it went through the roof an observation study exploring the rise in prep uptake among CORD-Papers-2022-06-02 (Version 1)

Title: It went through the roof: an observation study exploring the rise in PrEP uptake among Zimbabwean female sex workers in response to adaptations during Covid19
Abstract: INTRODUCTION: Sisters with a Voice (Sisters) a programme providing communityled differentiated HIV prevention and treatment services including condoms HIV testing preexposure prophylaxis (PrEP) and antiretroviral therapy linkage for sex workers reached over 26000 female sex workers (FSW) across Zimbabwe in 2020. Zimbabwe's initial Covid lockdown in March 2020 and associated movement restrictions interrupted clinical service provision for 6 weeks particularly in mobile clinics triggering the adaptation of services for the Covid19 context and a scale up of differentiated service delivery (DSD) models. PrEP service delivery decentralized with shifts from clinical settings towards community/homebased peerled PrEP services to expand and maintain access. We hypothesize that peerled communitybased provision of PrEP services influenced both demand and supplyside determinants of PrEP uptake. We observed the effect of these adaptations on PrEP uptake among FSW accessing services in Sisters in 2020. METHODS: New FSW PrEP initiations throughout 2020 were tracked by analysing routine Sisters programme data and comparing it with national PrEP initiation data for 2020. We mapped PrEP uptake among all negative FSW attending services in Sisters alongside Covid19 adaptations and shifts in the operating environment throughout 2020: prior to lockdown (JanuaryMarch 2020) during severe restrictions (AprilJune 2020) subsequent easing (JulySeptember 2020) and during drug stockouts that followed (OctoberDecember 2020). RESULTS AND DISCUSSION: PrEP uptake in 2020 occurred at rates <25% (315 initiations or fewer) per month prior to the emergence of Covid19. In response to Covid19 restrictions DSD models were scaled up in April 2020 including peer demand creation communitybased delivery multimonth dispensing and the use of virtual platforms for appointment scheduling and postPrEP initiation support. Beginning May 2020 PrEP uptake increased monthly peaking at an initiation rate of 51% (n = 1360) in September 2020. Unexpected rise in demand coincided with national commodity shortages between October and December 2020 resulting in restriction of new initiations with sites prioritizing refills. CONCLUSIONS: Despite the impact of Covid19 on the Sisters Programme and FSW mobility DSD adaptations led to a large increase in PrEP initiations compared to preCovid levels demonstrating that a peerled communitybased PrEP service delivery model is effective and can be adopted for longterm use.
Published: 2021-10-28
Journal: J Int AIDS Soc
DOI: 10.1002/jia2.25813
DOI_URL: http://doi.org/10.1002/jia2.25813
Author Name: Matambanadzo Primrose
Author link: https://covid19-data.nist.gov/pid/rest/local/author/matambanadzo_primrose
Author Name: Busza Joanna
Author link: https://covid19-data.nist.gov/pid/rest/local/author/busza_joanna
Author Name: Mafaune Haurovi
Author link: https://covid19-data.nist.gov/pid/rest/local/author/mafaune_haurovi
Author Name: Chinyanganya Lillian
Author link: https://covid19-data.nist.gov/pid/rest/local/author/chinyanganya_lillian
Author Name: Machingura Fortunate
Author link: https://covid19-data.nist.gov/pid/rest/local/author/machingura_fortunate
Author Name: Ncube Getrude
Author link: https://covid19-data.nist.gov/pid/rest/local/author/ncube_getrude
Author Name: Steen Richard
Author link: https://covid19-data.nist.gov/pid/rest/local/author/steen_richard
Author Name: Phillips Andrew
Author link: https://covid19-data.nist.gov/pid/rest/local/author/phillips_andrew
Author Name: Cowan Frances Mary
Author link: https://covid19-data.nist.gov/pid/rest/local/author/cowan_frances_mary
sha: 535c642d0a14572e9e095698cb28b36e49f11f86
license: cc-by
license_url: https://creativecommons.org/licenses/by/4.0/
source_x: Medline; PMC; WHO
source_x_url: https://www.medline.com/https://www.ncbi.nlm.nih.gov/pubmed/https://www.who.int/
pubmed_id: 34713613
pubmed_id_url: https://www.ncbi.nlm.nih.gov/pubmed/34713613
pmcid: PMC8554216
pmcid_url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8554216
url: https://doi.org/10.1002/jia2.25813 https://www.ncbi.nlm.nih.gov/pubmed/34713613/
has_full_text: TRUE
Keywords Extracted from Text Content: -mother's Covid-19 stock Initiations NAC What-sApp Covid-19 lockdown hubs oral her FSW National AIDS Council MoHCC women CeSHHAR worker-led AP FM FC LC
Extracted Text Content in Record: First 5000 Characters:Much has been written about the negative effects of the Sars-Cov2 pandemic (Covid-19) on sex workers' livelihoods, wellbeing and access to healthcare [1] [2] [3] [4] . Closure of entertainment venues, restrictions on personal mobility and clients' fears of contracting Covid-19 have reduced sex workers' incomes, while strain on health services and disruptions to supply chains decreased their access to healthcare, including HIV testing, prevention and treatment [5] . In some contexts, including Zimbabwe, sex workers have experienced increased stigma against them as potential "disease vectors", leading to harassment and violence, including from police [6, 7] . There have been calls for policies and programmes to recognize sex workers' enhanced vulnerability and respond accordingly [3, 8] . The need for ongoing flexibility during this time, however, also provided opportunities for introducing or scaling up existing differentiated service delivery (DSD) models that may previously have been thought too costly or unfeasible to implement. It also refocused attention on the structural drivers of vulnerability [9, 10] . Pre-exposure prophylaxis (PrEP) may be particularly well suited to testing new DSD approaches, given its recent introduction into national HIV programmes in many sub-Saharan African countries and initial slow uptake among some populations, including sex workers and adolescent and young women at particularly high risk [11] [12] [13] . Despite successful demonstration projects, PrEP initiation and retention continue to pose challenges to prevention programmes throughout the region, prompting calls for renewed efforts to increase uptake. One method for increasing uptake is by making it more easily available in community settings beyond health facilities [12] . In Zimbabwe, oral PrEP has been offered to sex workers since 2016, when the Ministry of Health and Child Care (MoHCC) adopted World Health Organization (WHO) guidelines. However, widespread access began in 2018 with phased rollout of a 2-year national Implementation Plan [14] . Sisters with a Voice (Sisters) is a nationally scaled, evidence-based comprehensive HIV prevention and treatment programme for sex workers implemented by the Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) on behalf of the MoHCC and National AIDS Council (NAC) since 2009. Sisters reached over 26,000 female sex workers (FSW) yearly across Zimbabwe in 2019 and 2020 with HIV prevention and treatment and sexual and reproductive health services, relying on robust sex worker-led community mobilization to link sex workers to services, including provision of condoms, lubricants, HIV testing, PrEP and linkage to antiretroviral therapy. The strength of Sisters is its integrated model of government ownership, services delivered through a network of fixed-site and mobile clinics co-located within MoHCC clinics and sex worker leadership through 370 peer educators supported and supervised by outreach workers [15] . Sisters rolled out PrEP in April 2019, screening all HIV-negative female, male and transgender sex workers attending clinics and drop-in centres following a pilot introduction as part of a trial [16, 17] . Initially, Sisters' PrEP implementation protocol specified that nurses should provide prevention, testing and counselling for all sex workers. All FSW who tested negative were screened for PrEP eligibility, and those who accepted were initiated on PrEP. Newly initiated FSW received 1 month's supply and were encouraged to return to the clinic at any time if they experienced adverse reactions, but otherwise advised to attend monthly follow-up visits for the first 3 months. After that, FSW were recommended to visit the clinic every 3 months for refills, adherence counselling, HIV testing, as well as checks for sexually transmitted infections and for other sexual and reproductive health services. Following the introduction of Covid-19 lockdown restrictions in late March 2020, Sisters was obliged to close all 10 permanent sites for 1 week and all mobile clinics for 6 weeks, re-opening them as "essential services" on 6 April 2020 and 18 May 2020, respectively. Subsequently, routine clinic visits were discouraged to "decongest" facilities. To maintain and expand access to PrEP, services were shifted into the community with greater reliance on peer educators and outreach workers to create demand and provide follow-up support. This paper describes the Covid-19-related DSD adaptations made to the PrEP provision within Sisters and explores the effect of these on trends on PrEP uptake. First, existing peer educators were trained on PrEP by their supervising outreach workers and encouraged to become advocates for PrEP within the sex work communities where they live and work. They disseminated information among their peers, dispelled myths and encouraged increased demand. The sex workers at highest risk, tracked weekly, were prioritized for PrEP discussions and referral to new com
Keywords Extracted from PMC Text: follow‐up oral HIV‐negative FSW fixed‐site NAC inter‐ Pre‐exposure LC hubs AP peer‐led community‐based PEPFAR FC scale‐up community‐based women " Elton John AIDS her stock Sars‐Cov2 ref:19‐115RS National AIDS Council peer‐led MoHCC FM long‐term Covid‐19 lockdown Covid‐19 CeSHHAR worker‐led
Extracted PMC Text Content in Record: First 5000 Characters:Much has been written about the negative effects of the Sars‐Cov2 pandemic (Covid‐19) on sex workers' livelihoods, wellbeing and access to healthcare [1, 2, 3, 4]. Closure of entertainment venues, restrictions on personal mobility and clients' fears of contracting Covid‐19 have reduced sex workers' incomes, while strain on health services and disruptions to supply chains decreased their access to healthcare, including HIV testing, prevention and treatment [5]. In some contexts, including Zimbabwe, sex workers have experienced increased stigma against them as potential "disease vectors", leading to harassment and violence, including from police [6, 7]. There have been calls for policies and programmes to recognize sex workers' enhanced vulnerability and respond accordingly [3, 8]. The need for ongoing flexibility during this time, however, also provided opportunities for introducing or scaling up existing differentiated service delivery (DSD) models that may previously have been thought too costly or unfeasible to implement. It also refocused attention on the structural drivers of vulnerability [9, 10]. Pre‐exposure prophylaxis (PrEP) may be particularly well suited to testing new DSD approaches, given its recent introduction into national HIV programmes in many sub‐Saharan African countries and initial slow uptake among some populations, including sex workers and adolescent and young women at particularly high risk [11, 12, 13]. Despite successful demonstration projects, PrEP initiation and retention continue to pose challenges to prevention programmes throughout the region, prompting calls for renewed efforts to increase uptake. One method for increasing uptake is by making it more easily available in community settings beyond health facilities [12]. In Zimbabwe, oral PrEP has been offered to sex workers since 2016, when the Ministry of Health and Child Care (MoHCC) adopted World Health Organization (WHO) guidelines. However, widespread access began in 2018 with phased rollout of a 2‐year national Implementation Plan [14]. Sisters with a Voice (Sisters) is a nationally scaled, evidence‐based comprehensive HIV prevention and treatment programme for sex workers implemented by the Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) on behalf of the MoHCC and National AIDS Council (NAC) since 2009. Sisters reached over 26,000 female sex workers (FSW) yearly across Zimbabwe in 2019 and 2020 with HIV prevention and treatment and sexual and reproductive health services, relying on robust sex worker‐led community mobilization to link sex workers to services, including provision of condoms, lubricants, HIV testing, PrEP and linkage to antiretroviral therapy. The strength of Sisters is its integrated model of government ownership, services delivered through a network of fixed‐site and mobile clinics co‐located within MoHCC clinics and sex worker leadership through 370 peer educators supported and supervised by outreach workers [15]. Sisters rolled out PrEP in April 2019, screening all HIV‐negative female, male and transgender sex workers attending clinics and drop‐in centres following a pilot introduction as part of a trial [16, 17]. Initially, Sisters' PrEP implementation protocol specified that nurses should provide prevention, testing and counselling for all sex workers. All FSW who tested negative were screened for PrEP eligibility, and those who accepted were initiated on PrEP. Newly initiated FSW received 1 month's supply and were encouraged to return to the clinic at any time if they experienced adverse reactions, but otherwise advised to attend monthly follow‐up visits for the first 3 months. After that, FSW were recommended to visit the clinic every 3 months for refills, adherence counselling, HIV testing, as well as checks for sexually transmitted infections and for other sexual and reproductive health services. Following the introduction of Covid‐19 lockdown restrictions in late March 2020, Sisters was obliged to close all 10 permanent sites for 1 week and all mobile clinics for 6 weeks, re‐opening them as "essential services" on 6 April 2020 and 18 May 2020, respectively. Subsequently, routine clinic visits were discouraged to "decongest" facilities. To maintain and expand access to PrEP, services were shifted into the community with greater reliance on peer educators and outreach workers to create demand and provide follow‐up support. This paper describes the Covid‐19‐related DSD adaptations made to the PrEP provision within Sisters and explores the effect of these on trends on PrEP uptake. First, existing peer educators were trained on PrEP by their supervising outreach workers and encouraged to become advocates for PrEP within the sex work communities where they live and work. They disseminated information among their peers, dispelled myths and encouraged increased demand. The sex workers at highest risk, tracked weekly, were prioritized for PrEP discussions and referral to new community "access
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