ObjectivesAntiretroviral therapy (ART) and isoniazid preventive therapy (IPT) are known to have a tuberculosis (TB) protective effect at the individual level among people living with HIV (PLHIV). In Zimbabwe where TB is driven by HIV infection, we have assessed whether there is a population-level association between IPT and ART scale-up and annual TB case notification rates (CNRs) from 2000 to 2018.DesignEcological study using aggregate national data.SettingAnnual aggregate national data on TB case notification rates (stratified by TB category and type of disease), numbers (and proportions) of PLHIV in ART care and of these, numbers (and proportions) ever commenced on IPT.ResultsART coverage in the public sector increased from <1% (8400 PLHIV) in 2004 to ~88% (>1.1 million PLHIV patients) by December 2018, while IPT coverage among PLHIV in ART care increased from <1% (98 PLHIV) in 2012 to ~33% (373 917 PLHIV) by December 2018. These HIV-related interventions were associated with significant declines in TB CNRs: between the highest CNR prior to national roll-out of ART (in 2004) to the lowest recorded CNR after national IPT roll-out from 2012, these were (1) for all TB case (510 to 173 cases/100 000 population; 66% decline, p<0.001); (2) for those with new TB (501 to 159 cases/100 000 population; 68% decline, p<0.001) and (3) for those with new clinically diagnosed PTB (284 to 63 cases/100 000 population; 77.8% decline, p<0.001).ConclusionsThis study shows the population-level impact of the continued scale-up of ART among PLHIV and the national roll-out of IPT among those in ART care in reducing TB, particularly clinically diagnosed TB which is largely associated with HIV. There are further opportunities for continued mitigation of TB with increasing coverage of ART and in particular IPT which still has a low coverage.

Zimbabwe has a high burden of HIV (i.e., estimated 1.3 million HIV-infected and 13.8% HIV incidence in 2017). In 2017, the country developed and implemented a pilot of HIV case surveillance (CS) based on the 2017 World Health Organisation (WHO) person-centred HIV patient monitoring (PM) and case surveillance guidelines. At the end of the pilot phase an evaluation was conducted to inform further steps. The pilot was conducted in two districts (i.e., Umzingwane in Matabeleland South Province and Mutare in Manicaland Province) from August 2017 to December 2018. A mixed-methods cross-sectional study of stakeholders and health facility staff was used to assess the design and operations, performance, usefulness, sustainability, and scalability of the CS system. A total of 13 stakeholders responded to an online questionnaire, while 33 health facility respondents were interviewed in 11 health facilities in the two districts. The HIV CS system was adequately designed for Zimbabwe’s context, integrated within existing health information systems at the facility level. However, the training was minimal, and an opportunity to train the data entry clerks in data analysis was missed. The system performed well in terms of surveillance and informatics attributes. However, viral load test results return was a significant problem. The HIV CS system was found useful at the health facility level and should be rolled out in a phased manner, beginning in Manicaland and Matabeleland South provinces. An electronic link needs to be made between the health facilities and the laboratory to reduce viral load test results delays.

ObjectivesWHO recommended strengthening the linkages between various HIV prevention programmes and adolescent sexual reproductive health (ASRH) services. The Smart-LyncAges project piloted in Bulawayo city and Mt Darwin district of Zimbabwe established a referral system to link the voluntary medical male circumcision (VMMC) clients to ASRH services provided at youth centres. Since its inception in 2016, there has been no assessment of the performance of the referral system. Thus, we aimed to assess the proportion of young (10–24 years) VMMC clients getting ‘successfully linked’ to ASRH services and factors associated with ‘not being linked’.DesignThis was a cohort study using routinely collected secondary data.SettingAll three VMMC clinics of Mt Darwin district and Bulawayo province.Primary outcome measuresThe proportion of ‘successfully linked’ was summarised as the percentage with a 95% CI. Adjusted relative risks (aRR) using a generalised linear model was calculated as a measure of association between client characteristics and ‘not being linked’.ResultsOf 1773 young people registered for VMMC services, 1478 (83%) were referred for ASRH services as they had not registered for ASRH previously. Of those referred for ASRH services, the mean (SD) age of study participants was 13.7 (4.3) years and 427 (28.9%) were out of school. Of the referred, 463 (31.3%, 95% CI: 30.0 to 33.8) were ‘successfully linked’ to ASRH services and the median (IQR) duration for linkage was 6 (0–56) days. On adjusted analysis, receiving referral from Bulawayo circumcision clinic (aRR: 1.5 (95% CI: 1.3 to 1.7)) and undergoing circumcision at outreach sites (aRR: 1.2 (95% CI: 1.1 to 1.3)) were associated with ‘not being linked’ to ASRH services.ConclusionLinkage to ASRH services from VMMC is feasible as one-third VMMC clients were successfully linked. However, there is need to explore reasons for not accessing ASRH services and take corrective actions to improve the linkages.

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ObjectivePeer education is an intervention within the voluntary medical male circumcision (VMMC)–adolescent sexual reproductive health (ASRH) linkages project in Bulawayo and Mount Darwin, Zimbabwe since 2016. Little is known if results extend beyond increasing knowledge. We therefore assessed the extent of and factors affecting referral by peer educators and receipt of HIV testing services (HTS), contraception, management of sexually transmitted infections (STIs) and VMMC services by young people (10–24 years) counselled.DesignA cohort study involving all young people counselled by 95 peer educators during October–December 2018, through secondary analysis of routinely collected data.SettingAll ASRH and VMMC sites in Mt Darwin and Bulawayo.ParticipantsAll young people counselled by 95 peer educators.Outcome measuresCensor date for assessing receipt of services was 31 January 2019. Factors (clients’ age, gender, marital and schooling status, counselling type, location, and peer educators’ age and gender) affecting non-referral and non-receipt of services (dependent variables) were assessed by log-binomial regression. Adjusted relative risks (aRRs) were calculated.ResultsOf the 3370 counselled (66% men), 65% were referred for at least one service. 58% of men were referred for VMMC. Other services had 5%–13% referrals. Non-referral for HTS decreased with clients’ age (aRR: ~0.9) but was higher among group-counselled (aRR: 1.16). Counselling by men (aRR: 0.77) and rural location (aRR: 0.61) reduced risks of non-referral for VMMC, while age increased it (aRR ≥1.59). Receipt of services was high (64%–80%) except for STI referrals (39%). Group counselling and rural location (aRR: ~0.52) and male peer educators (aRR: 0.76) reduced the risk of non-receipt of VMMC. Rural location increased the risk of non-receipt of contraception (aRR: 3.18) while marriage reduced it (aRR: 0.20).ConclusionWe found varying levels of referral ranging from 5.1% (STIs) to 58.3% (VMMC) but high levels of receipt of services. Type of counselling, peer educators’ gender and location affected receipt of services. We recommend qualitative approaches to further understand reasons for non-referrals and non-receipt of services.