Towards ending HIV in Zimbabwe through focusing on improving targeting of HIV testing and uptake of HIV prevention in adolescent girls and young women

在津巴布韦，艾滋病毒仍然是导致死亡的主要原因。2016年，七分之一的成年人感染了艾滋病毒。为了到2030年结束作为公共卫生威胁的艾滋病毒流行，联合国艾滋病毒/艾滋病联合规划署（艾滋病规划署）设定了以下目标：(a) 95%的艾滋病毒感染者得到诊断，(b) 95%的被诊断接受抗逆转录病毒治疗的人得到诊断，以及(c) 95%接受抗逆转录病毒治疗的人病毒载量无法检测（“抑制”）。这些目标的依据是，经抗逆转录病毒治疗和抑制的艾滋病毒感染者的预期寿命接近正常，不能将病毒传播给他人。在津巴布韦，尽管2007年至2017年期间艾滋病毒检测次数增加了四倍，但2016年这一比例分别为：(a) 73%、(b) 87%和(c) 86%。这在青少年和年轻人中尤其低。此外，所有艾滋病毒检测结果呈阳性的比例一直在下降，确定每一个新病例的费用更高。因此，津巴布韦正在转向差异化的艾滋病毒检测战略，针对艾滋病毒风险较高的亚人群，并使用一系列检测战略(例如：“指数检测”，即向被诊断为艾滋病毒感染者的家庭、家庭成员或伴侣提供艾滋病毒检测；自我测试)。然而，这种转变的影响尚不清楚，就像它是否物有所值一样。少女和年轻妇女（AGYW； 15-24岁）受到艾滋病毒的影响不成比例。世界卫生组织（世卫组织）建议将暴露前预防（PrEP；在未感染艾滋病毒的人群中使用特定抗逆转录病毒药物以预防艾滋病毒感染）作为艾滋病毒高风险人群（包括AGYW）的额外选择。在津巴布韦，PrEP已经开始推广，但目前只有4%的用户是AGYW（不包括那些报告为性交易的人）。需要一种方法来增加高危AGYW人群的PrEP使用。正在进行评估其他预防PrEP制剂（长效注射剂、植入物、其他抗逆转录病毒药物和与避孕药具联合使用）的安全性和有效性的研究。然而，关于AGYW对不同PrEP属性的偏好知之甚少，也没有关于如何确保这一群体的高吸收率和足够支持的信息。这项研究的总体目标是填补这些空白。这将通过以下方式实现：a.与津巴布韦卫生和儿童保管部及其他利益攸关方密切合作，确定艾滋病毒检测战略的最佳组合，在现有预算范围内最大限度地提高健康水平，评估其影响（在艾滋病毒感染、发病率和死亡率方面），以及预计这种组合是否能实现到2030年95%的艾滋病毒感染者得到诊断的目标。这项工作将利用对津巴布韦已经收集的数据进行分析后得出的数学模型进行。与AGYW共同制定针对有需要的AGYW的PrEP实施干预措施，吸引他们使用PrEP，并在使用PrEP时为他们提供支持，并有可能提供物有所值的服务。这将通过定性和定量方法（AGYW调查）和数学建模来实现。如果开发的PrEP实施干预措施有可能提供物有所值且价格合理，则将在5-7年级的随机试验中对其进行评估。这项研究将由伦敦大学学院（UCL）传染病建模和生物统计学讲师Valentina Cambiano博士领导，并将汇集来自伦敦大学学院、利物浦热带医学院、津巴布韦和津巴布韦性健康和艾滋病毒/艾滋病研究中心的专家以及国际决策者。需要这项研究来解决艾滋病毒负担高的低收入和中等收入国家所面临的问题。

In Zimbabwe HIV remains the leading cause of death. In 2016, 1 in 7 adults were living with HIV. In order to end the HIV epidemic as a public health threat by 2030, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set the targets of: (a) 95% of people living with HIV (PLWH) being diagnosed, (b) 95% of those diagnosed on antiretroviral therapy (ART), and (c) 95% of those on ART with an undetectable viral load ("suppressed"). These targets were based on the rationale that PLWH diagnosed, on ART and suppressed have near normal life-expectancy and cannot transmit the virus to others. In Zimbabwe in 2016 these were: (a) 73%, (b) 87% and (c) 86%, respectively, despite the number of HIV tests having increased by four-fold between 2007 and 2017. This is particularly low among adolescents and young people. In addition, the proportion of all HIV tests with a positive result has been declining, with a higher cost to identify each new case. For this reason, Zimbabwe is shifting to differentiated HIV testing strategies, targeting sub-populations at higher risk of HIV and using a range of testing strategies (e.g. "index testing", whereby household, family members or partners of people diagnosed with HIV are offered an HIV test; self-testing). However, the impact of this shift is unclear, as is whether it offers value for money.Adolescent girls and young women (AGYW; aged 15-24) are disproportionately affected by HIV. The World Health Organization (WHO) recommends Pre-Exposure Prophylaxis (PrEP; use of specific antiretrovirals in people without HIV to prevent HIV infection), as an additional choice for people at substantial risk of HIV (including AGYW). In Zimbabwe PrEP roll out has started, but only 4% of current users are AGYW (not counting those reporting as selling sex). An approach to increase PrEP use among those AGYW most at risk is required. Studies evaluating the safety and efficacy of additional PrEP formulations (long-acting injectables, implants, other antiretrovirals and in combination with contraceptives) are ongoing. However, little is known about preferences of AGYW for different PrEP attributes, nor is there information on how to ensure high uptake and sufficient support among this group.The overall aim of this fellowship is to fill these gaps. This will be achieved by: a. working closely with the Zimbabwe Ministry of Health and Child Care and other stakeholders to identify the optimal combination of HIV testing strategies that maximise health, within the budget available, to assess its impact (in terms of HIV infections, morbidity and mortality) and whether this combination is predicted to achieve the target of 95% of PLWH being diagnosed by 2030. This will be performed using a mathematical model informed by analysis of data already collected in Zimbabwe.b. co-developing with AGYW a PrEP implementation intervention for AGYW who need it, that attracts them to PrEP, and supports them while taking PrEP, with the potential to offer value for money. This will be achieved using qualitative and quantitative methods (survey of AGYW) and mathematical modelling.If the PrEP implementation intervention developed has the potential to offer value for money and being affordable, it will be then evaluated in a randomised trial in Years 5-7. The research will be led by Dr Valentina Cambiano, Lecturer in Infectious Disease Modelling and Biostatistics at University College London (UCL) and will draw together experts from UCL, the Liverpool School of Tropical Medicine and the Centre for Sexual Health and HIV/AIDS Research Zimbabwe and Zimbabwe and international policy makers. This research is required to address questions low- and middle- income countries with a high HIV burden are facing.