Addressing the HIV Epidemic in Criminalized Groups in Zimbabwe

: A Critical Step Toward HIV Epidemic Control

Abstract

Overview of this commentary
This commentary relates to nineteen peer-reviewed publications in scientific journals, one lecture series, and one book chapter, which have been central to HIV public health response. These sought to contribute to the attainment and maintenance of the UNAIDS targets for the HIV epidemic in Zimbabwe through the generation of evidence to guide the development and implementation of HIV interventions targeting MSM and other criminalised groups in Zimbabwe and beyond. The works in this thesis were motivated by the need to address the then significant knowledge gap about HIV in men who have sex with men (MSM). Viewing the HIV epidemic from the public health lenses also motivated the current works since the health problems that affect MSM affect the general population and vice-versa. In this way, addressing the HIV problem in the general population alone, and leaving out MSM, is not enough. All the HIV response achievements in the general population can be easily eroded in a matter of time if the response leaves out this key group in society.
Several methods were used to generate evidence contributing to the current thesis, including the formative evaluation to inform the main bio-behavioural survey presented. This used a qualitative design including focus group discussions, in-depth interviews, and ethnographic mapping. The main bio-behavioral survey used a quantitative design, with methods including respondent-driven sampling, and biometric testing. Relevant national and institutional bodies approved all the works.
Evidence from the thesis points to the high prevalence of undiagnosed HIV among MSM in Zimbabwe and beyond, with several factors having been found to contribute to this issue. They included a high prevalence of other sexually transmitted diseases such as hepatitis B, syphilis, stigma, and discrimination (including by health care providers, limiting utilization of health services such as HIV testing). Limited evidence to inform the design and implementation of HIV interventions that target MSM has also been noted as a contributing factor to the high HIV burden among MSM in Zimbabwe. This lack of evidence has been attributed to the criminalisation of the practice by the laws of the land, which makes it difficult for researchers to conduct research studies due to fear of being associated with the practice.
Implementation of interventions including PrEP among MSM has been found to have enormous potential, if well backed by information, education, and communication strategies that provide members of this group with factual messages about PrEP. Additionally, the usage of machine learning techniques has also shown enormous potential for HIV screening among MSM within their communities to identify high-risk individuals. Implementation of community-led monitoring to address the HIV problem among MSM also emerged as a highly effective intervention, only if efforts are put to address the current gaps that have been noted in Zimbabwe. Collaboration between the government of Zimbabwe and the private sector players through private-public partnerships is a strategy that has been demonstrated to be efficient in addressing the problem if adopted. The country’s preparedness to address unforeseen emergencies was noted as a crucial measure that is necessary to minimize the diversion of resources originally earmarked for the HIV response to addressing the emergencies.
The works in this thesis have contributed significantly to the understanding of the HIV epidemic among MSM in Zimbabwe and helped the country generate national HIV estimates, among other data needs. Advocacy for policy reforms to decriminalise same-sex relationships and protect MSM from discrimination, provision of targeted HIV testing, treatment, and prevention services, and further research and reaching out to other geographical areas and groups not covered in the current study, are among several other suggested recommendations to improve HIV response among MSM in Zimbabwe.
This document is divided into thirteen sections, starting with the introduction, which highlights its goal, objectives, and the guiding theoretical framework. The second section presents the contextual background around health and HIV in Zimbabwe. The HIV problem among MSM and its causes are presented in the third and fourth sections, respectively. The interventions that have been found to work well in addressing HIV among MSM, and the appropriate strategic approaches for consideration, make up the fifth and sixth sections of the thesis. The other critical factors for enhancing the success of public health interventions are presented in the seventh section of the thesis, followed by the thesis’ contribution to knowledge in section eight. The conclusion including the section on looking ahead is in the ninth section, followed by the references in section ten.

Date of Award	18 Nov 2024
Original language	English
Awarding Institution	University of Portsmouth
Supervisor	Helena Herrera (Supervisor) & Ngianga Ii Kandala (Supervisor)