Q3. From Q3 to Q4, the number tested increased by 10.6% (612 646), with an increase of 8.8% (23 457) in the number testing HIV-positive with similar yield (3.8%). New antiretroviral therapy (ART) initiations declined by 9.8% from Q2 to Q3 but increased in Q4 by 9.8%. Across all quarters, the number on ART increased (Q1, 419 028 to Q4, 476 010). The number receiving viral load (VL) testing in the prior 12 months increased (Q1, 255 290 to Q4, 312 869). No decrease was noted in VL suppression (Q1, 87.5% to Q4, 90.1%). HIV testing (P < .0001) and new ART initiations (P = .001) were inversely associated with stringency. After initial declines, rebound was brisk, with increases noted in the number HIV tested, newly initiated or currently on ART, VL testing, and VL suppression throughout the period, demonstrating HIV program resilience in the face of the COVID-19 crisis.

Background: Syphilis increases human immunodeficiency virus (HIV) acquisition risk and impacts the immunologic and virologic response among people living with HIV (PLHIV). We assessed the prevalence of active or current syphilis and HIV/syphilis and their correlates among men who have sex with men (MSM), transwomen, and genderqueer (TGW/GQ) individuals in Zimbabwe. Methods: Among a respondent-driven sample of MSM and TGW/GQ who were tested for HIV and syphilis in Harare and Bulawayo, Zimbabwe in 2019 (n = 1511), multiple logistic regression was used to assess correlates of active syphilis. Unadjusted logistic regression was used among PLHIV (n = 340) due to small sample size. All analyses were unweighted as data did not reach convergence for HIV. Results: Prevalence of active syphilis overall and among PLHIV was 5.5% and 10.1%, respectively, in Harare, and 5.6% and 11.0%, respectively, in Bulawayo. Participants were more likely to have active syphilis if they were PLHIV (adjusted odds ratio [aOR], 2.2; 95% confidence interval [CI], 1.4–3.6), aged 25–34 years (aOR, 2.2 years; 95% CI, 1.3–3.8 years; reference, 18–24 years), or self-report sexually transmitted infection symptoms (aOR, 1.8; 95% CI, 1.1–3.0). Compared with Bulawayo TGW/GQ, MSM in Harare (aOR, 0.2; 95% CI, 0.1–0.5) and Bulawayo (aOR, 0.2; 95% CI, 0.1–0.4), and TGW/GQ in Harare (aOR, 0.2; 95% CI, 0.1–0.6) were less likely to have active syphilis. Among PLHIV, coinfection was 13.0% among TGW/GQ and 9.7% among MSM. Odds of coinfection were higher for those aged 25 to 34 years (OR, 3.7 years; 95% CI, 1.2–11.1 years) and lower among Harare MSM (OR, 0.2; 95% CI, 0.1–0.7), Bulawayo MSM (OR, 0.1; 95% CI, 0.0–0.4), and Harare TGW/GQ (OR, 0.1; 95% CI, 0.0–0.4) compared with Bulawayo TGW/GQ. Conclusions: Findings highlight a high burden of syphilis among MSM and TGW/GQ and underscore the importance of HIV/syphilis detection and improved service delivery for these groups.