District based HIV testing strategies
Of the 62 districts in Zimbabwe 38% were in the low HIV prevalence /low antiretroviral therapy coverage, 34% in low HIV prevalence /high antiretroviral therapy coverage, 15% in high HIV prevalence/high antiretroviral therapy coverage and 13% in high HIV prevalence/low antiretroviral therapy coverage categories (Fig. 1).
Given these important differences, we recommend adapting strategies to district specific needs, based on HIV prevalence and ART coverage data. To identify PLHIV in districts with a low HIV prevalence and a low ART coverage (Rushinga, Harare, Uzumba-Maramba-Pfungwe, Mbire, Centenary, Binga, Gokwe-North and Gokwe-South) HIV testing strategies should be targeted to maximize the yield. In these low HIV prevalence, low ART coverage districts, health facility based strategies will be most efficient in combination with community testing in high risk groups. Health facility based strategies include index case testing, targeting sexual partners and HIV exposed infants, and intensified provider initiated testing (iPITC). Studies have shown index case testing as an effective and cost effective strategy in identifying PLHIV [8–12]. iPITC should be offered to all those admitted and to those seeking ambulatory health care at the general consultation or at specialized services, such as the tuberculosis, antenatal care, family planning, sexually transmitted infections, gender based violence, rape victims, orphans and vulnerable children . All eligible clients should be actively linked to HIV testing services . Community testing should prioritize subgroups with a higher prevalence, such as key populations, and hot spots identified from a mapping exercise conducted in Zimbabwe should guide programming . Social network testing using peer educators can be a useful tool to reach some of the key populations  .
In districts with a high HIV prevalence but a low ART coverage (such as Umuguza, Bubi, Zvishavane, Nkayi, Matobo, Mberengwa), access to HIV testing services should be prioritized. HIV testing services should be widely available, especially within the community (for instance door to door home testing or outreach testing in schools, workplaces, places of worship, parks, bars, market place, galas and other venues) to increase access . Innovative strategies, involving communities and clients, may work best in high prevalence settings. Despite them being unpopular, for these districts with a high prevalence but struggling to meet ART coverage targets it’s still worth to invest in wide spread mop-up community HIV testing campaigns with a leading role for health care workers . These HIV testing campaigns can be conducted as part of health fairs or multi-disease screening campaigns/events to reduce stigma associated with HIV testing [18, 19]. Studies have shown a high interest in HIV self-testing from a wide range of subgroups, including sero-discordant couples, men, young people, sex workers and their partners . Scale- up of HIV self-testing should be supported with procedures for confirmatory testing and linkage to care for those diagnosed HIV positive .
In districts which have already achieved ART coverage above 90%, i.e. those with low HIV prevalence/high ART coverage (such as Chegutu, Seke, Gweru, Mazowe, Marondera) and high HIV prevalence/high ART coverage (such as Beitbridge, Hwange, Mangwe, Lupane, Gwanda), HIV testing strategies should be more targeted. Most of these districts have almost reached saturation with HIV testing i.e. few remain untested hence the need to have more targeted HIV testing strategies.
In conclusion, district level mapping of uncovered needs may result in a more efficient use of limited resources to achieve the 1st 90. District based differentiated HIV testing strategies should be implemented based on HIV prevalence and ART coverage. Districts with low HIV prevalence and low ART coverage should employ targeted HIV testing approaches while those with high HIV prevalence and low ART coverage should focus on expanding access to HIV testing to the community. Districts with already high ART coverage should move to targeted HIV testing so that the few yet to be tested are reached. Further exploration to assess other possible factors across the cascade of care is warranted in the affected districts.