In Zimbabwe, half of the districts had high (>90%) ART coverage, and thus had achieved the second target of the UNAIDS 90-90-90 targets . However, substantial within-country variations in terms of HIV prevalence, HIV testing coverage, HIV testing yield, linkage to ART and ART coverage were observed. We have proposed four categories of districts according to gaps along the HIV cascade, for which district-specific recommendations can be formulated.
Suboptimal HIV testing target achievement and suboptimal linkage to ART
In the four districts with both suboptimal HIV testing achievement and linkage to ART, both the HIV prevalence and the HIV testing yield were above average, highlighting an important unmet need for HIV testing services. Therefore, HIV testing services should become more widely available. It has been seen that widespread door-to-door HIV testing substantially increases the acceptance of HIV testing and should be considered as a priority . In addition, strategies linking those who tested positive to ART should be strengthened (elaborated below).
High testing target achievement and suboptimal linkage to ART
Eighteen districts with suboptimal ART coverage that achieved their HIV testing target but with suboptimal linkage to ART 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, decentralisation 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 who are diagnosed with HIV but have not been 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 as a result of 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
Six districts with suboptimal ART coverage achieved their HIV testing targets and had high linkage to ART. In such a scenario, other indicators may assist in the formulation 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 may be 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 and counselling (iPITC) [25–31]. Community testing should prioritise subgroups with a higher prevalence. Key populations and hotspots 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 were two districts with suboptimal ART coverage that had suboptimal HIV testing target achievement but with high linkage to ART. In both, the HIV prevalence and testing yield were higher than average. Hence, 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, a “one size fits all” approach is unlikely to 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 suboptimal ART coverage.
Our study is among the first to assess the performance across the HIV care cascade at the sub-national level. To validate our findings, we compare data from a variety of sources. However, there are limitations due to the cross-sectional design of our study. Crossover of patients between prior or later years with 2018 may have occurred, for instance, when patients diagnosed in 2017 started ART in 2018, and those diagnosed in 2018 started ART in 2019. The district HIV testing targets were calculated by using the percentage of the number of PLHIV per district to distribute the national HIV testing target without considering the context and performance of each district cascade of care. The MoHCC have since started estimating district yearly HIV testing targets by taking into consideration the context and district-specific parameters. Moreover, district-level data on the third “90” from the UNAIDS 90-90-90 targets, i.e. viral suppression, was unavailable. Previous studies showed that the retention on ART was high, while access to viral load monitoring and viral load suppression remained suboptimal [33–35].