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:Gender norms against adolescent girls and young women (AGYW)'s having pre-marital sex and using condoms in marriage are included as barriers to motivation to use condoms in HIV prevention cascades. Representative data on gender norms are needed to test this assumption. Methods:General-population survey participants in Manicaland, Zimbabwe (ages≥15, N=9803) reported agreement/disagreement with statements on gender norms. AGYW at risk of HIV infection reported whether community views discouraged condom use. Multivariable logistic regression was used to measure associations between AGYW's perceiving negative gender norms and condom HIV prevention cascades. Results:57% of men and 70% of women disagreed that 'If I have a teenage daughter and she has sex before marriage, I would be ok with this'; and 41% of men and 57% of women disagreed that 'If I have a teenage daughter, I would tell her about condoms'. 32% and 69% of sexually-active HIV-negative unmarried AGYW, respectively, said negative community views were important in their decisions to use condoms and their friends were not using condoms. In each case, those who agreed had lower motivation to use condoms. Fewer unmarried AGYW with friends not using condoms used condoms themselves (39% vs. 68%; age- and site-adjusted odds ratios (aOR)=0.29, 95%CI, 0.15-0.55). 21% of men and 32.5% of women found condom use in marriage acceptable. 74% and 93% of married AGYW at risk, respectively, said negative community views influenced their decisions to use condoms and their friends did not use condoms. Fewer married AGYW reporting friends not using condoms were motivated to use condoms but no difference was found in their own condom use (4.1% vs. 6.9%; aOR=0.57, 95%CI, 0.08-2.66). Conclusions:Negative gender norms can form a barrier to motivation to use condoms in unmarried and married AGYW at risk of HIV infection, and, for unmarried AGYW, to condom use.

Introduction:HIV-negative adolescent girls and young women (AGYW), and men (ABYM), have disproportionately high HIV incidence in many African countries. We used a new HIV Prevention Cascade (HPC) approach to quantify levels of, and barriers to, prevention method use to guide interventions to increase effective uptake of primary HIV prevention. Methods:Data from the Manicaland HPC pilot study (2018-19; n=9803) in Zimbabwe were used to measure levels of sexual risk behaviour and construct HPCs for male condom, pre-exposure prophylaxis (females), voluntary medical male circumcision (males) and combination prevention use by HIV-negative sexually active AGYW (15-24 years) and male partners (15-29 years). Results:19% of AGYW (n=1140) and 37% of ABYM (n=955) who had started sex reported one or more HIV risk behaviour and met the definition of the priority populations for HIV prevention. Of these, 63% of AGYW and 87% of ABYM were motivated to use an HIV prevention method, 28% and 63% had access to a method and 16% and 53% used a method. Male condoms were the most commonly used prevention method, accounting for 97% of use in AGYW and 55% in ABYM. Barriers to motivation, access and capacity to use were reported for all priority populations and methods. Some barriers were common across HPCs (eg, lack of risk perception, social unacceptability and lack of acceptable provision); others were specific to particular prevention methods or priority populations (eg, lack of availability). Conclusion:HIV risk behaviours were commonly reported, but gaps in use of prevention methods exist among young people reporting these HIV risk behaviours in Manicaland. Population survey measurements of HPCs revealed large gaps in all steps in the cascade (lack of motivation, lack of access and lack of capacity to use prevention) and provided information on the reasons for these gaps that can aid in designing interventions that reduce new infections.

Background An individual's HIV risk, and consequently their HIV prevention needs, change over time. In this study we aimed to quantify these changes, examine which life-course events were associated with them, and investigate the extent to which those life-course events were associated with HIV acquisition. Methods We used longitudinal data from eight rounds of a general population cohort in Manicaland province, eastern Zimbabwe, on sociodemographic and HIV risk behaviours, as well as HIV serostatus from the first seven rounds. We first visualised how HIV risk behaviours, comprised of having multiple, concurrent, non-regular, or transactional partners, condom non-use, drug use, and visiting bars, changed for individuals over time using Sankey diagrams. We then examined whether logistic regression models incorporating life-course events-namely, changes in marital or employment status, in-migration, or birth of a child-were more strongly associated with changes in HIV risk behaviour than models using only sociodemographic variables. Finally, we compared how well sociodemographic, HIV risk behaviour, and life-course events were associated with the person's risk of HIV acquisition as follows: we used logistic regression to identify which states (divided into sociodemographic, HIV risk behaviour, and life-course events) were most strongly associated with risk of HIV acquisition; based on this we use three models (corresponding to the three divisions) to identify the top 20% of individuals predicted to be at risk of acquiring HIV by each model, and computed what proportion of the actual HIV infection events occurred in that group. Findings Between 1998 and 2021, 21 213 individuals were interviewed at least twice, contributing a total of 34 212 participant observations. In this setting, individuals had periods of HIV risk lasting less than 3 years; only 123% (102 of 831) of those reporting transactional sex had also reported this in the previous round. We found that life-course events such as changes in marital status, employment status, and in-migrant status were associated with these changes in HIV risk behaviour. Using life-course events, particularly ones related to changes in marital status, 23% and 30% more HIV acquisitions were identified than using HIV risk behaviours or sociodemographic information, respectively. Interpretation HIV risk changes dynamically in this population, and life-course events could be a powerful way to understand changes in HIV risk behaviour and risk of HIV acquisition. Funding Bill and Melinda Gates Foundation, UK Medical Research Council, and Department for International Development. Copyright (c) 2025 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

Background Gender norms against adolescent girls and young women (AGYW)’s having pre-marital sex and using condoms in marriage are included as barriers to motivation to use condoms in HIV prevention cascades. Representative data on gender norms are needed to test this assumption. Methods General-population survey participants in Manicaland, Zimbabwe (ages≥15, N=9803) reported agreement/disagreement with statements on gender norms. AGYW at risk of HIV infection reported whether community views discouraged condom use. Multivariable logistic regression was used to measure associations between AGYW’s perceiving negative gender norms and condom HIV prevention cascades. Results 57% of men and 70% of women disagreed that ‘If I have a teenage daughter and she has sex before marriage, I would be ok with this’; and 41% of men and 57% of women disagreed that ‘If I have a teenage daughter, I would tell her about condoms’. 32% and 69% of sexually-active HIV-negative unmarried AGYW, respectively, said negative community views were important in their decisions to use condoms and their friends were not using condoms. In each case, those who agreed had lower motivation to use condoms. Fewer unmarried AGYW with friends not using condoms used condoms themselves (39% vs. 68%; age- and site-adjusted odds ratios (aOR)=0.29, 95%CI, 0.15-0.55). 21% of men and 32.5% of women found condom use in marriage acceptable. 74% and 93% of married AGYW at risk, respectively, said negative community views influenced their decisions to use condoms and their friends did not use condoms. Fewer married AGYW reporting friends not using condoms were motivated to use condoms but no difference was found in their own condom use (4.1% vs. 6.9%; aOR=0.57, 95%CI, 0.08-2.66). Conclusions Negative gender norms can form a barrier to motivation to use condoms in unmarried and married AGYW at risk of HIV infection, and, for unmarried AGYW, to condom use.

[This corrects the article DOI: 10.1371/journal.pgph.0003194.].

Past infectious disease outbreaks have altered population fertility in ways that contribute to changes in population age-structure and subsequent needs for public services. However, little is known about how fertility changed over the Covid-19 pandemic in African populations where birth registration systems typically remain weak. Using serial cross-sectional data from population surveys conducted in Manicaland, Zimbabwe, before, during, and towards the end of Covid-19 (2018-23), we found that women's overall odds of current pregnancy had changed little at the height of Covid-19 but dropped following the relaxation of lockdown measures. In the middle of the pandemic, reductions in pregnancy rates in adolescents, associated with delays in sexual activity and marriage, offset increases in 25-34-year-old women linked to reduced use of contraception. Late in the pandemic, the overall odds of current pregnancy fell, with only a partial recovery in teenage sexual activity but a strong rebound in use of contraception.

The Covid-19 pandemic and associated restrictions have the potential to alter sexual risk behaviours for HIV acquisition with important implications for HIV prevention programmes in sub-Saharan Africa. To date, no large-scale data have been published to substantiate hypothesised changes in sexual risk behaviours. We used longitudinal survey data to assess the impact of Covid-19 on sexual risk behaviours in east Zimbabwe. Data on sexual behaviours in HIV-negative adults aged 15-54 years were collected in two rounds of a general population open-cohort survey conducted in Manicaland, Zimbabwe shortly before (July 2018 to December 2019; N = 7316) and several months into the Covid-19 epidemic (February to July 2021; N = 6356). Descriptive statistics and logistic regression models of serial cross-sectional and prospective cohort data were used to assess changes in sexual risk behaviours. The proportion of females aged 15-19 years reporting sexual debut declined from 29.7% before Covid-19 to 20.3% during Covid-19 (adjusted odds ratio (AOR) = 0.49, 95% confidence interval (95% CI), 0.38-0.63). Fewer sexually-active females reported multiple sexual partners during Covid-19 (3.35% versus 6.07%; AOR = 0.55, 95% CI, 0.43-0.72). No population-level changes in male behaviour between survey rounds were recorded but the cohort analysis revealed a complex pattern of behaviour change with HIV risk behaviours increasing for some individuals and decreasing for others. Overall HIV risk behaviours remained high in a sub-Saharan African population with a generalised HIV epidemic over a period of Covid-19 lockdowns when movements and social contacts were restricted.

Background:Differentiating risk for HIV infection is important for providing focussed prevention options to individuals. We conducted a longitudinal study to validate a risk-differentiation tool for predicting HIV or HSV-2 acquisition among HIV-negative youth. Setting:Population-based household survey in east Zimbabwe. Methods:HIV and HSV-2 status and HIV behavioural risk factors were assessed in two surveys conducted 12 months apart among young people. Associations between risk-behaviours and combined HIV/HSV-2 incident infection were estimated using proportional hazards models. We calculated the sensitivity and specificity of risk-differentiation questions in predicting HIV/HSV-2 acquisition and quantified changes between surveys among low, medium, and high-risk categories. Results:In total, 44 HIV/HSV-2 seroconversions were observed in 1812 person-years of follow up (2.43/100PY, 95%CI: 1.71-3.15); 50% of incident cases reported never having had sex at baseline. Risk of HIV/HSV-2 acquisition was higher for those reporting non-regular partners (women: HR=2.71, 95% CI:1.12-6.54, men: HR=1.37, 95%CI: 0.29-6.38) and those reporting having a partner with a sexually transmitted infection (STI) (HR=7.62 (1.22-47.51). Adding a question on non-regular partnerships increased tool sensitivity from 18.2% to 38.6%, and further to 77.3% when restricted to those who had ever had sex. Individual risk category increased for 28% of men and 17% of women over 12-months. Conclusion:The refined risk differentiation tool identified a high proportion of youth at risk of HIV acquisition. Despite this, half of incident infections were among individuals who reported no prior sexual activity. The shifting patterns of risk behaviours underscore the need for dynamic prevention engagement strategies in high HIV prevalence or incidence settings.

BACKGROUND:The absence of high-quality comprehensive civil registration and vital statistics systems across many settings in Africa has led to little empirical data on causes of death in the region. We aimed to use verbal autopsy data to provide comparative, population-based estimates of cause-specific mortality among adolescents and adults in eastern and southern Africa. METHODS:In this surveillance study, we harmonised verbal autopsy and residency data from nine health and demographic surveillance system (HDSS) sites in Kenya, Malawi, Tanzania, South Africa, Uganda, and Zimbabwe, each with variable coverage from Jan 1, 1995, to Dec 31, 2019. We included all deaths to adolescents and adults aged 12 or over that were residents of the study sites and had a verbal autopsy conducted. InSilicoVA, a probabilistic model, was used to assign cause of death on the basis of the signs and symptoms reported in the verbal autopsy. Levels and trends in all-cause and cause-specific mortality rates and cause-specific mortality fractions were calculated, stratified by HDSS site, sex, age, and calendar periods. FINDINGS:52 484 deaths and 5 157 802 person-years were reported among 1 071 913 individuals across the nine sites during the study period. 47 961 (91·4%) deaths had a verbal autopsy, of which 46 570 (97·1%) were assigned a cause of death. All-cause mortality generally decreased across the HDSS sites during this period, particularly for adults aged 20-59 years. In many of the HDSS sites, these decreases were driven by reductions in HIV and tuberculosis-related deaths. In 2010-14, the top causes of death were: road traffic accidents, HIV or tuberculosis, and meningitis or sepsis in adolescents (12-19 years); HIV or tuberculosis in adults aged 20-59 years; and neoplasms and cardiovascular disease in adults aged 60 years and older. There was greater between-HDSS and between-sex variation in causes of death for adolescents compared with adults. INTERPRETATION:This study shows progress in reducing mortality across eastern and southern Africa but also highlights age, sex, within-HDSS, and between-HDSS differences in causes of adolescent and adult deaths. These findings highlight the importance of detailed local data to inform health needs to ensure continued improvements in survival. FUNDING:National Institute of Child Health and Human Development of the US National Institutes of Health.

AbstractPeople living with HIV (PLHIV) report lower health-related quality-of-life (HRQoL) than HIV-negative people. HIV stigma may contribute to this. We explored the association between HIV stigma and HRQoL among PLHIV. We used cross-sectional data from 3991 randomly selected PLHIV who were surveyed in 2017–2018 for HPTN 071 (PopART), a cluster randomised trial in Zambia and South Africa. Participants were 18–44 years, had laboratory-confirmed HIV infection, and knew their status. HRQoL was measured using the EuroQol-5-dimensions-5-levels (EQ-5D-5L) questionnaire. Stigma outcomes included: internalised stigma, stigma experienced in the community, and stigma experienced in healthcare settings. Associations were examined using logistic regression. Participants who had experienced community stigma (n = 693/3991) had higher odds of reporting problems in at least one HRQoL domain, compared to those who had not (adjusted odds ratio, aOR: 1.51, 95% confidence interval, 95% Cl: 1.16–1.98, p = 0.002). Having experienced internalised stigma was also associated with reporting problems in at least one HRQoL domain (n = 552/3991, aOR: 1.98, 95% CI: 1.54–2.54, p < 0.001). However, having experienced stigma in a healthcare setting was less common (n = 158/3991) and not associated with HRQoL (aOR: 1.04, 95% CI: 0.68–1.58, p = 0.850). A stronger focus on interventions for internalised stigma and stigma experienced in the community is required.

Abstract Background Intimate partner violence (IPV) is widespread in the WHO African region with generalised HIV epidemics and may contribute to ongoing HIV transmission through its associations with behaviours associated with HIV acquisition risk and low use of prevention methods particularly in marital relationships. Methods We conducted a male condom HIV prevention cascade analysis using data from a general-population survey in Manicaland, Zimbabwe (July 2018-December 2019) to develop an understanding of how interventions that reduce IPV might be built upon to also reduce HIV incidence. Multivariable logistic regression was used to measure associations between currently-married HIV-negative women’s experience of IPV and: (1) being in the priority population for HIV prevention methods (i.e. married women engaging in behaviours associated with HIV acquisition risk or with a spouse who engages in similar behaviours or is living with HIV), and (2) male condom use by women in this priority population. Male condom HIV prevention cascades, with explanatory barriers for gaps between successive cascade bars (motivation, access and effective use), were compared for women in the priority population reporting and not reporting IPV. Results We found a positive association between IPV and being in the priority population for HIV prevention methods (72.3% versus 58.5%; AOR = 2.26, 95% CI:1.74–2.93). Condom use was low (< 15%) for women in the priority population and did not differ between those reporting and not reporting IPV. The HIV prevention cascades for women reporting and not reporting IPV were similar; both showing large gaps in motivation and capacity to use male condoms effectively. Women reporting motivation and access to male condoms were more likely to report their partner being a barrier to condom use if they experienced IPV (84.8% versus 75.5%; AOR = 2.25, 95% CI:1.17–4.31). Conclusion The findings of this study support the case for trials of integrated IPV/HIV prevention interventions that are tailored to improve HIV risk perception among HIV-negative married women and to make condom provision more acceptable for this group.

Reported COVID-19 cases and associated mortality remain low in many sub-Saharan countries relative to global averages, but true impact is difficult to estimate given limitations around surveillance and mortality registration. In Lusaka, Zambia, burial registration and SARS-CoV-2 prevalence data during 2020 allow estimation of excess mortality and transmission. Relative to pre-pandemic patterns, we estimate age-dependent mortality increases, totalling 3212 excess deaths (95% CrI: 2104-4591), representing an 18.5% (95% CrI: 13.0-25.2%) increase relative to pre-pandemic levels. Using a dynamical model-based inferential framework, we find that these mortality patterns and SARS-CoV-2 prevalence data are in agreement with established COVID-19 severity estimates. Our results support hypotheses that COVID-19 impact in Lusaka during 2020 was consistent with COVID-19 epidemics elsewhere, without requiring exceptional explanations for low reported figures. For more equitable decision-making during future pandemics, barriers to ascertaining attributable mortality in low-income settings must be addressed and factored into discourse around reported impact differences.

Background Rapid diagnostic tests have revolutionized the HIV response in low resource and high HIV prevalence settings. However, disconcerting levels of misdiagnosis at the point-of-care call for research into their root causes. As rapid HIV tests are technologies that cross borders and have inscribed within them assumptions about the context of implementation, we set out to explore the (mis)match between intended and actual HIV testing practices in Zimbabwe. Methods We examined actual HIV testing practices through participant observations in four health facilities and interviews with 28 rapid HIV testers. As time was identified as a key sphere of influence in thematic analyses of the qualitative data, a further layer of analysis juxtaposed intended (as scripted in operating procedures) and actual HIV testing practices from a temporal perspective. Results We uncover substantial discrepancies between the temporal flows assumed and inscribed into rapid HIV test kits (their intended use) and those presented by the high frequency testing and low resource and staffing realities of healthcare settings in Zimbabwe. Aside from pointing to temporal root causes of misdiagnosis, such as the premature reading of test results, our findings indicate that the rapidity of rapid diagnostic technologies is contingent on a slow, steady, and controlled environment. This not only adds a different dimension to the meaning of “rapid” HIV testing, but suggests that errors are embedded in the design of the diagnostic tests and testing strategies from the outset, by inscribing unrealistic assumptions about the context within which they used. Conclusion Temporal analyses can usefully uncover difficulties in attuning rapid diagnostic test technologies to local contexts. Such insight can help explain potential misdiagnosis ‘crisis points’ in point-of-care testing, and the need for public health initiatives to identify and challenge the underlying temporal root causes of misdiagnosis.

Background:HIV treatment has clear Health-Related Quality-of-Life (HRQoL) benefits. However, little is known about how Universal Testing and Treatment (UTT) for HIV affects HRQoL. This study aimed to examine the effect of a combination prevention intervention, including UTT, on HRQoL among People Living with HIV (PLHIV). Methods:Data were from HPTN 071 (PopART), a three-arm cluster randomised controlled trial in 21 communities in Zambia and South Africa (2013-2018). Arm A received the full UTT intervention of door-to-door HIV testing plus access to antiretroviral therapy (ART) regardless of CD4 count, Arm B received the intervention but followed national treatment guidelines (universal ART from 2016), and Arm C received standard care. The intervention effect was measured in a cohort of randomly selected adults, over 36 months. HRQoL scores, and the prevalence of problems in five HRQoL dimensions (mobility, self-care, performing daily activities, pain/discomfort, anxiety/depression) were assessed among all participants using the EuroQol-5-dimensions-5-levels questionnaire (EQ-5D-5L). We compared HRQoL among PLHIV with laboratory confirmed HIV status between arms, using adjusted two-stage cluster-level analyses. Results:At baseline, 7,856 PLHIV provided HRQoL data. At 36 months, the mean HRQoL score was 0.892 (95% confidence interval: 0.887-0.898) in Arm A, 0.886 (0.877-0.894) in Arm B and 0.888 (0.884-0.892) in Arm C. There was no evidence of a difference in HRQoL scores between arms (A vs C, adjusted mean difference: 0.003, -0.001-0.006; B vs C: -0.004, -0.014-0.005). The prevalence of problems with pain/discomfort was lower in Arm A than C (adjusted prevalence ratio: 0.37, 0.14-0.97). There was no evidence of differences for other HRQoL dimensions. Conclusions:The intervention did not change overall HRQoL, suggesting that raising HRQoL among PLHIV might require more than improved testing and treatment. However, PLHIV had fewer problems with pain/discomfort under the full intervention; this benefit of UTT should be maximised during roll-out.

ObjectivesTo propose a novel framework for COVID-19 vaccine allocation based on three components of Vulnerability, Vaccination, and Values (3Vs). MethodsA combination of geospatial data analysis and artificial intelligence methods for evaluating vulnerability factors at the local level and allocate vaccines according to a dynamic mechanism for updating vulnerability and vaccine uptake. ResultsA novel approach is introduced including (I) Vulnerability data collection (including country-specific data on demographic, socioeconomic, epidemiological, healthcare, and environmental factors), (II) Vaccination prioritization through estimation of a unique Vulnerability Index composed of a range of factors selected and weighed through an Artificial Intelligence (AI-enabled) expert elicitation survey and scientific literature screening, and (III) Values consideration by identification of the most effective GIS-assisted allocation of vaccines at the local level, considering context-specific constraints and objectives. ConclusionsWe showcase the performance of the 3Vs strategy by comparing it to the actual vaccination rollout in Kenya. We show that under the current strategy, socially vulnerable individuals comprise only 45% of all vaccinated people in Kenya while if the 3Vs strategy was implemented, this group would be the first to receive vaccines.

IntroductionExtensive cross-sectional evidence has demonstrated an association between psychological distress (PD) and hypertension. However, evidence on the temporal relationship is limited, especially in low-income and middle-income countries. The role of health risk behaviours including smoking and alcohol consumption in this relationship is also largely unknown. The aim of this study was to investigate the association between PD and later development of hypertension, and how this association may have been influenced by health risk behaviours, among adults in east Zimbabwe.MethodsThe analysis included 742 adults (aged 15–54 years) recruited by the Manicaland general population cohort study, who did not have hypertension at baseline in 2012–2013, and who were followed until 2018-2019. In 2012–2013, PD was measured using the Shona Symptom Questionnaire, a screening tool validated for use in Shona-speaking countries including Zimbabwe (cut-off point: 7). Smoking, alcohol consumption and use of drugs (health risk behaviours) were also self-reported. In 2018-2019, participants reported if they had diagnosed with hypertension by a doctor or nurse. Logistic regression was used to assess the association between PD and hypertension.ResultsIn 2012, 10.4% of the participants had PD. The odds of new reports of hypertension were 2.04 times greater (95% CI 1.16 to 3.59) among those with PD at baseline, after adjusting for sociodemographic and health risk behaviour variables. Female gender (adjusted odds ratio, AOR 6.89, 95% CI 2.71 to 17.53), older age (AOR 2.67, 95% CI 1.63 to 4.42), and greater wealth (AOR 2.10, 95% CI 1.04 to 4.24 more wealthy, 2.88, 95% CI 1.24 to 6.67 most wealthy) were significant risk factors for hypertension. The AOR for the relationship between PD and hypertension did not differ substantially between models with and without health risk behaviours.ConclusionPD was associated with an increased risk of later reports of hypertension in the Manicaland cohort. Integrating mental health and hypertension services within primary healthcare may reduce the dual burden of these non-communicable diseases.

Background In the early phase of the coronavirus disease 2019 (COVID-19) pandemic, health services were disrupted worldwide, including HIV prevention services. While some studies have begun to document the effects of COVID-19 on HIV prevention, little has been done to qualitatively examine how lockdown measures were experienced and perceived to affect access to HIV prevention methods in sub-Saharan Africa. Objectives To explore how the COVID-19 pandemic was perceived to affect access to HIV prevention methods in eastern Zimbabwe. Method This article draws on qualitative data from the first three data collection points (involving telephone interviews, group discussions, and photography) of a telephone and WhatsApp-enabled digital ethnography. Data were collected from 11 adolescent girls and young women and five men over a 5-month period (March-July 2021). The data were analysed thematically. Results Participants reported widespread interruption to their condom supply when beerhalls were shut down as part of a nationwide lockdown. Restrictions in movement meant that participants who could afford to buy condoms from larger supermarkets or pharmacies were unable to. Additionally, the police reportedly refused to issue letters granting permission to travel for the purpose of accessing HIV prevention services. The COVID-19 pandemic was also described to obstruct the demand (fear of COVID-19, movement restrictions) and supply (de-prioritised, stock-outs) for HIV prevention services. Nonetheless, under certain formal and informal circumstances, such as accessing other and more prioritised health services, or 'knowing the right people', some participants were able to access HIV prevention methods. Conclusion People at risk of HIV experienced the COVID-19 epidemic in Zimbabwe as disruptive to access to HIV prevention methods. While the disruptions were temporary, they were long enough to catalyse local responses, and to highlight the need for future pandemic response capacities to circumvent a reversal of hard-won gains in HIV prevention.

Objectives This study examined whether HIV status and antiretroviral therapy (ART) exposure were associated with self-reported hypertension in Zimbabwe. Design Study data were taken from a cross-sectional, general population survey, which included HIV testing (July 2018–December 2019). Setting The data were collected in Manicaland Province, Zimbabwe. Participants 9780 people aged 15 years and above were included. Outcome measure Self-reported hypertension was the outcome measure. This was defined as reporting a previous diagnosis of hypertension by a doctor or nurse. After weighting of survey responses by age and sex using household census data, χ2 tests and logistic regression were used to explore whether HIV status and ART exposure were associated with self-reported hypertension. Results The weighted prevalence of self-reported hypertension was 13.6% (95% CI 12.9% to 14.2%) and the weighted prevalence of HIV was 11.1% (10.4% to 11.7%). In univariable analyses, there was no evidence of a difference in the weighted prevalence of self-reported hypertension between people living with HIV (PLHIV) and HIV-negative people (14.1%, 11.9% to 16.3% vs 13.3%, 12.6% to 14.0%; p=0.503) or between ART-exposed and ART-naive PLHIV (14.8%, 12.0% to 17.7% vs 12.8%, 9.1% to 16.4%,p=0.388). Adjusting for socio-demographic variables in logistic regression did not alter this finding (ORs:HIV status:0.88, 0.70 to 1.10, p=0.261; ART exposure:0.83, 0.53 to 1.30, p=0.411). Conclusions Approximately one in seven PLHIV self-reported having hypertension, highlighting an important burden of disease. However, no associations were found between HIV status or ART exposure and self-reported hypertension, suggesting that it will be valuable to focus on managing other risk factors for hypertension in this population. These findings should be fully accounted for as Zimbabwe reorients its health system towards non-communicable disease control and management.