In Zimbabwe, half of the districts had high (>90%) ART coverage, thus achieved the 2nd UNAIDS target. However, there is substantial within-country variation in terms of HIV prevalence, HIV testing coverage, HIV testing yield, linkage to ART, and ART coverage. We proposed four typologies of districts with gaps along the HIV cascade, for which district-specific recommendations can be formulated.
Suboptimal HIV testing target achievement and suboptimal linkage to ART
In 4 districts with suboptimal ART coverage and both suboptimal HIV testing achievement and linkage to ART, both the HIV prevalence and the HIV testing yield was above average. Hence, there is an important unmet need. Therefore, HIV testing services should become more widely available. Widespread door-to-door HIV testing has been shown to increase uptake of HIV testing substantially and should be considered as a priority . In addition, strategies linking those who tested positive to ART should be strengthened (debated in the next paragraph).
High testing target achievement and suboptimal linkage to ART
Eighteen districts with insufficient ART coverage that meet their HIV testing target but with suboptimal linkage should assess if strategies known to improve linkage to care and ART initiation are in place. These strategies include same-day ART initiation, community (home-based) ART initiation, decentralization of ART services to the primary health care level, and integration of HIV care in other health care services [13–17]. Linkage to ART should be regularly assessed at the health facility level. Those diagnosed with HIV but not started on ART should be tracked. Consent for tracking should be incorporated into the testing strategy . Patients diagnosed at higher level referral health facilities should be initiated on ART before down referral to lower-level health facilities for follow up, with tracking of arrival after referral . Some districts may have specific challenges. Poor linkage to ART around Kwekwe and the surrounding districts might be explained by the presence of illegal artisanal miners in the region. Illegal artisanal miners are highly mobile, and strategies to link and retain these highly mobile populations should be identified [20,21]. Also, in districts bordering Zambia and Mozambique (Centenary, Mudzi and Nyanga), the poor linkage may be due to patients crossing the border due to the economic challenges in Zimbabwe. The Southern African Development Community (SADC) HIV and AIDS Cross Border Initiative should be fully implemented to enable the provision of care and tracking of such patients [22–24].
High testing target achievement and high linkage to ART
Some districts with low ART coverage are meeting their HIV testing targets and have high linkage to ART. Other indicators may assist the identification of a district-specific strategy. If the prevalence and HIV testing yield are lower than average, HIV testing may need to be delivered in a more targeted manner. Health facility-based strategies in combination with community testing in high-risk groups, maybe most efficient. Health facility-based strategies that have worked elsewhere include index case testing, targeting sexual partners and HIV-exposed infants, and intensified provider-initiated testing (iPITC) [25–31]. Community testing should prioritize subgroups with a higher prevalence. Key populations and hot spots identified from a mapping exercise conducted in Zimbabwe may guide programming . Social network testing, using peer educators, can be a useful tool to reach some of the key populations .
Suboptimal HIV testing target achievement and high linkage to ART
There are two districts with suboptimal ART coverage that have suboptimal HIV testing target achievement but high linkage to ART. In both, the HIV prevalence and testing yield are higher than average. Henceforth, HIV testing strategies recommended for high prevalence settings, discussed above, should be considered.
In conclusion, there is substantial within-country variation in terms of HIV prevalence, HIV testing target achievement, HIV testing yield, linkage to ART, and ART coverage. Hence, “one size fit all” approach will unlikely result in achieving the next UNAIDS 95-95-95 targets by the end of 2030. District-level mapping of uncovered needs and gaps along the HIV cascade of care is needed, particularly for districts with low ART coverage.