1. Estimation of the HIV care cascade for female sex workers in Zimbabwe: Baseline results of the SAPPH-IRe Trial Frances M Cowan

2. 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.

3. Established in 2009 with five sites- expanded in 2013 to 36 sites nationally Developed in close consultation with SWs and other stakeholders ‘Sisters with a Voice’ Clinical services Supported by 130 peer educators (50% paralegals) Community mobilisation >17,800 SW seen

4. ‘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

5. Overview of trial design

6. Conduct baseline survey using RDS in 14 outreach sites Recruit ≈ 200 SWs per site (total n=2,800 ) Usual Care Sites Health education, HTC Referral to government HIV care services as needed, Syndromic STI Contraception, Condoms Cervical Ca screening, Legal advice Random allocation of 7 matched sites to intervention arms 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 After 18 months conduct endline survey using RDS in all 14 sites. Recruit ≈ 200 SWs per site (total n=2,800 ) Process Evaluation Program data collection

7. Primary Outcome Secondary Outcomes 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

8. 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 Analysis Weighted prevalence estimates accounting for RDS for whole populations and sub-populations Random effects regression to explore associations Respondent Driven Sampling Survey

9. Baseline RDS survey results

10. Enrolment Survey conducted Nov 13 2013 to 20 Dec 2013 Aimed to recruit 200 women each site BINDURA207 CHINHOYI220 CHIPINGE190 CHIVHU196 GUTU184 GWANDA153 HWANGE202 JURU197 KADOMA200 KARIBA202 MAGUNJE200 MARONDERA165 NGUNDU198 ZVISHAVANE208

11. Age at survey Agen% (95% CIs) * 18-24 785 26.8 (16.2 - 37.3) 25-29673 22.1 (19.7 - 24.7) 30-39894 36.0 (28.6 - 41.7) >4037015.1 (9.0 - 19.8) Total2722100 * percents are RDS weighted

12. Age started sex work Agen% (95% CIs)* <18 492 18.0 (8.4 - 28.1) 18-19173 6.0 (1.6 - 13.7) 20-24839 30.1 (21.2 - 42.1) 25-2965023.0 (14.9 - 33.3) >3056822.8 (12.0 - 29.5) * percents are RDS weighted

13. Behaviour - # clients last week # clients last week n% (95% CIs) None200 6.9 (2.6 - 11.6) 1-51352 52.6 (34.3 - 72.3) 6-10578 19.5 (11.0 - 33.1) 11-152186.3 (3.4 - 9.8) 16+374 14.7 (2.9 - 36.2) * percents are RDS weighted

14. Overall HIV prevalence 56.4% (95% CI 42.2-80.0) Agen% (95% CIs) * 18-24 233/655 36% (26-46%) 25-29372/665 55% (48-62%) 30-39649/948 69% (60-73%) >40345/44077% (71-82%) Total2722100 * percents are RDS weighted

15. Consistent condom use with clients 59.3 % (36.4 - 83.3) Ever experienced IPV37.4% (17.3 - 59.1) Ever experienced Client BV 28.3% (10.8- 58.0) Raped in last 12 months4.3% (1.1-13.2) Other attributes * percents are RDS weighted

16. HIV Care Cascade

17. maybe consider 95% CI’s since have given them throughout 100% 61% 40% 31% 50% Additional 19% with viral suppression but reporting not on ART

18. 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

19. Acknowledgements Co Investigators Joanna Busza - LSHTM Valentina Cambiano - UCL Dr Milton Chemhuru Provincial Medical Director Midlands Dagmar Hanisch -UNFPA James Hargreaves LSHTM Dr Nyasha Masuka PMD Matebeleland North Sue Mavedzenge RTI International Dr Owen Mugurungi – Director HIV AIDS and TB Unit, MoHCC Andrew Phillips UCL Professor Simba Rusakaniko UZ- CHS 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 Basile Tambashe - Country Representative UNFPA