1. Learnings from the Sisters with a Voice programme in Zimbabwe
Frances M Cowan
Centre for Sexual Health and HIV AIDS Research Zimbabwe
University College London

2. Research and programme partners
Zimbabwe Ministry of Health and Child Care
National AIDS Council
Centre for Sexual Health and HIV AIDS Research, Zimbabwe
University College London
London School of Hygiene and Tropical Medicine
RTI International
Population Services International Zimbabwe
GIZ
United Nations Population Fund
Could remove this slide

3. SIDA Integrated support program Irish AID
Funding partners
UKAID
SIDA Integrated support program
Irish AID
CDC
USAID
BMGF
GFATM
Could remove this slide

4. The Sisters with a Voice Programme
National sex worker programme with 36 sites across the country
Established in 2009 with 5 sites
Expanded to 36: 6 fixed and 30 mobile
Clinical services: STI treatment, HTS, condoms, linkage to ART and PrEP (SAPPHIRE trial)
Large community empowerment component, including mobilisation and outreach activities
Support by 170 peer educators (50% paralegals)
By June 2016:
>40,000 women visited the programme
>112,000 visits
>15,000 HIV tests
>43,000 STIs treated
>5,000 women diagnosed HIV +ve and referred to ART services (yield reducing)

5. Programme and surveillance data, 2009-2016
All women assigned unique identifier and data capture of all programme visits enabling tracking of women over geography and time
Programme data ( ), expanding from 5 to 36 sites
Paper to database ( ), Electronic data capture (2014-)
Analysis of first 5 years of programme data using a cohort approach (29000 women, visits)
RDS surveys (2011 and 2015 in 3 sites, 2013 and sites)
Site mapping, seed selection, 2-coupon approach
Site sample size ranging between
Behaviour, stigma, access to services, HIV prevalence, viral load, RITA
Careful diagnostics, RDS-2 estimation
Size estimation studies including RDS surveys 2016 in 4 sites
Young women who sell sex aged – RDS surveys in 7 sites in 2016/7
Lag Avidity assays planned for samples collected from 2883 FSW 2016 (SAPPH-IRe endline); 2700 (size estimation study); YWSS (DREAMS impact evaluation)

6. Map of 36 Sisters Sites Data collected and planned
RDS 2013, 2016; Programme
RDS 2011, 2015; Programme
SE and RDS 2016; Programme
YWSS RDS 2016/7; programme
Programme

7. Research supporting programme scale up
2013 Q1
2009
Demonstration projects Mbare and 4 sites Harare- Nyamapanda
Expanded to 16 sites – 3 fixed sites + 13 outreach
36 sites - 6 fixed + 30 outreach
Intensify outreach, youth program (inc DREAMS), PrEP expansion
322 SW
3,394 SW
6,105 SW
13, ,149 SW
Formative work to support programme development
RDS + qual studies prevention care cascade
SAPPH-IRe baseline, analysis program data
SAPPH-IRe endline, migration study, size estimation, YWSS

8. Evidence of poor linkage to care
RDS survey in 3 sites in (n=870)
50-70% of SWs HIV +
50% of HIV +ve knew their status
25-37% of HIV +ve SWs were on ART
12-22% of HIV –ve SWs had HTC within 6 months
66% of women reported consistent condom use with clients
Sex workers being well networked
Violence common
“I was afraid that I would be arrested. …..” “ It’s just the thought of being seen as a sex worker that gives me the shivers …”
Cowan et al PLoS ONE 2013,
Mtetwa et al BMC Public Health 2013;
Mtetwa et al BMC Public Health 2015

10. Cluster randomised trial of enhanced ART prevention and treatment – including PrEP
Goal: to reduce the % of SWs living in communities with infectious HIV - - ie HIV viral load > 1,000 copies/ml

11. 2013 - Conduct baseline survey using RDS* in 14 outreach sites
Recruit ≈ 200 SWs per site (total recruited n=2,722 )
Random allocation of 7 matched sites to intervention arms
Usual Care Sites
Health education, HTC
Referral to government HIV care services as needed,
Syndromic STI
Contraception,
Condoms
Cervical Ca screening,
Legal advice
Program data collection
Process Evaluation
SAPPH-IRe Intervention 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
April conduct endline survey using RDS* in all 14 sites. Recruit ≈ 200 SWs per site (total n=2,800 )
* Respondent driven sampling

12. THEORY OF CHANGE Secondary Outcomes
Population impact and cost effective-ness (modelling)
% of HIV-infected SWs who are infectious
% on ART who have viral load >1000 who have resistance
QoL, mental health
% adherent to ART for treatment
% of SWs always using condoms
% SWs who know HIV status
Perceived levels of peer support
% engaged in prevention/care)
THEORY OF CHANGE

13. SAPPH-IRe intervention aims to build a ‘Sisterhood’ to support HTC + PrEP + ART uptake/adherence
General support
Adherence Sisters Programme
Enhanced community mobilisation
Specific CM sessions
testing
linking to care
PrEP
Adherence
SMS reminders
Active follow up -phone /home visits
ART and PrEP users together – don’t need to disclose HIV status
Women nominate their Sister
Monthly training as a group with their Sister
What Is being an adherence sister all about?
Your Thoughts, Feelings and Behaviour
Choosing Your Thoughts
Supporting your Sister

15. Cascade of care for HIV +ve sex workers a) <25 years
Cascade of care for HIV +ve sex workers a) <25 years b) > 25 years
61% cv 77% of those reporting ART use were virologically suppressed
Mavedzenge et al . IAS 2015

16. Refining program to meet needs of YWSS
20% of SW report in surveys that they started selling sex before age 20
4% of program attenders <20 years
Different priorities
Tailored program for young people

17. RDS surveys conducted in 2011 and 2015 in Mutare, Hwange Vic Falls to evaluate GIZ program – Poster
Mutare n=409
Hwange n=255
VF n=251
2011
2015
RDS%
HIV Prevalence
50.6
63.7
41.3
69.6
62.1
HIV +ve- Know status
48.8
68.2
51.0
59.3
48.9
77.8
HIV +ve- Know status, on ART
79.9
89.3
43.9
72.8
48.7
85.6
HIV +ve on ART (of all +ve)
38.1
61.2
22.4
39.5
23.8
66.8
HIV testing last 6/12 amongst
those self-reporting HIV-ve
30.1
78.6
24.8
78.1
12.8
80.8
Consistent condom use – clients
65.0
71.8
63.6
69.4
72.7
62.6
Consistent condom use – non clients
33.3
63.4
33.9
55.1
36.1
43.7 17

18. Greater empowerment of SWs

19. Lesson we have learned Data guided is best! A sisterhood is forming
Sex workers increasingly engaged in prevention and care

20. Wilson D (2015) HIV Programs for Sex Workers: Lessons and Challenges for Developing and Delivering Programs. PLoS Med 12(6): e
Programs are insufficiently guided by understanding of epidemic transmission dynamics, situation analyses, and programmatic mapping; receive limited domestic financing in many countries
Inadequate measures to ensure consistency and quality
Need to evolve to address informal sex workers, male and transgender sex workers, and mobile and internet-based sex workers.
Recommends
increasing our understanding of HIV epidemic transmission dynamics,
improving situation analyses and programmatic mapping,
delivering well-codified, comprehensive programs using “Science of Delivery” principles
developing more effective models to reach informal sex workers, male and transgender sex workers, and mobile and internet-based sex workers.

21. Acknowledgements Nyasha Masuka Sue Mavedzenge Sibongile Mtetwa
Joanna Busza Valentina Cambiano Sungai Chabata Samson Chidiya Tarisai Chiyaka Calum Davey Jeffrey Dirawo Liz Fearon James Hargreaves Dagmar Hanisch Karin Hatzold
Nyasha Masuka
Sue Mavedzenge
Sibongile Mtetwa
Boniface Mudenge
Owen Mugurungi
Sithembile Musemburi
Phillis Mushati
Getrude Ncube
Andrew Phillips
Brian Rice
Acknowledge sisters and logo