Chabata Sungai T, Hensen Bernadette, Chiyaka Tarisai, Mushati Phillis, Musemburi Sithembile, Dirawo Jeffrey, Busza Joanna, Floyd Sian, Birdthistle Isolde, Hargreaves James R, Cowan Frances M
Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
BMJ Glob Health. 2021 Apr;6(4). doi: 10.1136/bmjgh-2020-003892.
Young women who sell sex (YWSS) in Zimbabwe remain at high risk of HIV infection. Effective HIV prevention strategies are needed. Through support to access a combination of evidence-based interventions, including oral pre-exposure prophylaxis (PrEP), the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) partnership aimed to reduce new HIV infections among adolescent girls and young women by 40% over 24 months.
Non-randomised 'plausibility' evaluation, powered to detect a 40% HIV incidence difference between DREAMS and non-DREAMS sites. Two large cities with DREAMS funding were included, and four smaller non-DREAMS towns for comparison. In all sites, YWSS were enrolled to a cohort through peer-referral. Women were followed up for 24 months. HIV seroconversion was the primary outcome, with secondary outcomes identified through a theory of change. Outcomes were compared between YWSS recruited in DREAMS cities and non-DREAMS towns, adjusting for individual-level confounders and HIV prevalence at enrolment.
From April to July 2017, 2431 women were enrolled, 1859 of whom were HIV negative at enrolment; 1019 of these women (54.8%) were followed up from March to May 2019 and included in endline analysis. Access to clinical services increased, but access to socioeconomic interventions promoted by DREAMS was limited. A total of 79 YWSS HIV seroconverted, with HIV incidence among YWSS in DREAMS cities lower (3.1/100 person-years) than in non-DREAMS towns (5.3/100 person-years). In prespecified adjusted analysis, HIV incidence was lower in DREAMS cities but with weak statistical evidence (adjusted rate ratio (RR)=0.68; 95% CI 0.40 to 1.19; p=0.18). Women in DREAMS cities were more likely to report ever and ongoing PrEP use, consistent condom use, fewer sexual partners and less intimate partner violence.
It is plausible that DREAMS lowered HIV incidence among YWSS in two Zimbabwean cities, but our evaluation provides weak statistical evidence for impact and suggests any reduction in incidence was lower than the anticipated 40% decline. We identified changes to some important 'pathways to impact' variables, including condom use.
在津巴布韦，从事性交易的年轻女性（YWSS）仍然面临着很高的艾滋病毒感染风险。需要有效的艾滋病毒预防策略。通过支持她们获得一系列循证干预措施，包括口服暴露前预防（PrEP），“坚定、坚韧、赋权、无艾滋病、受指导和安全”（DREAMS）伙伴关系旨在在24个月内将少女和年轻女性中的新增艾滋病毒感染病例减少40%。
进行非随机的“合理性”评估，旨在检测DREAMS地区和非DREAMS地区之间40%的艾滋病毒发病率差异。纳入了两个获得DREAMS资助的大城市，并选取了四个较小的非DREAMS城镇作为对照。在所有地区，通过同伴推荐将YWSS纳入队列。对这些女性进行了24个月的随访。艾滋病毒血清转换是主要结局，通过变革理论确定次要结局。对在DREAMS城市和非DREAMS城镇招募的YWSS的结局进行比较，并对个体层面的混杂因素和入组时的艾滋病毒流行率进行调整。
2017年4月至7月，共有2431名女性入组，其中1859名女性入组时艾滋病毒检测呈阴性；这些女性中有1019名（54.8%）在2019年3月至5月接受了随访并纳入终末分析。获得临床服务的机会有所增加，但DREAMS所推动的社会经济干预措施的可及性有限。共有79名YWSS发生了艾滋病毒血清转换，DREAMS城市中YWSS的艾滋病毒发病率（3.1/100人年）低于非DREAMS城镇（5.3/100人年）。在预先设定的调整分析中，DREAMS城市的艾滋病毒发病率较低，但统计证据较弱（调整率比（RR）=0.68；95%置信区间0.40至1.19；p=0.18）。DREAMS城市中的女性更有可能报告曾经或正在使用PrEP、始终坚持使用避孕套、性伴侣较少以及亲密伴侣暴力行为较少。
DREAMS有可能降低了津巴布韦两个城市中YWSS的艾滋病毒发病率，但我们的评估提供的影响的统计证据较弱，并且表明发病率的任何降低都低于预期的40%的下降幅度。我们确定了一些重要的“影响途径”变量的变化，包括避孕套的使用情况。
