Towards ending HIV in Zimbabwe through focusing on improving targeting of HIV testing and uptake of HIV prevention in adolescent girls and young women

In Zimbabwe HIV remains the leading cause of death. In 2016, 1 in 7 adults were living with HIV.

In order to end the HIV epidemic as a public health threat by 2030, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set the targets of: (a) 95% of people living with HIV (PLWH) being diagnosed, (b) 95% of those diagnosed on antiretroviral therapy (ART), and (c) 95% of those on ART with an undetectable viral load ("suppressed"). These targets were based on the rationale that PLWH diagnosed, on ART and suppressed have near normal life-expectancy and cannot transmit the virus to others.

In Zimbabwe in 2016 these were: (a) 73%, (b) 87% and (c) 86%, respectively, despite the number of HIV tests having increased by four-fold between 2007 and 2017. This is particularly low among adolescents and young people. In addition, the proportion of all HIV tests with a positive result has been declining, with a higher cost to identify each new case.

For this reason, Zimbabwe is shifting to differentiated HIV testing strategies, targeting sub-populations at higher risk of HIV and using a range of testing strategies (e.g. "index testing", whereby household, family members or partners of people diagnosed with HIV are offered an HIV test; self-testing). However, the impact of this shift is unclear, as is whether it offers value for money.

Adolescent girls and young women (AGYW; aged 15-24) are disproportionately affected by HIV. The World Health Organization (WHO) recommends Pre-Exposure Prophylaxis (PrEP; use of specific antiretrovirals in people without HIV to prevent HIV infection), as an additional choice for people at substantial risk of HIV (including AGYW). In Zimbabwe PrEP roll out has started, but only 4% of current users are AGYW (not counting those reporting as selling sex).

An approach to increase PrEP use among those AGYW most at risk is required. Studies evaluating the safety and efficacy of additional PrEP formulations (long-acting injectables, implants, other antiretrovirals and in combination with contraceptives) are ongoing. However, little is known about preferences of AGYW for different PrEP attributes, nor is there information on how to ensure high uptake and sufficient support among this group.

The overall aim of this fellowship is to fill these gaps. This will be achieved by:

a. working closely with the Zimbabwe Ministry of Health and Child Care and other stakeholders to identify the optimal combination of HIV testing strategies that maximise health, within the budget available, to assess its impact (in terms of HIV infections, morbidity and mortality) and whether this combination is predicted to achieve the target of 95% of PLWH being diagnosed by 2030. This will be performed using a mathematical model informed by analysis of data already collected in Zimbabwe.

b. co-developing with AGYW a PrEP implementation intervention for AGYW who need it, that attracts them to PrEP, and supports them while taking PrEP, with the potential to offer value for money. This will be achieved using qualitative and quantitative methods (survey of AGYW) and mathematical modelling.

If the PrEP implementation intervention developed has the potential to offer value for money and being affordable, it will be then evaluated in a randomised trial in Years 5-7.

The research will be led by Dr Valentina Cambiano, Lecturer in Infectious Disease Modelling and Biostatistics at University College London (UCL) and will draw together experts from UCL, the Liverpool School of Tropical Medicine and the Centre for Sexual Health and HIV/AIDS Research Zimbabwe and Zimbabwe and international policy makers.

This research is required to address questions low- and middle- income countries with a high HIV burden are facing.