Evaluating the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe programme, what's worked and what more needs to be done?

This paper is a commentary framing a series of papers on the evaluation of several aspects of the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) programme. The paper highlights the scope and challenges with evaluating a large, complex and ambitious programme like DREAMS.

Engagement in HIV services over time among young women who sell sex in Zimbabwe.

Introduction: Young female sex workers (FSW) are disproportionately vulnerable to HIV. Zimbabwe data show higher HIV incidence and lower engagement in services compared to older FSW. Utilizing data from a combination HIV prevention and treatment intervention, we describe engagement in the HIV services over time among FSW 18-24 years, compared to those ≥25 years of age.

Viral load monitoring for people living with HIV in the era of test and treat: progress made and challenges ahead - a systematic review.

Background: In 2016, we conducted a systematic review to assess the feasibility of treatment monitoring for people living with HIV (PLHIV) receiving antiretroviral therapy (ART) in low and middle-income countries (LMICs), in line with the 90-90-90 treatment target. By 2020, global estimates suggest the 90-90-90 target, particularly the last 90, remains unattainable in many LMICs. This study aims to review the progress and identify needs for public health interventions to improve viral load monitoring and viral suppression for PLHIV in LMICs.

No increased HIV risk in general population near sex work sites: A nationally representative cross-sectional study in Zimbabwe.

Objectives: Sex work sites have been hypothesised to be at the root of the observed heterogeneity in HIV prevalence in sub-Saharan Africa. We determined if proximity to sex work sites is associated with HIV prevalence among the general population in Zimbabwe, a country with one of the highest HIV prevalence in the world.

Methods: In this cross-sectional study we use a unique combination of nationally representative geolocated individual-level data from 16,121 adults (age 15-49 years) from 400 sample locations and the locations of 55 sex work sites throughout Zimbabwe; covering an estimated 95% of all female sex workers (FSWs).

Associations between ambient temperature and risk of preterm birth in Sweden: A comparison of analytical approaches.

Background: Evidence indicates that high temperatures are a risk factor for preterm birth. Increasing heat exposures due to climate change are therefore a concern for pregnant women. However, the large heterogeneity of study designs and statistical methods across previous studies complicate interpretation and comparisons.

Engaging women and men in the gender-synchronised, community-based Mbereko+Men intervention to improve maternal mental health and perinatal care-seeking in Manicaland, Zimbabwe: A cluster-randomised controlled pragmatic trial.

Background: Maternal mental morbidity and low perinatal health service utilisation in resource-constrained settings contribute substantially to the global burden of poor maternal, newborn, and child health. The community-based Mbereko+Men program in rural Zimbabwe engaged women and men in complementary activities to improve men's support for women and babies, coparents' equitable, informed health decision-making, and ultimately, maternal mental health and care-seeking for maternal and newborn health services. The study aimed to test the effectiveness of the Mbereko+Men program on maternal mental health at 0-6 months after childbirth.

Exploring the beliefs, experiences and impacts of HIV-related self-stigma amongst adolescents and young adults living with HIV in Harare, Zimbabwe: A qualitative study.

Background: HIV-related self-stigma is a significant barrier to HIV management. However, very little research has explored this phenomenon, particularly in sub-Saharan Africa. This study explored the beliefs, experiences, and impacts of HIV self-stigma amongst adolescents and young adults (AYALHIV) in Harare, Zimbabwe to inform future interventions.

Perspectives on the use of modelling and economic analysis to guide HIV programmes in sub-Saharan Africa.

HIV modelling and economic analyses have had a prominent role in guiding programmatic responses to HIV in sub-Saharan Africa. However, there has been little reflection on how the HIV modelling field might develop in future. HIV modelling should more routinely align with national government and ministry of health priorities, recognising their legitimate mandates and stewardship responsibilities, for HIV and other wider health programmes.

Identifying sexual risk-taking and ill health in the meeting with young people-experiences of using an assessment tool.

Background: Identifying young people exposed to sexual risk-taking or violence is fundamental, when seeking to strengthen their health. However, young people seldom share sexual health concerns or experiences of violence with healthcare professionals (HCPs). Studies evaluating how use of a risk assessment tool influences the dialogue about sexual health and violence are sparse.

Transgender health content in medical education: a theory-guided systematic review of current training practices and implementation barriers & facilitators.

Health disparities faced by transgender people are partly explained by barriers to trans-inclusive healthcare, which in turn are linked to a lack of transgender health education in medical school curricula. We carried out a theory-driven systematic review with the aim to (1) provide an overview of key characteristics of training initiatives and pedagogical features, and (2) analyze barriers and facilitators to implementing this training in medical education. We used queer theory to contextualize our findings.

'I was in need of somewhere to release my hurt:' Addressing the mental health of vulnerable adolescent mothers in Harare, Zimbabwe, through self-help groups.

Background: Adolescents experiencing multiple vulnerabilities, including poverty, curtailed education, transactional sex and early childbearing, are at risk of poor mental health. In Zimbabwe, girls who are pregnant or new mothers and involved in selling sex struggle to cope with the combined pressures of parenthood, financial insecurity, and social stigma. A pilot intervention brought such girls together into self-help groups to increase peer support, resources and skills.

Differentiated prevention and care to reduce the risk of HIV acquisition and transmission among female sex workers in Zimbabwe: study protocol for the 'AMETHIST' cluster randomised trial.

Background: Female sex workers (FSW) in sub-Saharan Africa are disproportionately affected by HIV and are critical to engage in HIV prevention, testing and care services. We describe the design of our evaluation of the 'AMETHIST' intervention, nested within a nationally-scaled programme for FSW in Zimbabwe. We hypothesise that the implementation of this intervention will result in a reduction in the risk of HIV transmission within sex work.

Brief Report: Adolescent Girls Who Sell Sex in Zimbabwe: HIV Risk, Behaviours, and Service Engagement.

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.

Did you hear about HIV self-testing? HIV self-testing awareness after community-based HIVST distribution in rural Zimbabwe.

Background: Several trials of community-based HIV self-testing (HIVST) provide evidence on the acceptability and feasibility of campaign-style distribution to reach first-time testers, men and adolescents. However, we do not know how many remain unaware of HIVST after distribution campaigns, and who these individuals are. Here we look at factors associated with never having heard of HIVST after community-based campaign-style HIVST distribution in rural Zimbabwe between September 2016 and July 2017.

The Unfinished Business of Defining Premature Ejaculation: The Need for Targeted Research.

Introduction: Fifteen years have passed since the International Society of Sexual Medicine first established the 3-pronged criteria for premature ejaculation (PE): a short ejaculation latency, lack of ejaculatory control, and bother/distress. Although the process of establishing valid criteria for any condition or disorder is an ongoing one, a dearth of targeted research on these criteria has hindered professional societies from updating and revising them.

Objectives: To review and critique existing criteria used in the diagnosis of PE, to identify specific problems with them, and to recommend studies that will address shortcomings.

Disorders of Ejaculation: An AUA/SMSNA Guideline.

Purpose: Men who ejaculate before or shortly after penetration, without a sense of control, and who experience distress related to this condition may be diagnosed with premature ejaculation (PE), while men who experience difficulty achieving sexual climax may be diagnosed with delayed ejaculation (DE). The experience of many clinicians suggest that these problems are not rare and can be a source of considerable embarrassment and dissatisfaction for patients. The role of the clinician in managing PE and DE is to conduct appropriate investigation, to provide education, and to offer available treatments that are rational and based on sound scientific data.

Advances and Missteps in Diagnosing Premature Ejaculation: Analysis and Future Directions.

Background: There are several problems with diagnostic criteria for premature ejaculation (PE) that lack objectivity, clarity and precision. They hamper accurate determination of PE prevalence estimates, investigations into the etiology of the dysfunction, impact on partners, development of validated Patient Reported Outcomes, regulatory authority oversight, and which men might benefit from specific treatment interventions.

Aim: We sought to review, analyze and comment on the evolution of the definitions of PE and offer suggestions for future directions for PE definitions.

"It went through the roof": an observation study exploring the rise in PrEP uptake among Zimbabwean female sex workers in response to adaptations during Covid-19.

Introduction: Sisters with a Voice (Sisters), a programme providing community-led differentiated HIV prevention and treatment services, including condoms, HIV testing, pre-exposure prophylaxis (PrEP) and antiretroviral therapy linkage for sex workers, reached over 26,000 female sex workers (FSW) across Zimbabwe in 2020. Zimbabwe's initial Covid "lockdown" in March 2020 and associated movement restrictions interrupted clinical service provision for 6 weeks, particularly in mobile clinics, triggering the adaptation of services for the Covid-19 context and a scale up of differentiated service delivery (DSD) models. PrEP service delivery decentralized with shifts from clinical settings towards community/home-based, peer-led PrEP services to expand and maintain access.

Efficiency in PrEP Delivery: Estimating the Annual Costs of Oral PrEP in Zimbabwe.

Although oral PrEP is highly effective at preventing HIV acquisition, optimizing continuation among beneficiaries is challenging in many settings. We estimated the costs of delivering oral PrEP to populations at risk of HIV in seven clinics in Zimbabwe. Full annual economic costs of oral PrEP initiations and continuation visits were estimated from the providers' perspective for a six-clinic NGO network and one government SGBV clinic in Zimbabwe (January-December 2018).

Exploring Reflections, Motivations, and Experiential Outcomes of First Same-Sex/Gender Sexual Experiences among Lesbian, Gay, Bisexual, and Other Sexual Minority Individuals.

First sex is an important event in an individual's sexual development. Previous literature has, however, primarily investigated first sex, overlooking important contextual factors specific to same-sex/gender sexual experiences. Seventeen in-depth semi-structured interviews were conducted with lesbian, gay, bisexual, and other sexual minority (LGB+) individuals, ages 18-23 years.

Effect of peer-distributed HIV self-test kits on demand for biomedical HIV prevention in rural KwaZulu-Natal, South Africa: a three-armed cluster-randomised trial comparing social networks versus direct delivery.

Study Objective: We investigated two peer distribution models of HIV self-testing (HIVST) in HIV prevention demand creation compared with trained young community members (peer navigators).

Methods: We used restricted randomisation to allocate 24 peer navigator pairs (clusters) in KwaZulu-Natal 1:1:1: (1) standard of care ( peer navigators distributed clinic referrals, pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) information to 18-30 year olds. (2) Peer navigators distributed HIVST packs (SOC plus two OraQuick HIVST kits) (3) peer navigators recruited young community members (seeds) to distribute up to five HIVST packs to 18-30 year olds within their social networks.

Feasibility study of the Home-based Exercises for Responsible Sex (HERS) intervention to promote correct and consistent condom use among young women.

Background: Male condoms are effective in preventing common sexually transmitted infections (STIs) and unintended pregnancy, if used correctly and consistently. However, condom use errors and problems are common and young people report negative experiences, such as reduced pleasure. The Kinsey Institute Home-Based Exercises for Responsible Sex (KIHERS) is a novel condom promotion intervention for young women, which aims to reduce condom errors and problems, increase self-efficacy and improve attitudes towards condoms, using a pleasure-focussed approach.

Innovative demand creation strategies to increase voluntary medical male circumcision uptake: a pragmatic randomised controlled trial in Zimbabwe.

Introduction: Reaching men aged 20-35 years, the group at greatest risk of HIV, with voluntary medical male circumcision (VMMC) remains a challenge. We assessed the impact of two VMMC demand creation approaches targeting this age group in a randomised controlled trial (RCT).

Methods: We conducted a 2×2 factorial RCT comparing arms with and without two interventions: (1) standard demand creation augmented by human-centred design (HCD)-informed approach; (2) standard demand creation plus offer of HIV self-testing (HIVST).