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BACKGROUND:\ud National-level population size estimates (PSEs) for hidden populations are required for HIV programming and modelling. Various estimation methods are available at the site-level, but it remains unclear which are optimal and how best to obtain national-level estimates.\ud \ud SETTING:\ud Zimbabwe METHODS:: Using 2015-2017 data from respondent-driven sampling surveys (RDS) among female sex workers (FSW) aged 18+ years, mappings, and programme records, we calculated PSEs for each of 20 sites across Zimbabwe, using up to three methods per site (service and unique object multipliers, census, and capture-recapture). We compared estimates from different methods, and calculated site medians. We estimated prevalence of sex work at each site using census data available on the number of 15-49 year-old women, generated a list of all 'hotspot' sites for sex work nationally, and matched sites into strata in which the prevalence of sex work from sites with PSEs was applied to those without. Directly and indirectly estimated PSEs for all hotspot sites were summed to provide a national-level PSE, incorporating an adjustment accounting for sex work outside hotspots.\ud \ud RESULTS:\ud Median site PSEs ranged from 12,863 in Harare to 247 in a rural growth-point. Multiplier methods produced the highest PSEs. We identified 55 hotspots estimated to include 95% of all FSW. FSW nationally were estimated to number 40,491, 1.23% of women aged 15-49 years, (plausibility bounds 28,177-58,797, 0.86-1.79%, those under 18 considered sexually exploited minors).\ud \ud CONCLUSION:\ud There are large numbers of FSW estimated in Zimbabwe. Uncertainty in population size estimation should be reflected in policy-making.

Young women who sell sex (YWSS) in Southern Africa are highly vulnerable to HIV, as the risks of being young and female in a high prevalence setting coalesce with those of commercial sex. YWSS are less able to negotiate safe sex, more likely to have higher risk partners, and less likely to use available health services compared to older sex workers. In Zimbabwe’s national HIV programme for sex workers, fewer than 1% of clients were 15–29. We developed monthly interactive workshops for YWSS based on an Activity Pack consisting of 21 sessions organised into six modules. The aim was to encourage YWSS’ interaction with each other, build their trust, confidence and skills, and encourage uptake of clinical services. We conducted a process evaluation to assess programme strengths, identify challenges, and recommend changes. This paper presents findings synthesising programme records with qualitative data and discusses feasibility, acceptability, and outputs during the pilot phase. In total, 143 YWSS attended meetings and most were from the target 15–19-year-old age group. Participants enjoyed the sessions and reported improved cooperation, willingness to negotiate with clients, and self-reflection about their futures. Staff found facilitating sessions easy and activities clear and appropriate. Challenges included identifying appropriate referrals, initial recruitment of women in some sites, and managing participants’ requests for financial compensation. The number of clients aged 15–19 increased at sex worker clinics in all sites. This programme is the first to target YWSS in Zimbabwe to address their disproportionately low service use. It proved feasible to staff and acceptable to participants over a one-year period. Given enhanced vulnerability of YWSS, this programme provides one workable model for reaching this underserved group.

BACKGROUND: HIV epidemiology and intervention uptake among female sex workers (FSW) in sub-Saharan Africa remain poorly understood. Data from outreach programmes are a neglected resource. METHODS: Analysis of data from FSW consultations with Zimbabwe's National Sex Work programme, 2009-14. At each visit, data were collected on socio-demographic characteristics, HIV testing history, HIV tests conducted by the programme and antiretroviral (ARV) history. Characteristics at first visit and longitudinal data on programme engagement, repeat HIV testing and HIV sero-conversion were analysed using a cohort approach. RESULTS: Data were available for 13360 women, 31389 visits, 14579 reported HIV tests, 2750 tests undertaken by the programme and 2387 reported ARV treatment initiations. At first visit, 72% of FSW had tested for HIV; 50% of these reported being HIV-positive. Among HIV-positive women, 41% reported being on ARV. 56% of FSW attended the programme only once. FSW who had not previously had an HIV positive test had been tested within the last 6 months 27% of the time during follow up. After testing HIV-positive, women started on ARV at a rate of 23 / 100 person years of follow-up. Among those with two or more HIV tests, the HIV sero-conversion rate was 9.8 / 100 person years of follow-up (95% confidence interval 7.1-15.9). CONCLUSIONS: Individual-level outreach programme data can be used to estimate HIV incidence and intervention uptake among FSW in Zimbabwe. Current data suggest very high HIV prevalence and incidence among this group and help identify areas for programme improvement. Further methodological validation is required.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially.

BACKGROUND\ud Strengthening engagement of female sex workers with health services is needed to eliminate HIV. We assessed the efficacy of a targeted combination intervention for female sex workers in Zimbabwe.\ud \ud METHODS\ud We did a cluster-randomised trial from 2014 to 2016. Clusters were areas surrounding female sex worker clinics and were enrolled in matched pairs. Sites were randomly assigned (1:1) to receive usual care (free sexual-health services supported by peer educators, including HIV testing on demand, referral for antiretroviral therapy [ART], and health education) or an intervention that supported additional regular HIV testing, on-site initiation of ART, pre-exposure prophylaxis, adherence, and intensified community mobilisation. The primary outcome was the proportion of all female sex workers with HIV viral load 1000 copies per mL or greater, assessed through respondent-driven sampling surveys. We used an adapted cluster-summary approach to estimate risk differences. This trial is registered with Pan African Clinical Trials Registry, number PACTR201312000722390.\ud \ud RESULTS\ud We randomly assigned 14 clusters to usual care or the intervention (seven in each group). 3612 female sex workers attended clinics in the usual-care clusters and 4619 in the intervention clusters during the study. Half as many were tested (1151 vs 2606) and diagnosed as being HIV positive (546 vs 1052) in the usual-care clusters. The proportion of all female sex workers with viral loads of 1000 copies per mL or greater fell in both study groups (from 421 [30%] of 1363 to 279 [19%] of 1443 in the usual-care group and from 399 [30%] of 1303 to 240 [16%] of 1439 in the intervention group), but with a risk difference at the end of the assessment period of only -2·8% (95% CI -8·1 to 2·5, p=0·23). Among HIV-positive women, the proportions with viral loads less than 1000 copies per mL were 590 (68%) of 869 in the usual-care group and 588 (72%) of 828 in the intervention group at the end of the assessment period, adjusted risk difference of 5·3% (95% CI -4·0 to 14·6, p=0·20). There were no adverse events.\ud \ud INTERPRETATION\ud Our intervention of a dedicated programme for female sex workers led to high levels of HIV diagnosis and treatment. Further research is needed to optimise programme content and intensity for the broader population.\ud \ud FUNDING\ud UN Population Fund (through Zimbabwe's Integrated Support Fund funded by UK Department for International Development, Irish Aid, and Swedish International Development Cooperation Agency).

INTRODUCTION: Female sex workers (FSW) in sub-Saharan Africa have a higher prevalence of HIV than other women of reproductive age. Social, legal, and structural barriers influence their access to care. Little is known about the HIV diagnosis and care cascade in most countries in Southern Africa. We aimed to describe the HIV diagnosis and care cascade among FSW in Zimbabwe. METHODS: We conducted cross-sectional respondent driven sampling (RDS) surveys of FSW in 14 sites across Zimbabwe as the baseline for a cluster-randomised controlled trial investigating a combination HIV prevention and care package. We administered a questionnaire, tested women for HIV and measured viral load. We report the mean, minimum, and maximum respondent-driven sampling-2 weighted site values. RESULTS: The survey included 2722 women, approximately 200 per site. The mean HIV prevalence was 57.5% (42.8-79.2 site minimum and maximum). Of HIV-positive women, 64.0% (51.6-73.7) were aware of their status, 67.7% (53.4-84.1) of these reported taking antiretroviral therapy, and 77.8% (64.4-90.8) of these had a suppressed HIV viral load (

OBJECTIVES To determine the HIV prevalence and extent of engagement with HIV prevention and care among a representative sample of Zimbabwean sex workers working in Victoria Falls, Hwange and Mutare. DESIGN Respondent driven sampling (RDS) surveys conducted at each site. METHODS Sex workers were recruited using respondent driven sampling with each respondent limited to recruiting 2 peers. Participants completed an interviewer-administered questionnaire and provided a finger prick blood sample for HIV antibody testing. Statistical analysis took account of sampling method. RESULTS 870 women were recruited from the three sites. HIV prevalence was between 50 and 70%. Around half of those confirmed HIV positive were aware of their HIV status and of those 50-70% reported being enrolled in HIV care programmes. Overall only 25-35% of those with laboratory-confirmed HIV were accessing antiretroviral therapy. Among those reporting they were HIV negative, 21-28% reported having an HIV test in the last 6 months. Of those tested HIV negative, most (65-82%) were unaware of their status. Around two-thirds of sex workers reported consistent condom use with their clients. As in other settings, sex workers reported high rates of gender based violence and police harassment. CONCLUSIONS This survey suggests that prevalence of HIV is high among sex workers in Zimbabwe and that their engagement with prevention, treatment and care is sub-optimal. Intensifying prevention and care interventions for sex workers has the potential to markedly reduce HIV and social risks for sex workers, their clients and the general population in Zimbabwe and elsewhere in the region.