Background: To reduce HIV incidence among adolescent girls who sell sex (AGSS) in Zimbabwe, we need to better understand how vulnerabilities intersect with HIV infection and how those living with HIV engage in care. Methods: In 2017, we conducted social mapping in 4 locations in Zimbabwe and recruited girls aged 16-19 years who sell sex, using respondent-driven sampling or census sampling methods. Participants completed a questionnaire and provided finger prick blood samples for HIV antibody testing. Results: Of 605 AGSS recruited, 74.4% considered themselves sex workers, 24.4% reported experiencing violence in the past year, 91.7% were not in school, and 83.8% had less than a complete secondary education. Prevalence of HIV increased steeply from 2.1% among those aged 16 years to 26.9% among those aged 19 years; overall, 20.2% of AGSS were HIV-positive. In the multivariate analysis, age, education, marital status, and violence from a client were associated with HIV. Among the 605 AGSS, 86.3% had ever tested for HIV, with 64.1% having tested in the past 6 months. Among AGSS living with HIV, half (50.8%) were aware of their status, among whom 83.9% reported taking antiretroviral therapy. Conclusion: The steep rise in HIV prevalence among those aged between 16 and 19 years suggests the window to engage with AGSS before HIV acquisition is short. To accelerate reductions in incidence among AGSS, intensified combination prevention strategies that address structural factors and tailor services to the needs of AGSS are required, particularly ensuring girls enroll and remain in school.

Background: In Zimbabwe, adolescent girls and young women (AGYW) experience high rates of HIV and other sexual and reproductive health challenges. In 2013, the Zimbabwe Ministry of Health and Child Care partnered with the United Nations Population Fund to implement the Sista2Sista programme, a structured peer group intervention aimed at improving health outcomes among vulnerable in- and out-of-school AGYW. Methods: Programme data was analysed for 91 612 AGYW aged 10-24 years old who participated in Sista2Sista from 2013 to 2019. Logistic regression was used to determine odds ratios (OR) and evaluate programme exposure as a factor in a set of defined variables. Results: 58 471 AGYW (63.82%) graduated from the Sista2Sista programme by completing at least 30 of 40 exercises. Graduates were more likely to take an HIV test (2.78 OR 95% CI 2.52-3.10), less likely to get married (0.63 OR 95% CI 0.55-0.73) and less likely to drop out of school (0.60 OR 95% CI 0.53-0.69). At higher thresholds of programme completion, additional positive outcomes were observed. Participants who completed all 40 exercises were more likely to return to school (1.41 OR 95% CI 1.18-1.69), more likely to use contraception (1.38 OR 95% CI 1.21-1.56), more likely to report sexual abuse (1.76 OR 95% CI 1.17-2.66), and less likely to become pregnant as adolescents (0.41 OR 95% CI 0.24-0.72). Individual counselling improved the likelihood of programme graduation. Conclusions: The Sista2Sista programme had a positive effect on HIV and other sexual health outcomes among vulnerable AGYW in Zimbabwe. Strategies to improve graduation rates should be explored.

Background: National-level population size estimates (PSEs) for hidden populations are required for HIV programming and modelling. Various estimation methods are available at the site-level, but it remains unclear which are optimal and how best to obtain national-level estimates. Setting: Zimbabwe. Methods: Using 2015–2017 data from respondent-driven sampling (RDS) surveys among female sex workers (FSW) aged 18+ years, mappings, and program records, we calculated PSEs for each of the 20 sites across Zimbabwe, using up to 3 methods per site (service and unique object multipliers, census, and capture-recapture). We compared estimates from different methods, and calculated site medians. We estimated prevalence of sex work at each site using census data available on the number of 15–49-year-old women, generated a list of all “hotspot” sites for sex work nationally, and matched sites into strata in which the prevalence of sex work from sites with PSEs was applied to those without. Directly and indirectly estimated PSEs for all hotspot sites were summed to provide a national-level PSE, incorporating an adjustment accounting for sex work outside hotspots. Results: Median site PSEs ranged from 12,863 in Harare to 247 in a rural growth-point. Multiplier methods produced the highest PSEs. We identified 55 hotspots estimated to include 95% of all FSW. FSW nationally were estimated to number 40,491, 1.23% of women aged 15–49 years, (plausibility bounds 28,177–58,797, 0.86–1.79%, those under 18 considered sexually exploited minors). Conclusion: There are large numbers of FSW estimated in Zimbabwe. Uncertainty in population size estimation should be reflected in policy-making.

Young female sex-workers (FSW) aged 18–24 are at high risk of HIV due to high numbers of sexual partners, difficulty negotiating condom use, increased risk of gender-based violence, and limited access to services. Here we describe changes in sexual behaviours among young FSW across Zimbabwe between 2013 and 2016, and risk factors for prevalent HIV in 2013 and 2016. FSW ≥ 18 years were recruited using respondent-driven sampling in 14 sites across Zimbabwe in 2013 and 2016 as part of the SAPPH-IRe trial. We collected data on socio-demographics and sexual behaviour and offered HIV testing. Statistical analyses were RDS-II weighted. Characteristics of young FSW aged 18–24 were described, stratified by age. Logistic regression was used to assess difference in sexual behaviours by reported HIV status between 2013 and 2016, and to explore associations with prevalent HIV in 2013 and 2016. 656 young FSW were recruited in 2013 and 503 in 2016. Characteristics of young FSW were similar across both surveys. HIV prevalence was similar at both time points (35% vs 36%) and rose steeply with age. Compared to young FSW in 2013, reported condom-less sex with a steady partner and condom-less sex with clients was higher in 2016 among women self-reporting HIV negative status (OR = 6.41; 95%CI: 3.40-12.09; P<0.001) and (OR = 1.69; 95%CI: 1.14-2.51, P = 0.008), respectively, but not among young FSW self-reporting HIV positive status (OR = 2.35; 95%CI: 0.57-9.76; P = 0.236) and (OR = 1.87; 95%CI: 0.74-4.74; P = 0.186). After adjusting for age in 2016, young FSW who had ever been married had increased odds of testing HIV positive (OR = 1.88; 95% CI 1.04–3.39; P = 0.036) compared with those who had never married. Young FSW who completed secondary education or higher were less likely to test HIV positive (OR = 0.41; 95% CI 0.20–0.83; P = 0.012) compared with those with primary education or less. Young FSW remain at very high risk of HIV. Strategies to identify young FSW when they first start selling and refer them into services that address their economic, social and sexual vulnerabilities are critical.

WORD COUNT 259, MAX 250) BACKGROUND Strengthening female sex workers’ (FSW) engagement with services is needed to eliminate HIV. We aimed to determine the impact of a targeted combination intervention for FSW in Zimbabwe. METHODS We conducted a cluster-randomised trial between 2014-2016 randomising 14 clusters (areas surrounding FSW clinics) in matched pairs to usual-care (free sexual-health services supported by peer educators, including HIV testing on demand, referral for antiretroviral therapy (ART), and health education) or enhanced-intervention arms (regular HIV testing, on-site ART and pre-exposure prophylaxis; adherence support, and intensified community mobilization). Primary outcome: proportion of all FSW with HIV viral load (VL) >=1,000 copies per mL, assessed through respondent driven sampling surveys. We used an adapted cluster-summary approach to estimate risk differences. RESULTS At intervention sites, 4,619 FSW attended clinics compared to 3,612 in comparison sites, twice as many were tested (2,606 vs 1,151) and diagnosed HIV positive (1,052 vs 546). The proportion of all FSW with VL >=1,000 copies per mL fell in both arms, (29.5% (407/1317) to 19.1% (272/1397) in usual-care and 30.2% (384/1259) to 16.4% (232/1393) in enhanced intervention arm) but with a risk difference of only 2.8% (95% CI: -8.1%, 2.5%) at endline, p-value=0.23. Among HIV-positive women, the proportions with VL<1000 copies per mL rose to 72.0% (562/794) in the enhanced-intervention and 67.5% (569/841) in the usual-care arm, adjusted risk difference of 5.3% (95% CI: -4.0%, 14.6%), p-value=0.20. There were no adverse events. INTERPRETATION Within a dedicated FSW programme, high levels of HIV diagnosis and treatment are achievable. Further research is required to optimise programme content and intensity for population impact. FUNDING The Sisters Antiretroviral therapy Programme for Prevention of HIV: an Integrated Response (SAPPH-IRe) trial was funded by United Population Population Fund (UNFPA) via Zimbabwe’s Integrated Support Fund which received funds from DfID, Irish Aid and SIDA. A small amount of funding for survey work is from GIZ. USAID supported the cost of PSI Zimbabwe to deliver ART and PrEP to sex workers as part of the trial. We received a donation of Truvada for PrEP use for the trial from Gilead Sciences. INTRODUCTION Worldwide, female sex workers have approximately 13.5-times higher odds of HIV infection than women in the general population1. Many have reduced access to testing and treatment, and face barriers to adherence1,2. In Zimbabwe, analysis of data from 2009-2013 found HIV incidence among female sex workers to be over 10 new cases per 100 person-years at risk3. Only 67% were aware of their HIV status, while less than 50% living with HIV had an undetectable viral load, defined as <1000 copies per mL4. Consistent condom use with clients was reported by 65-73%. Heterosexual transmission of HIV is unlikely to occur with viral load of <1500 copies per mL5. Modelling suggests that over 40% of new infections among the general population are attributable to unsafe sex work, because of both high HIV incidence and high prevalence of infectious HIV among this group, leading to transmission to others6. While guidelines for interventions for female sex workers exist7, few evaluations have assessed impact on engagement with HIV prevention and care, particularly in Africa and since the preventative effects of ART and efficacy of oral pre-exposure prophylaxis (PrEP) have become clear8 Reducing the burden of infectious HIV among female sex workers requires interventions that strengthen demand, enhance supply, and support optimal use of any prevention or treatment strategy adopted. Demand-side interventions should increase risk perception, support positive attitudes towards HIV prevention and treatment, foster positive social norms, and build social cohesion to enhance risk reduction. Supply-side interventions should increase accessibility and availability of HIV-testing and treatment, and of HIV prevention tools such as condoms, contraception, and PrEP. For adherence, interventions should support behavioural self-efficacy and skills9. Based on these principles, we enhanced the existing Sisters programme to develop the Sisters Antiretroviral Prevention Programme – an Integrated Response (SAPPH-IRe) combination-HIV-prevention-and-treatment-intervention package, and evaluated its impact on the proportion of all female sex workers with an HIV viral load >=1000 copies per mL in a cluster-randomised trial in Zimbabwe (see Theory of Change Webappendix 2 page 4). Our hypothesis was that the targeted and dedicated delivery and support of our enhanced intervention would reduce the proportion of female sex workers living with an HIV viral load >=1000 copies per mL when compared with the current WHO-guideline-based usual care.

Background Strengthening engagement of female sex workers with health services is needed to eliminate HIV. We assessed the efficacy of a targeted combination intervention for female sex workers in Zimbabwe. Methods We did a cluster-randomised trial from 2014 to 2016. Clusters were areas surrounding female sex worker clinics and were enrolled in matched pairs. Sites were randomly assigned (1:1) to receive usual care (free sexual-health services supported by peer educators, including HIV testing on demand, referral for antiretroviral therapy [ART], and health education) or an intervention that supported additional regular HIV testing, on-site initiation of ART, pre-exposure prophylaxis, adherence, and intensified community mobilisation. The primary outcome was the proportion of all female sex workers with HIV viral load 1000 copies per mL or greater, assessed through respondentdriven sampling surveys. We used an adapted cluster-summary approach to estimate risk differences. Findings We randomly assigned 14 clusters to usual care or the intervention (seven in each group). 3612 female sex workers attended clinics in the usual-care clusters and 4619 in the intervention clusters during the study. Half as many were tested (1151 vs 2606) and diagnosed as being HIV positive (546 vs 1052) in the usual-care clusters. The proportion of all female sex workers with viral loads of 1000 copies per mL or greater fell in both study groups (from 421 [30%] of 1363 to 279 [19%] of 1443 in the usual-care group and from 399 [30%] of 1303 to 240 [16%] of 1439 in the intervention group), but with a risk difference at the end of the assessment period of only -2.8% (95% CI -8.1 to 2.5, p=0 . 23). Among HIV-positive women, the proportions with viral loads less than 1000 copies per mL were 590 (68%) of 869 in the usual-care group and 588 (72%) of 828 in the intervention group at the end of the assessment period, adjusted risk difference of 5.3% (95% CI -4.0 to 14.6, p=0.20). There were no adverse events. Interpretation Our intervention of a dedicated programme for female sex workers led to high levels of HIV diagnosis and treatment. Further research is needed to optimise programme content and intensity for the broader population. Copyright (C) 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license.

62 Introduction: Female sex workers (FSW) in sub-Saharan Africa have a higher prevalence of HIV 63 than other women of reproductive age. Social, legal, and structural barriers influence their 64 access to care. Little is known about the HIV diagnosis and care cascade in most countries in 65 southern Africa. We aimed to describe the HIV diagnosis and care cascade among FSW in 66 Zimbabwe. 67 Methods: We conducted cross-sectional respondent driven sampling (RDS) surveys of FSW in 68 14 sites across Zimbabwe as the baseline for a cluster-randomised controlled trial investigating 69 a combination HIV prevention and care package. We administered a questionnaire, tested 70 women for HIV and measured viral load. We report the mean, minimum and maximum RDS-2 71 weighted site values. 72 Results: The survey included 2,722 women, approximately 200 per site. The mean HIV 73 prevalence was 57.5% (42.8-79.2 site minimum and maximum). Of HIV positive women, 64.0% 74 (51.6-73.7) were aware of their status, 67.7% (53.4-84.1) of these reported taking ART and 75 77.8% (64.4-90.8) of these had HIV viral load <1000 copies/ml. Among all HIV positive women, 76 49.5% had a viral load < 1000 copies/ml. 77 Conclusions: While the majority of HIV positive women aware of their status are accessing 78 ART, 36.0% of HIV positive women are unaware of their status and 29.3% of all FSW have an 79 unsuppressed HIV viral load. Investigation and investment into models of testing, treatment 80 and care are necessary to reach UNAIDS 90:90:90 targets. 81

Introduction: Young female sex workers (FSWs) are at greater HIV risk than their older counterparts. Yet, the extent of their engagement with HIV services is largely unknown. We compared engagement among FSWs aged 18–24 years with those 25 years and older. Methods: We used respondent-driven sampling to recruit FSWs from 14 communities in Zimbabwe from November to December 2013. We collected data on demographics, behavior, service uptake, and HIV and viral load testing. Data were pooled and weighted using respondent-driven sampling-2 estimation. We analyzed HIV care cascade variables by age group. To identify potential drivers of younger FSW service use, we explored factors associated with knowing one's HIV status. Results: Among 2617 participants, mean age was 31 years and 26% were 18–24 years. Over half of FSWs initiated sex work before the age of 25 years. Overall HIV prevalence was 59% but was lower among younger FSWs (35% vs 67%, P < 0.01). Younger HIV-infected FSWs were significantly less engaged at each step of the care cascade. Among younger FSWs reporting antiretroviral therapy use, 62% had an undetectable viral load compared with 79% in older FSWs. In multivariable regression, young FSWs encouraged to have an HIV test by another FSW (adjusted odds ratio = 2.54; 95% confidence interval: 1.44 to 4.50), and those with no recent clients (adjusted odds ratio = 4.31; 95% confidence interval: 1.30 to 14.33) were more likely to report knowing their status. Conclusions: 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: Female sex workers (FSW) in sub-Saharan Africa have a higher prevalence of HIV than other women of reproductive age. Social, legal, and structural barriers influence their access to care. Little is known about the HIV diagnosis and care cascade in most countries in Southern Africa. We aimed to describe the HIV diagnosis and care cascade among FSW in Zimbabwe. Methods: We conducted cross-sectional respondent driven sampling (RDS) surveys of FSW in 14 sites across Zimbabwe as the baseline for a cluster-randomised controlled trial investigating a combination HIV prevention and care package. We administered a questionnaire, tested women for HIV and measured viral load. We report the mean, minimum, and maximum respondent-driven sampling-2 weighted site values. Results: The survey included 2722 women, approximately 200 per site. The mean HIV prevalence was 57.5% (42.8–79.2 site minimum and maximum). Of HIV-positive women, 64.0% (51.6–73.7) were aware of their status, 67.7% (53.4–84.1) of these reported taking antiretroviral therapy, and 77.8% (64.4–90.8) of these had a suppressed HIV viral load (<1000 copies/mL). Among all HIV-positive women, 49.5% had a viral load < 1000 copies/mL. Conclusions: Although most HIV-positive women aware of their status are accessing antiretroviral therapy, 36.0% of HIV-positive women are unaware of their status and 29.3% of all FSW have an unsuppressed HIV viral load. Investigation and investment into models of testing, treatment, and care are necessary to reach UNAIDS targets for HIV elimination.

BACKGROUND:HIV epidemiology and intervention uptake among female sex workers (FSW) in sub-Saharan Africa remain poorly understood. Data from outreach programs are a neglected resource.METHODS:Analysis of data from FSW consultations with Zimbabwe's National Sex Work program, 2009-2014. At each visit, data were collected on sociodemographic characteristics, HIV testing history, HIV tests conducted by the program and antiretroviral (ARV) history. Characteristics at first visit and longitudinal data on program engagement, repeat HIV testing, and HIV seroconversion were analyzed using a cohort approach.RESULTS:Data were available for 13,360 women, 31,389 visits, 14,579 reported HIV tests, 2750 tests undertaken by the program, and 2387 reported ARV treatment initiations. At first visit, 72% of FSW had tested for HIV; 50% of these reported being HIV positive. Among HIV-positive women, 41% reported being on ARV. 56% of FSW attended the program only once. FSW who had not previously had an HIV-positive test had been tested within the last 6 months 27% of the time during follow-up. After testing HIV positive, women started on ARV at a rate of 23/100 person years of follow-up. Among those with 2 or more HIV tests, the HIV seroconversion rate was 9.8/100 person years of follow-up (95% confidence interval: 7.1 to 15.9).CONCLUSIONS:Individual-level outreach program data can be used to estimate HIV incidence and intervention uptake among FSW in Zimbabwe. Current data suggest very high HIV prevalence and incidence among this group and help identify areas for program improvement. Further methodological validation is required.

Young women who sell sex (YWSS) in Southern Africa are highly vulnerable to HIV, as the risks of being young and female in a high prevalence setting coalesce with those of commercial sex. YWSS are less able to negotiate safe sex, more likely to have higher risk partners, and less likely to use available health services compared to older sex workers. In Zimbabwe's national HIV programme for sex workers, fewer than 1% of clients were 15-29. We developed monthly interactive workshops for YWSS based on an Activity Pack consisting of 21 sessions organised into six modules. The aim was to encourage YWSS' interaction with each other, build their trust, confidence and skills, and encourage uptake of clinical services. We conducted a process evaluation to assess programme strengths, identify challenges, and recommend changes. This paper presents findings synthesising programme records with qualitative data and discusses feasibility, acceptability, and outputs during the pilot phase. In total, 143 YWSS attended meetings and most were from the target 15-19-year-old age group. Participants enjoyed the sessions and reported improved cooperation, willingness to negotiate with clients, and self-reflection about their futures. Staff found facilitating sessions easy and activities clear and appropriate. Challenges included identifying appropriate referrals, initial recruitment of women in some sites, and managing participants' requests for financial compensation. The number of clients aged 15-19 increased at sex worker clinics in all sites. This programme is the first to target YWSS in Zimbabwe to address their disproportionately low service use. It proved feasible to staff and acceptable to participants over a one-year period. Given enhanced vulnerability of YWSS, this programme provides one workable model for reaching this underserved group.

HIV epidemiology and intervention uptake among female sex workers (FSW) in sub-Saharan Africa remain poorly understood. Data from outreach programs are a neglected resource.Analysis of data from FSW consultations with Zimbabwe's National Sex Work program, 2009-2014. At each visit, data were collected on sociodemographic characteristics, HIV testing history, HIV tests conducted by the program and antiretroviral (ARV) history. Characteristics at first visit and longitudinal data on program engagement, repeat HIV testing, and HIV seroconversion were analyzed using a cohort approach.Data were available for 13,360 women, 31,389 visits, 14,579 reported HIV tests, 2750 tests undertaken by the program, and 2387 reported ARV treatment initiations. At first visit, 72% of FSW had tested for HIV; 50% of these reported being HIV positive. Among HIV-positive women, 41% reported being on ARV. 56% of FSW attended the program only once. FSW who had not previously had an HIV-positive test had been tested within the last 6 months 27% of the time during follow-up. After testing HIV positive, women started on ARV at a rate of 23/100 person years of follow-up. Among those with 2 or more HIV tests, the HIV seroconversion rate was 9.8/100 person years of follow-up (95% confidence interval: 7.1 to 15.9).Individual-level outreach program data can be used to estimate HIV incidence and intervention uptake among FSW in Zimbabwe. Current data suggest very high HIV prevalence and incidence among this group and help identify areas for program improvement. Further methodological validation is required.