A cross-sectional study looked at engagement in the PrEP and HIV care cascades among gay and bisexual, transgender, and genderqueer people who were assigned male at birth in Harare and Bulawayo, Zimbabwe.
Less than half of HIV-negative participants were aware of PrEP, and few were on PrEP. Study participants were more likely to be living with HIV than the general male population in Zimbabwe. Those living with HIV were far less likely to be aware of their status than the general population; however, rates of antiretroviral use and viral suppression were similar for those who were aware.
Around 13% of adults in Zimbabwe are living with HIV. In 2020, 87% of people living with HIV in the country were aware of their status, 97% of people aware of their status were receiving treatment, and 90% of those on treatment were virally suppressed. Addressing HIV prevention and care needs of key populations, such as gay and bisexual men and transgender women, can sustain this progress and close gaps towards UNAIDS 95-95-95 goals.
Gender and sexual minorities face significant stigma and discrimination in Zimbabwe. Sex between men is illegal, same sex marriage is prohibited, it is illegal for someone assigned male at birth to dress in feminine clothing, transgender people are unable to have their gender identity legally recognised, and there is little access to gender-affirming care.
In Sub-Saharan Africa, gay and bisexual men had an HIV prevalence three times higher than the general population. Globally, gay and bisexual men are 22 times more likely to acquire HIV and transgender women are 12 times more likely compared to the general population. Together, these two populations make up nearly 20% of new global HIV diagnoses.
Researchers from Columbia University’s global public health programme ICAP set out to measure the prevalence of HIV and better understand barriers and facilitators in the continuum of HIV services among gay and bisexual men, transgender women, and genderqueer individuals. (Genderqueer is a non-binary gender term used in Zimbabwe).
Researchers used a cross-sectional survey study design that collected both biological and behavioural data and was delivered in non-clinical settings in 2019. Eligible participants included adults living in Harare or Bulawayo who were assigned male at birth and reported oral or anal sex with a man within the preceding year. The survey used respondent-driven sampling, where participants received coupons to recruit peers. Participants received $5 for each successful peer recruitment, for up to three peers, and also for each study visit.
At the first visit, participants completed a survey on a tablet that asked about sociodemographics; sexual history; behaviours, knowledge, and beliefs around STIs and HIV; condom use; alcohol and drug use; experience with programmes and services targeted for gender and sexual minorities; and experiences with stigma and discrimination.
Consenting participants were tested for HIV during the first visit, regardless of self-reported status, and also hepatitis B, syphilis and TB. Test results were delivered the same day and participants were referred to appropriate services depending on the results.
A total of 1,511 people (695 Harare, 816 Bulawayo) took part in the study and were tested for HIV. Most participants were young, with 47% aged 18-24 and 36% aged 25-34. Most (82%) were single and never married. Nearly all were Black African and of Zimbabwean nationality.
Seventy-eight per cent of all participants were gay and bisexual men and the rest were transgender women and genderqueer individuals (grouped together for data analysis based on stakeholder feedback). This differed by city; in Harare 40% of participants were transgender women or genderqueer, compared to only 7% of participants in Bulawayo.
Among cisgender men, 54% identified as gay/homosexual, 45% identified as bisexual, 2 participants identified as straight/heterosexual, and one participant reported their sexual orientation as other. Among transgender women and genderqueer participants, 77% identified as gay/homosexual, 22% as bisexual, none as straight/heterosexual, and two participants identified their sexual orientation as other.
Around 1% in Harare and 9% in Bulawayo had only primary school education. Most (71%) completed school, with the rest having college, university, or vocational degrees. Unemployment was high among participants, at 38% overall. Nearly all participants reported having a regular place to sleep at night.
Ninety per cent (n = 1,377) of participants self-reported an HIV-negative or unknown status; of these, 85% (n=1,167) tested HIV negative.
Less than half (46%) of HIV-negative participants were aware of PrEP. Sixty-nine per cent of those of those aware of PrEP had never taken it; among those who hadn’t taken it 71% said they’d be willing to start. Those who hadn’t taken PrEP gave the following reasons: they did not know where to access it (25%), feared side effects (20%), did not feel at risk for HIV (20%), didn’t want to start PrEP (14%) and/or because they had insufficient information (6%).
Of the 31% of HIV-negative participants who had ever taken PrEP, most (75%) had done so in the preceding six months. Of those with recent use, 70% reported daily use and 43% had taken PrEP the day before the survey. Those who had taken discontinued PrEP did so because of side effects (60%), trusting their partner (7%), inability to access PrEP (5%), concerns about others finding out (2%), or other reasons (26%).
Factors associated with PrEP awareness and uptake
Researchers performed multivariable logistic regression to identify factors associated with PrEP awareness and uptake; all of the following findings are statistically significant with 95% confidence intervals.
Gay and bisexual men in Bulawayo were the least aware of PrEP, with gay and bisexual men in Harare being 2.5 times more likely to be aware of PrEP, and transgender and genderqueer participants in Harare and Bulawayo being three times more likely and 2.4 times more likely to be aware of PrEP, respectively. Researchers noted that the presence of tailored services for gay and bisexual men in Harare, and lack of such in Bulawayo, may explain the differences in awareness by location.
In general, transgender and genderqueer participants had the most awareness around PrEP, and they were 1.6 times more likely to have ever taken PrEP compared to gay and bisexual men in the study. Age was significant to PrEP awareness, with participants aged 35 and older half as likely to be aware of PrEP compared to participants aged 18–24 years. Those who completed school were 2.7 times more likely to be aware of PrEP compared to those who did not, while those with further education having even greater awareness.
"Less than half of HIV-negative gay and bisexual men, transgender women, and genderqueer individuals were aware of PrEP, and use was low."
Participants who had a self-reported social network larger than the sample average were 1.4 times more likely to be aware of PrEP and 1.6 times more likely to have ever taken PrEP. Those who had ever spoken with a peer educator or outreach worker were nearly twice as likely to be aware of PrEP and 1.6 times more likely to have ever taken PrEP.
Recent engagement with HIV services also increased PrEP awareness and uptake. Participants who had received information on condom use and safe sex in the past year were twice as likely to be aware of PrEP, and those who had received free condoms in the past year were 1.4 times more likely to be aware of PrEP and nearly twice as likely to have ever taken PrEP.
Those answering all HIV transmission questions correctly in the survey were 1.4 times more likely to be aware of PrEP, and those who had ever had an HIV test were twice as likely to be aware of PrEP. However, participants who reported non-injection recreational drug use in the previous six months were half as likely to be aware of or to have ever taken PrEP.
Participants who had been diagnosed with an STI in the previous year were twice as likely to be aware of PrEP and 2.4 times more likely to have every taken PrEP. Those who reported transactional sex in the previous six months were twice as likely to have ever taken PrEP.
The study was not designed to detect causal links, but the researchers noted that this higher uptake among those with recent STIs or sex work could mean that Zimbabwe has done a better job of getting individuals with a greater risk for HIV acquisition on PrEP compared to those with lower risk.
HIV care cascade
Out of all the gay and bisexual men in the study who tested for HIV (n=1,176), 248 were living with HIV – an overall prevalence of 21%. By city, HIV prevalence among gay and bisexual men was 17% in Harare and 23% in Bulawayo. Less than half (48%) reported knowing their status. Of those, 94% reported being on antiretroviral therapy (ART), and 79% of those on ART were virally suppressed, defined in this study as a viral load of less than 1,000.
Of all the transgender women and genderqueer individuals who tested for HIV (n=335), 92 were living with HIV – an overall prevalence of 28%. By city, HIV prevalence among transgender women and genderqueer individuals was 28% in Harare and 25% in Bulawayo. Just over a third (37%) reported knowing their status. Of those, 91% reported being on antiretroviral therapy, and 87% of those on ART were virally suppressed.
Some of the individuals living with HIV reported being HIV-negative or not knowing their status, but their viral load was less than 200. Researchers did another analysis and counted these individuals as aware of their status, on ART, and virally suppressed.
In the second analysis, 73% of gay and bisexual men were aware of their status, of those 97% were on ART and 97% of those on ART were virally suppressed. For transgender women and genderqueer individuals, 58% were aware of their status, 94% of those aware were on ART, and 92% of those on ART were virally suppressed.
Factors associated with status awareness and viral suppression
The researchers performed multivariable logistic regression to identify factors associated with HIV status awareness and viral suppression; all of the following findings are statistically significant with 95% confidence intervals.
Age was a significant factor in both status awareness and viral suppression for gay and bisexual men. Compared to participants aged 35 and older, those aged 18-24 were 66% less likely to be aware of their status and those aged 25-34 were 74% less likely. Participants younger than age 35 were around 65% less likely to be virally suppressed compared to those aged 35 and older.
After controlling for other factors, there were no significant factors related to HIV status awareness among transgender women and genderqueer individuals. Researchers did not complete multivariable analyses to find factors associated with viral suppression for transgender women and genderqueer individuals due to the small sample size.
Less than half of HIV-negative gay and bisexual men, transgender women, and genderqueer individuals were aware of PrEP, and use was low. Those who had larger networks and those who had interacted with peer educators were more likely to be aware of PrEP, underscoring the important role of peers in PrEP scale-up among these populations. Those who had interacted with various HIV services, such as testing and receiving condoms or information on safer sex, also had greater PrEP awareness and/or uptake.
However, the researchers noted that there were still substantial gaps in awareness for those receiving HIV prevention information or being treated for an STI, meaning these touchpoints could be one place to increase PrEP awareness. They called for strengthening PrEP interventions at STI services. They also suggest that awareness messaging may be strengthened by including information on where to access PrEP, PrEP eligibility, and side effect mitigation.
HIV prevalence was high among participants. Awareness of HIV status lagged behind the general population, particularly for transgender women and genderqueer individuals. This demonstrates a need for tailored HIV testing interventions among these key populations.
Rates of ART use and viral suppression were equal to or greater than the general population for those aware of their status. However, young gay and bisexual men may benefit from efforts to increase ART uptake and viral suppression.
Harris T et al. HIV care cascade and associated factors among men who have sex with men, transgender women, and genderqueer individuals in Zimbabwe: findings from a biobehavioural survey using respondent-driven sampling. The Lancet HIV, 9: E182-E201, 2022.
Parmley L et al. Engagement in the pre-exposure prophylaxis (PrEP) cascade among a respondent-driven sample of sexually active men who have sex with men and transgender women during early PrEP implementation in Zimbabwe. Journal of the International AIDS Society, 25: e25873, 2022 (open access).