Because of its recent regulatory approval in southern and eastern Africa, CAB PrEP represents a scientific advancement with unknown implementation costs in most African countries. To our knowledge, this paper is the first study comparing PrEP costs in health facilities where clients had a choice between three PrEP methods. We collected and analyzed the direct service delivery costs for each method using the same costing approach and assumptions at three facilities in Lesotho and six facilities in Zimbabwe. On average, in Lesotho, the direct costs of providing CAB PrEP were $57.22 for an initiation visit and $54.20 for a refill visit (same PrEP product dose dispensed in both visit types), while the direct costs of oral PrEP were $22.47 (initiation visit with one month of PrEP dispensed) and $31.98 (refill visit dispensing a three-month dose of medication), and the direct costs of the dapivirine ring were $34.27 (initiation visit with one month of PrEP dispensed) and $50.70 (refill visit dispensing a three-month supply). In Zimbabwe, the average per-visit direct costs to provide CAB PrEP were $48.26 (initiation visit) and $47.40 (refill visit), to provide oral PrEP were $13.47 (initiation visit with one month of PrEP dispensed) and $21.78 (refill visit dispensing a three-month dose), and to provide the dapivirine ring were $42.56 (refill visit dispensing a three-month supply). Initiation visits for the dapivirine ring were not observed in Zimbabwe. At a time when national governments are creating budgets for the HIV response with decreased financial support from bilateral and multilateral partners, this paper will inform HIV prevention planning by providing critical client-level data from the healthcare provider perspective.

BACKGROUND:Tuberculosis household contacts are at elevated risk of HIV, and systematic screening for tuberculosis is an opportunity for people to know their status. We aimed to assess the coverage and positivity of HIV testing during household systematic screening for tuberculosis. METHODS:For this systematic review and meta-analysis (PROSPERO: CRD42024471979), we searched MEDLINE, Embase, Global Health, and Africa Wide databases from Jan 1, 2000, to June 24, 2025. The primary analysis population was household contacts of people with tuberculosis without known HIV. Studies were included if HIV testing was offered to household contacts, and in the primary analysis if people known to be living with HIV were excluded from the population eligible for testing. We extracted or derived coverage (proportion of people eligible for testing who received an HIV test) and positivity (proportion of people tested with a positive result) and calculated pooled proportions using random effects meta-analysis. We narratively summarised themes from qualitative reports. Meta-regression examined the association of national HIV prevalence, time period, and participant age, with coverage and positivity of HIV testing. FINDINGS:Searches identified 31 quantitative studies (110 090 people), of which 17 (40 407 people) were included in primary analyses. Seven qualitative studies reported community or provider perspectives. The pooled proportion of eligible household contacts tested for HIV was 72·9% (95% CI 60·3-83·9), ranging from 0% to 100%. Pooled positivity of testing was 5·9% (3·6-8·8) overall. Positivity was 9·7% (5·8-14·5; ten studies) in countries with ≥10% national adult HIV prevalence. Qualitative studies highlighted context-dependent facilitators and barriers of household contacts' capability, opportunity, and motivations to engage with HIV testing. INTERPRETATION:Few studies have evaluated HIV testing for tuberculosis household contacts. Coverage of testing was reasonable but varied substantially across studies. Positivity of testing was high. Further research is needed to understand and optimise acceptability and ensure feasibility of HIV testing within screening of tuberculosis among household contacts, and tuberculosis-HIV programmes in high HIV-incidence settings should consider monitoring implementation of HIV within routine tuberculosis household contact screening. FUNDING:National Institute for Health and Care Research and Wellcome Trust.

Community-led distribution of HIV self-test (HIVST) kits has potential to combine the benefits of community-based HIV testing with the strengths of community-led interventions. We report the process evaluation from the community-led arm of a cluster-randomized trial in rural Zimbabwe comparing community-led versus community-based HIVST distribution where distributors were paid. Twenty communities were supported to design HIVST distribution models that suited their context. We conducted community meetings where we introduced community-led HIVST, including messages on the benefits of viral load suppression (Undetectable=Untransmissible; "U=U"). Communities determined how, and by whom, distribution would be done. Communities implemented their distribution model over 4-6 weeks. We conducted in-depth interviews with community members (n=20), distributors (n=20) and health workers (n=20) as well as 12 focus group discussions (n=91) with community members. We triangulated findings with participant observations during community meetings and implementation and descriptively analysed program data on HIVST distribution. Qualitative data were analysed thematically. Participant observations found communities collaboratively developed and embraced HIVST distribution, demonstrating strong enthusiasm for participation. Messaging on U=U was met with interest and surprise, as many community members were unaware of this information, and became a key motivator for HIVST implementation and uptake. Across communities, 348 distributors distributed 27,812 kits door-to-door and/or from their homes or other community venues. Communities where model development was led by local leaders - rather than collective processes- expressed lower level of satisfaction and had slow implementation. Health workers supported HIVST distribution well, with opportunities for improvement noted. While distributors felt proud to deliver HIVST, many experienced logistical burdens, and need for material support from the programme and community. Communities designed HIVST delivery models that were acceptable and feasible, however efforts to make community-led models sustainable are critical. Delivering messages on U=U should continue to be prioritized and embedded within community-based HIVST distribution models.

INTRODUCTION:Evidence from routine, national programme data on HIV self-testing (HIVST) scale-up is limited. This study examines HIVST scale-up in eight African countries, describing how HIVST has been integrated into testing strategies and how testing coverage, test positivity, and linkage to antiretroviral therapy (ART) have evolved. METHODS:We conducted a retrospective descriptive analysis of national programme data from January 2019 to December 2023 across Kenya, Lesotho, Malawi, Mozambique, South Africa, Tanzania, Uganda and Zimbabwe. Data were disaggregated by quarter and subnational district. Indicators included HIVST kits distributed, conventional testing volumes, new HIV diagnoses and new ART initiations. We derived testing rates, testing positivity, ART linkage, and stability of HIVST distribution by district and over time. RESULTS:HIVST scale-up varied across countries. By the most recent quarter, HIVST accounted for 63% of total testing in Lesotho, 19%-25% in Malawi and Zimbabwe, but <15% in Kenya, Tanzania, Uganda and South Africa. In Malawi, Lesotho and Zimbabwe, large volumes of HIVST partially offset declines in conventional testing during the COVID-19 pandemic. HIVST remained modest (<15% of total tests) in Kenya and Tanzania. In Mozambique, both conventional testing and HIVST expanded. In South Africa, conventional testing remained high after COVID-19, while HIVST expanded slowly. Despite divergent trajectories, new HIV diagnoses and ART initiations remained stable in most settings, indicating programmes adapted to maintain case-finding even as testing volumes shifted. CONCLUSIONS:This descriptive analysis shows HIVST has been scaled to different degrees, with its contribution to overall testing shaped by national contexts, and distribution models. Interpretation is constrained by incomplete reporting, the inability to identify kits used out of kits distributed and distinguishing first-time from repeat testers. These findings can guide optimizing HIV testing services, an essential step towards meeting global HIV targets and ending AIDS by 2030.

Performance-based financing (PBF) is a funding strategy that pays for outcomes rather than the cost of inputs. Verification through facility records (quantity verification) and patient interviews in communities (community verification) is a known cornerstone of PBF to ensure reported results are accurate. However, the literature suggests it's common to tie payment to quantity verification results, which measure internal record alignment but do not assess the validity of records (e.g., whether records represent delivered services). We sought to understand the extent to which reported voluntary medical male circumcisions (VMMCs) in a PBF program could be verified in facility records and with patients, and if the two sources aligned at the facility-level. We performed a mixed method verification including quantity verification and community verification to verify reported results for Population Services International's VMMC program in Zimbabwe from 2016 - 2018. We also interviewed verifiers to help understand the findings and we assessed the correlation between quantity and community verification performance scores at the facility-level to see whether facilities that have strong record keeping tended to also have strong validation from patients and vice versa. Among the 36,877 VMMCs selected from DHIS2 for quantity verification, 94% of records were sufficiently complete. Among records selected for community verification, only 55% (2,010/3,676) of patients were interviewed. Among those interviewed, 17% (342/2,010) provided answers that did not plausibly match the record. Verifiers reported that some patients admitted providing incorrect contact information to avoid follow-up and most verifiers suspected staff had fabricated data. We found no correlation between performance scores at the facility-level. Overall, results from the quantity verification were not a good proxy for the community verification. Programs that pay based on facility records alone risk overpaying for services and misreporting performance. To increase the use of community verification findings, PBF programs should consider using and improving our proposed results to action framework.

The global health community has recognized the importance of integrating and sustaining health programs within national health systems rather than managing stand-alone 'vertical' interventions. Corresponding with these objectives, international aid donors are embracing the principle of localization. Voluntary Medical Male Circumcision (VMMC) in Zimbabwe is a large vertical HIV prevention program that was primarily funded through development assistance for health. Program stakeholders want to sustainably integrate VMMC into routine health services so that the program will continue to be a cost-effective HIV prevention strategy. The research team studied the effectiveness of a district-level intervention to empower local stakeholders in this integration effort. To evaluate this intervention, the research team conducted a document review of district-level work plans, combined with a survey administered to district teams assessing sustainability capacity of the program. Over a two-year period, Task Teams in all five intervention districts successfully integrated the VMMC program by reducing barriers and leveraging opportunities in other parts of the health system. Key outcomes impacted all WHO health system building blocks, including enhanced leadership and governance, improved service delivery through better access and acceptability, an expanded health workforce through training, more efficient use of medical technologies, improved data quality, and the mobilization of local funds to support program financing and sustainability. The sustainability survey showed a reduction in funding stability but a significant increase in communications, program adaptation, and organizational capacity. By institutionalizing participatory work planning, fostering local ownership, and mobilizing resources, the project demonstrated a successful model for integrating, scaling, and sustaining VMMC services. Other health programs in low- and middle-income countries seeking to integrate and sustain health services at subnational levels should consider this diagonal, bottom-up model to promote local leadership development and health system strengthening.

Introduction: Understanding how HIV epidemics are likely to behave in the future is key to informing HIV response strategies in low-income countries. Up-to-date HIV epidemiological estimates are important for policy decision- making, but surveillance data can be out of date. This study compared forecasts from HIV epidemiological models.Methods: Five independent modelling groups (EMOD-HIV, Goals, HIV Synthesis, Optima and PopART-IBM) calibrated their mathematical models to datapoints provided by the Ministry of Health and produced several indicators of the HIV epidemic in Zimbabwe for the period 1990 to 2040, under a status quo scenario in which it was assumed continuation of interventions at the current level.Results: All models predicted a continuous decline in HIV incidence and prevalence. However, there was variability in the estimated 2023 incidence rate (range: 2.0-3.3 per 1 000 person-years) and prevalence (range: 12.1%-14.3%). Variance was even larger in 2040 for incidence (range: 1.0-3.0 per 1 000 person-years), while this was not the case for prevalence (range: 3.9%-6.0%). All the models predicted that the country would reach a target of less than 7 800 new HIV infections per year by 2025.Conclusion: Five independent mathematical models fitted to the Zimbabwe Ministry of Health and Child Care's HIV surveillance data provided consistent predictions of continued decline in HIV incidence and prevalence in Zimbabwe if interventions continue to be implemented at the current levels, with prevalence predicted to be around a third of its level in 2000 by 2040.

Using a validated HIV transmission model for Zimbabwe, we simulated January 2025 U.S. President's Plan for AIDS Relief (PEPFAR) funding cuts' impacts on HIV incidence and HIV-related deaths. We found extending funding cuts through 2030 would increase HIV incidence by 78% and add 85 000 infections, producing 25 000 additional HIV-related deaths. However, if PEPFAR reinstated funding within 12 months, much or all of this harm could be offset through more efficient resource allocation, specifically, reallocating funds for oral PrEP towards long-acting PrEP.

The Dapivirine vaginal ring (DPV-VR) is an intravaginal silicone ring that delivers an antiretroviral drug (Dapivirine) directly to vaginal tissues for 28 days. This ring protects women against HIV during the receptive vaginal sex at the site of potential infection. In 2021, the WHO recommended DPV as an additional prevention method for high-risk women for HIV with other approaches. With its discreet usage and disposal, DPV-VR has become a preferred HIV method among young women in Sub-Saharan Africa with a prevalent patriarchal social structure that prevents women from making decisions on their bodily autonomy. This study is aimed to assess the acceptability and feasibility of introducing DPV-VR as an HIV prevention method among young women in Zimbabwe and assess motivations and barriers of DPV-VR uptake among target population. We conducted an open-label prospective cohort study from 26 April 2022 to 23 January 2023 across 8 districts in Zimbabwe. Sexually active HIV-negative women aged between 18 and 25 years who were identified as high risk were offered a choice of oral PrEP or DPV-VR. Participants who chose DPV-VR were followed up for six months to receive monthly ring replacement and measure feasibility and acceptability. In-depth interviews were conducted with recipients of care who discontinued, continued for six months, or seroconverted while enrolled in the study to understand their experiences. A minimum of five clients who seroconverted were interviewed to identify potential timeline of seroconversions and risky behaviors. A total of 1,596 eligible participants were enrolled to study, and 1206 (76%) received DPV-VR and 390 AGYW opted for oral PrEP. Continuation rates were comparable among two groups at one month at 83% in the DPV ring arm and 84% in the oral PrEP arm. At 6 months, 64% of DPV users continued, compared to 16% in the oral PrEP arm. Participants who preferred to self-insert the ring increased from 50% at one-month follow up to 85.4% at 6 months. Seroconversion rates were comparable across two groups, as 9 out of 1095 (0.82%) DPV-VR users were seroconverted compared to 2 out of 390 (0.51%) oral PrEP users (p=0.608). Some DPV users mentioned pelvic pain and lower abdominal pain as common side effects. In in-depth interviews, participants mentioned motivators for DPV uptake such as its discreet use and not having to take medication daily. They also recommended to develop rings that last longer than current 28-day lifespan for women in rural areas or mobile who do not have continuous access to resources. This research provides evidence of DPV-VR as an acceptable and feasible HIV prevention in LMICs. Clients found it easy to insert the ring by themselves, and it provides a discreet way to protect themselves from HIV infection. Nevertheless, there are social barriers that hinder women's decision-making power in protecting their bodies. Therefore, it is recommended to conduct further studies to identify solutions for barriers and scale-up.

INTRODUCTION:HIV pre-exposure prophylaxis (PrEP) is an effective biomedical intervention for preventing HIV; however, PrEP adoption initially lagged across sub-Saharan Africa (SSA) and may have been affected by barriers to engagement in PrEP care. Stable, heterosexual HIV-serodifferent couples are a priority population of PrEP expansion efforts. We assessed factors associated with PrEP awareness and willingness among HIV-serodifferent couples in SSA to guide PrEP interventions for this population. METHODS:We conducted a cross-sectional analysis using pooled data from nationally representative, two-stage cluster sampling, HIV-focused household surveys completed during 2019-2022 in seven African countries. We analysed data from 1738 persons without HIV aged ≥15 years in stable, heterosexual HIV-serodifferent couples and included clinical information from their partners with HIV. Higher HIV risk was defined by unawareness of a partner's HIV-positive status or having a partner with an unsuppressed viral load (≥200 copies/ml). Lower HIV risk was defined by awareness of a partner's HIV-positive status and having a partner with a suppressed viral load (<200 copies/ml). We conducted multivariable logistic regression using survey weights and jackknife variance estimation to assess factors associated with PrEP awareness and willingness. RESULTS:Overall, 18.1% were aware of PrEP, 69.1% were willing to use PrEP and 5.1% had ever used PrEP. Forty-four percent had higher HIV risk. Higher odds of PrEP awareness were associated with being female (adjusted odds ratio [aOR]: 1.73; 95% confidence interval [CI]: 1.15-2.59), secondary education or higher (aOR: 6.42; 95% CI: 2.97-13.91) and lower HIV risk (aOR: 1.58; 95% CI: 1.00-2.48). Higher odds of PrEP willingness were associated with employment in the past year (aOR: 1.55; 95% CI: 1.01-2.37), previous PrEP awareness (aOR: 2.44; 95% CI: 1.36-4.36) and lower HIV risk (aOR: 1.70; 95% CI: 1.07-2.70). CONCLUSIONS:Persons in stable, heterosexual HIV-serodifferent couples with lower HIV risk were more aware of and willing to use PrEP than those with higher risk. Our findings highlight the importance of encouraging HIV status disclosure, educating about HIV-serodifference and PrEP, and providing PrEP linkage during HIV testing and prevention counselling to increase PrEP awareness, willingness and use among HIV-serodifferent couples in SSA.

Adolescent girls and young women (AGYW; aged 15-24 years) in Zimbabwe face high risk of contracting HIV. Despite proven effectiveness of Pre-Exposure Prophylaxis (PrEP), its uptake and continuation among AGYW is low. We aimed to explore views on PrEP, norms around sexual behaviour and how programs can improve PrEP uptake among this group. From December 2021 to March 2023 nine focus group discussions were held with 92 (8-12 per group) sexually active AGYW, purposively selected from programs offering sexual and reproductive health (SRH) services to AGYW in Harare, Mazowe and Matabeleland South. Discussions were participatory and analysed thematically. Participants were aged 16-24 years; 73% had attained some high school education, 9% had never tested for HIV and 70% never used PrEP. Across all groups there was recognition that AGYW are at risk of contracting HIV. Knowledge of PrEP varied, with AGYW enrolled in the national sex worker and SRH programs more knowledgeable than the rest. A recurrent theme was that PrEP was viewed as undesirable due to its association with anti-retroviral treatment and risky sexual behaviours. AGYW thought their parents and partners would find their use of PrEP unacceptable. Unmarried sexually active AGYW seemed the most vulnerable and at high risk of HIV acquisition. Issues identified as important for improving uptake and adherence included ensuring private, confidential and free services, education of parents and partners on SRH issues and friendly attitudes of health workers. Additionally, AGYW indicated preference for the long-acting PrEP formulations, viewed as convenient and more private. Despite the recognition of being at risk of HIV, HIV related stigma and concerns about being viewed as having risky sexual behavior prevent them from taking PrEP. There is need to design youth-friendly PrEP programs that uphold privacy & confidentiality, prevent stigma and minimize opposition from parents and partners.

In 2023, Zimbabwe attained the 95-95-95 UNAIDS targets. However, some sub-populations are substantially less likely to have tested for HIV. Knowledge of characteristics of these groups is crucial in designing interventions that address their needs. We estimated the prevalence and predictors of "never-having tested for HIV" status following community-based distribution of HIV self-test kits in rural Zimbabwe. We analysed data from a household survey conducted as part of a cluster randomised trial comparing two community-based HIVST distribution models in six rural districts in 2018-19. HIVST distribution was conducted over one month, followed by the household survey after four months. Survey participants aged 16 years and above completed self-administered Audio-Computer-Assisted-Survey-Instrument. Unadjusted and adjusted mixed effect logistic regression was used to identify factors associated with never-having-tested for HIV. Of the 11,076 analysed participants, the median (IQR) age was 32(22,45) years and 54.5% were female. Seventeen percent of participants had never tested for HIV, primarily due to a perceived lack of HIV risk (50%). Never testers were more likely to be: men (adjusted odds ratio [AOR]=1.69;95%Confidence Interval [CI]=1.52-1.87); younger (16-24 years (AOR=3.84; 95%CI=3.23-4.55), 25-34 years (AOR=1.30; 95%CI=1.07-1.59)) and at-least 45 years old: (AOR=2.17; 95%CI=1.80-2.60); having lower levels of education: primary/less (AOR=1.68; 95%CI=1.46-1.98), some secondary (AOR=1.62; 95%CI=1.42-1.86) compared to at least complete secondary, unemployed (AOR=1.39; 95%CI=1.15-1.69); never married (AOR=3.48; 95%CI=2.98-4.07) and previously married (AOR=1.41; 95%CI=1.19-1.68) compared to currently married; having stigmatizing beliefs (AOR=1.42; 95%CI=1.24-1.62); having: low (AOR=1.52, 95%CI=1.32-1.74) and medium (OR=1.53, 95%CI=1.33-1.75) levels of treatment optimism; not participating in household decisions (AOR=1.96; 95%CI=1.70-2.27) and not reporting condomless sex (AOR=2.58; 95%CI=2.31-2.87). The Ministry of Health need to scale up acceptable and targeted interventions to improve HIV testing in different subpopulations which includes but not limited to young people, unmarried, unemployed, those with stigmatizing beliefs and those not participating in decision making.

Human immunodeficiency virus (HIV) viral suppression rates are disproportionately worse in youth compared to other age groups, and improving this will require addressing the whole HIV cascade, including HIV testing, linkage to care and support to maintain viral suppression. We conducted a cluster-randomized trial of community-based services incorporating HIV testing, treatment and adherence support integrated with sexual and reproductive health (SRH) services for youth (16-24 years) in Zimbabwe. Our hypothesis was that integrated services in community-based settings would increase demand and access. In total, 24 clusters (geographically demarcated areas) were randomized 1:1 to intervention or control (existing services). Primary outcome was virological suppression (defined as HIV viral load <1,000 copies per ml) among youth with HIV (YWH), ascertained through a population-level outcome survey of 17,682 youth (18-24 years). Secondary outcomes, corresponding to UNAIDS 90-90-90 targets, were the proportion of YWH who knew their HIV status, the proportion of YWH who knew their HIV status who were taking antiretroviral therapy (ART) and the proportion of YWH taking ART who achieved viral suppression (HIV viral load <1,000 copies per ml). There was no difference by arm in primary outcome (mean cluster prevalence-41.3% (intervention) versus 38.3% (control); risk ratio (RR)-1.07 (95% confidence interval (CI), 0.88-1.30)) or in proportion of YWH who were diagnosed. In the intervention arm, a lower proportion of diagnosed YWH were taking treatment (RR = 0.91 (95% CI, 0.83-0.99)), but a higher proportion of those on ART had viral suppression (RR = 1.18 (95% CI, 1.02-1.37)). The intervention did not impact the proportion of youth with undiagnosed HIV, which explains the lack of effect on the primary outcome. Among those taking treatment, the intervention improved viral suppression. Delivery of integrated HIV and SRH services was feasible and facilitated uptake by youth of essential services beyond HIV, addressing an important programmatic gap. Trial registration number: NCT03719521 .

Zvandiri is a differentiated psychosocial support program delivering peer-counselling to children, adolescents and young adults living with HIV (CAYALHIV), functioning at a national scale in Zimbabwe and in 14 other African countries. Stigma and mental health issues are significant drivers of suboptimal health outcomes in CAYALHIV, particularly in low-resource settings where the professional workforce is inadequate to meet the volume of need. Task shifting to peer counsellors has shown promise in improving care yet developing robust mechanisms to ensure consistent quality has received limited attention to date. To promote quality services delivered by peer counsellors (ages 18 - 24 years), Zvandiri sought to pragmatically address the feasibility and effectiveness of integrating the World Health Organization's EQUIP (Ensuring Quality in Psychological Support) competency-based assessment into a standard peer-counsellor training. Sixteen CATS, ages 19 - 22 years (M8:F8), already working as Zvandiri peer-counsellors, were identified by their supervisors as needing skills strengthening and selected to participate in the standard five-day CATS training. Additional days were added for baseline and endline competency assessments. This pilot integrating EQUIP's competency-based approach into the CATS training effectively identified gaps in counselling skills at baseline, enabling trainers to target these competencies throughout the training. The endline assessment demonstrated that all 16 participants developed stronger counselling skills. A follow-up open-text self-assessment was conducted seven months post-training with both participants and supervisors. There was consistency in the reporting of increased confidence and improved client interactions, with changes attributed to the enhanced counselling skills learnt in the training. Based on these findings, Zvandiri will integrate EQUIP assessments into the initial training provided to peer-counsellors when they first join Zvandiri and within the CATS' regular group supervision, in a targeted way to support the identification of further skills strengthening required to maintain quality delivery of counselling services at scale by peer-counsellors.

Introduction The transition of voluntary medical male circumcision (VMMC), an HIV prevention service, in Zimbabwe from a donor-funded to a government-owned programme involves the collective efforts and alignment of national and subnational government leaders, managers, healthcare providers, village health workers, community members, donors and implementing partners. We sought to understand stakeholders’ perspectives on barriers, facilitators and recommendations as a vertical HIV prevention programme transitioned to an integrated, government-led model.Methods We conducted 54 semistructured stakeholder interviews at the national and subnational levels. Interviews were audio recorded, transcribed and thematically analysed.Results Participants highlighted a range of psychological and structural barriers and facilitators to integrating and sustaining the VMMC programme. Respondents mentioned financing and staffing barriers to integration, particularly a lack of domestic resources, the transition from a fee-for-service to a facility-based performance model and staff attrition. Notably, resistance to changing the VMMC programme’s operations was a significant barrier that may be tied to individual psychological barriers such as loss of power and job security. Donors and partners continued to control the funding for VMMC. Ideally, the Ministry of Health and Child Care should have more autonomy over these decisions. At the subnational level, there is an opportunity for increased responsibility and a greater sense of ownership through the decentralisation of governance.Conclusions To ensure successful integration and local ownership of VMMC as an HIV prevention programme, stakeholders must address both psychological and structural barriers while aligning their perspectives on the transition. Individual providers have valid concerns about their financial security and the burden of additional responsibilities without adequate compensation. It is crucial for donors and partners to reduce their involvement and oversight. Additionally, resolving the financial barriers that prevent the government from having complete control of the programme will require empowering local government stakeholders to fully take ownership.

BACKGROUND:While most Performance Based Financing (PBF) programs perform community verifications to confirm patients received reported services, many focus analysis and payment calculations on facility record verification due to their lower cost. Risk-based sampling can reduce the cost of community verifications by targeting areas with the highest risk of overreporting but there is little research on the factors associated with risk to guide sampling decisions. OBJECTIVE:This study explores facility-level and district-level factors associated with overreporting within a PBF setting. METHODS:Using community verification data from a Voluntary Medical Male Circumcision (VMMC) program in Zimbabwe, we estimated two binary outcomes with generalized mixed effects models. Our primary outcome is a measure of overreporting, defined as when interviewed patients did not plausibly confirm receipt of the VMMC. Additionally, we assessed factors associated with patients who were selected but ultimately not interviewed. We employed inverse probability of treatment weighting to address non-response and bootstrapping-based multiple imputation to address missingness. RESULTS:We found that patients in the target age range, which were compensated at a higher price point, were less likely to be interviewed and over two times more likely to be classified as overreported compared to patients outside this age range (OR: 2.92, 95% CI: 2.38-3.59). Patients from outside the fixed health facility were more likely to be interviewed and less likely to be classified as overreported. In-person interviews as opposed to phone interviews appeared to be a worthwhile investment (OR: 1.61, 95% CI: 1.20-2.16). CONCLUSION:We identified various factors that were associated with unsubstantiated VMMCs to inform risk-based sampling; however, our findings also suggest potential data fabrication. Programs should consider employing similar methods to reduce costs and increase the use of community verification data.

AbstractThe global health community has recognized the importance of integrating and sustaining health programs and forming equitable partnerships. Corresponding with these objectives, international aid donors are embracing the principle of localization. The Voluntary Medical Male Circumcision (VMMC) in Zimbabwe is a large vertical HIV prevention program primarily funded through development assistance for health. Program stakeholders want to sustainably integrate VMMC into routine health services so that the program will continue to be a cost-effective HIV prevention strategy through 2030. The purpose of this paper is to describe a bottom-up process of sustainably integrating the program into routine health services through an approach that empowers local stakeholders. At the district level, we facilitated changes to accelerate integration and sustainability. To evaluate our intervention, we used a mixed methods design comprising analysis of district-level work plans with qualitative and quantitative indicators, combined with a survey assessing sustainability capacity of the program, administered at midline and endline to district teams. In all five pilot districts we facilitated the transition of VMMC into the government’s district administration, resulting in a locally owned and managed program, while also strengthening individual and team capacity. We observed improvements across all World Health Organization health system building blocks, suggesting that the intervention strengthened the overall health system. The sustainability survey showed a reduction in funding stability but a significant increase in communications, program adaptation, and organizational capacity. Compared to traditional top-down change initiatives, the participatory approach to integration was an effective way of addressing specific VMMC challenges at the district level whilst maintaining management and oversight at provincial and national levels. Other health programs in low- and middle-income countries seeking to integrate and sustain health services at subnational levels should consider this diagonal, bottom-up model to promote local leadership development and health system strengthening.