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Estimation of the HIV care cascade for female sex workers in Zimbabwe: Baseline results of the SAPPH-IRe Trial. Frances M Cowan. Collaborative project. Zimbabwe Ministry of Health and Child Care and Centre for Sexual Health and HIV AIDS Research, Zimbabwe,

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Estimation of the HIV care cascade for female sex workers in Zimbabwe: Baseline results of the SAPPH-IRe Trial

Frances M Cowan

collaborative project
Collaborative project

Zimbabwe Ministry of Health and Child Care and Centre for Sexual Health and HIV AIDS Research, Zimbabwe,

in collaboration with UNFPA, PSI Zimbabwe, the National AIDS Council, University College London, the London School of Hygiene and Tropical Medicine, and RTI International.

sisters with a voice
‘Sisters with a Voice’

Established in 2009 with five sites- expanded in 2013 to 36 sites nationally

Developed in close consultation with SWs and other stakeholders

  • Clinical services
  • Supported by 130 peer educators (50% paralegals)
  • Community mobilisation
  • >17,800 SW seen
sisters services
‘Sisters’ services
  • Health education
  • Safer sex counseling
  • Free male and female condoms
  • HIV testing and counseling
  • Referral to treatment and care

for HIV positive women

  • Syndromic management of STIs
  • Contraception

Conduct baseline survey using RDS in 14 outreach sites

Recruit ≈ 200 SWs per site (total n=2,800 )

Random allocation of 7 matched sites to intervention arms

Process Evaluation

Program data collection

  • SAPPH-IRe Ix Sites
  • Usual care plus:
  • HIV negatives
  • Repeat HTC, Offer of PrEP
  • HIV positives
  • PoC CD4; On site ART
  • Intensified community mobilisation with SMS adherence support
  • Adherence sisters program

Usual Care Sites

Health education, HTC

Referral to government HIV care services as needed,

Syndromic STI



Cervical Ca screening,

Legal advice

After 18 months conduct endline survey using RDS in all 14 sites. Recruit ≈ 200 SWs per site (total n=2,800 )

Secondary Outcomes

Primary Outcome

Proportion of all SW who are infectious with HIV (viral load >1000 copies/ml).

% HIV-infected SW who are infectious

% on taking ART who have viral load >1000 who have drug resistance

Self-reported QoL, psychological health and functioning

% adherent to ART for treatment

% SWs always using condoms with clients in last month

% of SWs who know HIV status

Perceived levels of peer support

% engaged in prevention/care) appropriate to their individual place on the care continuum

respondent driven sampling survey
Respondent Driven Sampling Survey

Rapid mapping at each site

Seed selection

  • 8 at 4 sites, 6 at 10 sites

RDS Survey

    • Interviewer-administered on tablets
    • DBS for HIV Ab testing and Viral Load


      • Weighted prevalence estimates accounting for RDS for whole populations and sub-populations
      • Random effects regression to explore associations
  • Survey conducted Nov 13 2013 to 20 Dec 2013
  • Aimed to recruit 200 women each site
age at survey
Age at survey
  • * percents are RDS weighted
age started sex work
Age started sex work
  • * percents are RDS weighted
behaviour clients last week
Behaviour - # clients last week
  • * percents are RDS weighted
consistent condom use with clients
Consistent condom usewith clients
  • Other attributes

59.3 % (36.4 - 83.3)

  • Ever experienced IPV 37.4% (17.3 - 59.1)
  • Ever experienced Client BV 28.3% (10.8- 58.0)
  • Raped in last 12 months 4.3% (1.1-13.2)
  • * percents are RDS weighted


  • maybe consider 95% CI’s since have
  • given them throughout
  • Additional 19% with viral suppression but reporting not on ART
  • 61%
  • 50%
  • 40%
  • 31%
in summary
In summary
  • Programmatic and past research data suggest SWs are not adequately linked to services
  • Analysis of baseline survey data suggests that service access is improving but still sub-optimal, particularly in terms of testing and diagnosis.
  • Trial will provide evidence of cost effectiveness of strengthening ART provision for both prevention and treatment among SWs

And Others

Valentina Cambiano UCL

Samson Chidiya – UNFPA

Tarisai Chinyaka – CeSHHAR

Calum Davey – LSHTM

Jeffrey Dirawo – CeSHHAR

Vimbai Mdege NAC

Sibongile Mtetwa - CeSHHAR

Sithembile Msembiri - CeSHHAR

Phillis Mushati - CeSHHAR

BasileTambashe - Country Representative UNFPA

Co Investigators

  • Joanna Busza - LSHTM
  • Valentina Cambiano - UCL
  • Dr Milton Chemhuru Provincial Medical Director Midlands
  • Dagmar Hanisch -UNFPA
  • James Hargreaves LSHTM
  • Dr Nyasha MasukaPMD MatebelelandNorth
  • Sue Mavedzenge RTI International
  • Dr Owen Mugurungi – Director HIV AIDS and TB Unit, MoHCC
  • Andrew Phillips UCL
  • Professor Simba Rusakaniko UZ-CHS