Ministry of Health and Child Care (Zimbabwe)

Background: Tuberculosis (TB) is the leading cause of death among people living with HIV (PLHIV). Globally in 2023, an estimated 161,000 PLHIV died of TB. TB preventive treatment (TPT) can reduce TB mortality yet scale up remains a challenge. We documented Zimbabwe's experience in scaling TPT among PLHIV. Methodology: We analyzed routine aggregate data from the President Emergency Plan for AIDS Relief (PEPEFAR) database, Data for Accountability Transparency and Impact Monitoring (DATIM). We conducted a desk review of national guidelines, reports, training manuals, policy and strategic plans. Program reports were reviewed to understand scale up best practices, successes and challenges. Results: TPT coverage (cumulative number completed TPT divided by PLHIV on ART) increased from <1% (144/950,235) in 2018 to 101% (1,040,460/1,029,583) in 2024, in PEPFAR supported health facilities. Adults had a higher TPT coverage of 102% (1,006,544/990,818) than children 87% (33,916/38,765). TPT completion (number started TPT divided number completing TPT) was significantly higher among adults, 99.2% compared to children, 97.9%, difference 1.2 percentage points (CI 0.98-1.50, p < 0.01). Key interventions resulting in improved TPT coverage and completion, included removal of the 3months waiting period for PLHIV to initiate TPT, introduction of shorter regimens, pharmacovigilance, implementation monitoring, stakeholder engagement, and communication of updated policies. Conclusion: We report a significant increase in TPT coverage and completion rates. We observed lower TPT coverage and completion among children compared to adults. TPT scale-up lessons from Zimbabwe can inform TPT expansion in countries of similar context.

BACKGROUND:Long-acting antiretroviral therapy (LA-ART) may reduce adherence barriers for postpartum women with HIV (PPWH), reducing vertical transmission (VT) and improving pediatric life expectancy (pLE), but efficacy and drug costs are uncertain. METHODS:Using a microsimulation model, we simulated mother-infant dyads for two cohorts of PPWH engaged in care, receiving oral tenofovir/lamivudine/dolutegravir (TLD) in pregnancy, and facing adherence challenges in Zimbabwe: mothers without (NVS) and with (VS) viral suppression at delivery. We modeled two post-delivery strategies: standard of care (SOC: TLD continuation) or LA-ART (switching to LA-cabotegravir/rilpivirine [CAB/RPV]). Key inputs included: 6-month-postpartum viral suppression (LA-ART: NVS = 85%/VS = 90%; SOC: NVS = 63%/VS = 78%), ART costs/year (CAB/RPV=$144/TLD=$43.20), and VT risk (0.06%-0.89%/month, range by maternal RNA). Outcomes include VT, pLE, costs (maternal ART in breastfeeding plus pediatric HIV-related lifetime care), and incremental cost-effectiveness ratios (ICERs, $/year-of-life-saved [YLS]; cost-effective: ICER≤$800/YLS [0.5× Zimbabwe GDP]. RESULTS:LA-ART would reduce VT compared with SOC (NVS: from 7.49% to 6.58%/VS: from 4.17% to 3.80%), averting ∼160 infections/year in Zimbabwe. For NVS, LA-ART would improve pLE (SOC = 66.08y, LA-ART = 66.40y) at nearly equal cost (SOC = $764/child, LA-ART = $763/child); LA-ART would not be cost-effective if CAB/RPV cost >$228/year or 6-month suppression were <74%. For VS, LA-ART would lead to higher pLE and costs (67.52y, $555/child) than SOC (67.40y, $445/child), with ICER=$2449/YLS; LA-ART would become cost-effective if CAB/RPV cost ≤$84/year. CONCLUSIONS:LA-ART for breastfeeding women experiencing adherence challenges could reduce infant infections. If efficacies and costs are confirmed, LA-ART for NVS women would improve outcomes and be minimally cost-saving; for VS women, LA-ART would be cost-effective in Zimbabwe at costs ≤$84/year.

Multiple HIV Prevention Cascades (HPC) formulations have been proposed to assist advocacy, monitoring of HIV prevention implementation and research to identify ways to increase use of HIV prevention methods. Schaefer and colleagues proposed a unifying formulation suitable for widespread use across different populations which could be used for routine monitoring or advocacy. Robust methods for defining and interpreting this HPC formulation using real world data are necessary to aid promotion and utilisation of this framework to address necessary gaps in primary HIV prevention method use. We used 2018-19 data from the Manicaland Pilot HIV Prevention Cascades Study in eastern Zimbabwe to validate the HPC framework for pre-exposure prophylaxis (PrEP), voluntary medical male circumcision (VMMC), female and male condoms, and combination prevention. Validation involved: (1) testing feasibility of populating the HPC; (2) comparing simple vs. complex HPC measures using 2-sample proportion tests; and (3) using logistic regression to assess whether HPC cascade bars predicted prevention use and whether sub-bars explained loss from the HPC. It was possible to populate the HPC for individual and combined prevention methods using pilot survey data. Most steps were associated with prevention method usage outcomes, except for VMMC. There were significant overlaps between individuals reporting positive responses for the main motivation bar and those citing barriers to motivation. To refine the HPC's access bar definition, it is suggested to consider individuals who report access barriers. While the HPC framework identifies barriers to individual prevention methods, challenges arise in identifying those for combined prevention. Our study successfully utilised questionnaires from the Manicaland HPC pilot survey to measure the HPC for individual and combined prevention methods. In conclusion, it is feasible to populate this framework using general population survey data and designated questionnaire modules. We propose a final formulation of the HPC, and questionnaire modules and methods to create it. With proper promotion, such as through measurement within national to local population surveys, the HPC framework can allow comparison of prevention method use, identification of intervention targets and enhance prevention services, aiding in the crucial reduction of HIV incidence.

BACKGROUND:The lives of adolescents and young people living with HIV (LHIV) are dominated by complex psychological and social stressors. These may be more pronounced among those perinatally infected. This longitudinal mixed-methods study describes the clinical and psychosocial challenges faced by HIV perinatally infected young mothers in Harare, Zimbabwe to inform tailored support. METHODS:HIV perinatally infected young mothers were recruited in 2013 and followed up in 2019. In 2013, they completed a structured interview, clinical examination, psychological screening and had viral load and drug resistance testing. A subset completed in-depth interviews (n = 10). In 2019, they were re-interviewed and had viral load testing. Data were analyzed using STATA 15.0. and thematic analysis. RESULTS:Nineteen mothers aged 17-24 years were recruited in 2013. Eleven (57.9%) were successfully recontacted in 2019; 3 had died, 2 had relocated and 3 were untraceable. In 2013, all 19 mothers were taking antiretroviral therapy (median duration 8 years, range 2-11 years) and median CD4 count was 524 (IQR 272). In 2013, eight mothers (42.1%) had virological failure (≥1000 copies/ml) (3 of whom subsequently died) and 7 (36.8%) had evidence of drug resistance. In 2019, the proportion with virological failure was 2/11 (18.1%). Six of 11 (54.5%) had switched to second line therapy. In 2013, 64.3% were at risk of common mental disorder and this risk was higher at follow-up (72.7%). Qualitative data highlighted three pertinent themes: HIV status disclosure, adherence experiences and, social and emotional support. CONCLUSIONS:Findings from this study underscore the significant clinical, social and psychological challenges faced by perinatally infected young mothers. The high rates of virological failure, drug resistant mutations, mental health issues and mortality observed in this population indicate the need for tailored and comprehensive health and support services to assist these young mothers.

BACKGROUND:In Africa, for people with HIV on a dolutegravir-based regimen with a viral load of more than 1000 copies per mL despite enhanced adherence counselling, the appropriate course of action is uncertain. We aimed to evaluate the predicted effects of alternative antiretroviral regimen switching options in this population, including consideration of cost-effectiveness. METHODS:We used an existing individual-based model to simulate risk and experience of HIV in 100 000 adults alive between 1989 and 2076. Using sampling of parameter values, we created 1000 setting-scenarios, reflecting the uncertainty in assumptions and a range of settings similar to those seen in eastern, central, southern, and western Africa. For each setting-scenario, we predicted the outcomes from the three alternative policies for people with sustained viral load non-suppression on a dolutegravir-containing regimen from 2026: a switch to a protease inhibitor-based regimen (switch policy), a switch to a protease inhibitor-based regimen only if HIV drug resistance testing beforehand shows integrase inhibitor resistance (resistance test policy), and no switch with no HIV drug resistance test (no switch policy). We considered predicted outcomes over 10-year and 50-year periods from 2026, used a 3% discount rate, and a cost-effectiveness threshold of US$500 per disability-adjusted life-year (DALY) averted. Ritonavir-boosted darunavir costs $210 per year, and dolutegravir less than $20. We assumed a cost of HIV drug resistance testing of $200 and considered variations around this. For comparing policies, we calculated net DALYs, which account for the health consequences of differences in costs and provide a measure of the impact of a policy on overall population burden of disease. FINDINGS:Across setting-scenarios, there was a mean of 14 480 deaths per year (95% CI 13 750-15 210) over 50 years with a mean annual discounted cost of $103·2 million (95·8-106·5) with the switch policy in the context of having scaled to a setting with an adult population of 10 million in 2024. Compared with the switch policy, the no switch policy was predicted to lead to an overall increased number of DALYs incurred (mean 4400 per year, 95% CI 3200-5500), although it resulted in the lowest overall cost, with a difference in annual discounted costs of $5·1 million (95% CI 4·6-5·6) lower than the switch policy. The resistance test policy led to a similar risk of death and DALYs to the switch policy at a lower overall cost (difference in annual discounted costs $3·5 million per year, 95% CI 3·1-3·9), leading to 6900 (95% CI 5500-8200) fewer net DALYs per year. Net DALYs for the resistance test versus no switch policies were similar (-1000 net DALYs, 95% CI 400 to -2300). The incremental cost-effectiveness ratio when comparing the resistance test policy with the no switch policy was $376 per DALY averted; the switch policy was dominated. INTERPRETATION:Introduction of HIV drug resistance testing for people with sustained viral load non-suppression on dolutegravir-based antiretroviral therapy is likely to be cost-effective. We suggest that exploratory planning for increased access and scale-up of high-quality, low-cost drug resistance testing for the region is undertaken. FUNDING:Gates Foundation as part of the HIV Modelling Consortium.