The Key Populations Research and Implementation Programme focuses on the sexual and reproductive health, HIV prevention and care needs and the broader social welfare of female sex workers in Zimbabwe.

CeSHHAR runs the National ‘Sisters with a Voice’ programme for female sex workers on behalf of Ministry of Health and Child Care and National AIDS Council. Sisters with a Voice is one of the few nationally scaled programmes for sex workers in Africa.

CeSHHAR implements the National Sex Work Programme “Sisters with a Voice” on behalf of the National AIDS Council (NAC) and the Ministry of Health and Child Care (MoHCC). It is supported by Global Fund to Fight AIDS, TB and Malaria (GFATM), USAID and PEPFAR through PSI, the Elton John AIDS Foundation, UNFPA, the Institute for Tropical Medicine – Antwerp and the Bill and Melinda Gates Foundation. In Zimbabwe 54% of female sex workers are HIV infected and incidence is estimated at 10% per annum. Initiated in 2009, Sisters aims to optimise coverage, linkage and retention in HIV prevention and care cascades, reduce HIV and STI acquisition and transmission, improve the mental and physical health of sex workers, reduce the vulnerability of sex workers to violence and to empower the sex worker community and sustain collective capacity for action.

Clinical services

Funding Source: Global Fund to Fight AIDS, TB and Malaria (GFATM), USAID, PEPFAR, Elton John AIDS Foundation

Services are provided through 10 static, 23 highway mobile clinic and 24 local mobile clinic sites across all 10 provinces of Zimbabwe. 6 Static Clinics in major towns: Harare, Mutare, Masvingo, Gweru, Bulawayo and Karoi. 4 Border Static Clinics: Beitbridge, Chirundu, Forbes and Victoria Falls. 23 Highway Mobile sites: Marondera, Juru, Bindura, Murehwa, Chipinge, Rusape, Birchenough Bridge, Checheche, Gwanda, Lupane,Zvishavane, Kadoma, Kwekwe, Gokwe, Magunje, Kariba, Chinhoyi,Hwange, Chiredzi, Chivhu, Ngundu, Jerera, Headlands. 24 local mobile sites within Harare, Bulawayo, Masvingo, Mutare and Gweru. Clinics offer comprehensive sexual and reproductive health services including HIV testing and counselling, linkage to ART, initiation on pre-exposure prophylaxis (PrEP), family planning services, condom promotion and provision and STI diagnosis and treatment.

 

Community outreach and mobilization
Funding Source: GFATM, USAID, PEPFAR, Elton John AIDS Foundation

The sex work programme is peer led with sex workers taking the lead in delivery of HIV
prevention programmes to their peers. Sisters is supported by 337 peer educators and
microplanners who are supervised by 32 Outreach Workers and Peer Educator Supervisors. Peer educators identify sex workers in the community, offer ongoing health education, including condom distribution and demonstration and create demand for  programmes. Through these activities sex workers are encouraged to test for HIV, attend quarterly STI screening visits and adherence support is offered. Community outreach is vital for mapping and validation of hotspots to ensure that the programme is
reaching out to its target population where the need is greatest and is able to respond to changes in the nature and location of sex work.

 

Supporting Sex Worker CBOs
Funding Source: Elton John AIDS Foundation
Funding Period: March 2018 to December 2020

Partnerships for support, strengthening and capacity building are established with four CBOs: Zimbabwe Rainbow Community (ZRC), Women Against All Forms of Discrimination (WAAD), Trans* and Intersex Rising Zimbabwe (TIRZ) and TransSmart. Each CBO received a sub-grant of USD7,500 for 2019 and developed its own budget in line with priority areas identified during capacity assessments. This included supporting key personnel, procurement of equipment, organisational policy development, implementation of activities, advocacy and community mobilisation, particularly in remote areas. Each CBO was provided with a standalone office at the Harare Drop In Centre (DIC). The DIC also provides a shared boardroom and garden where CBOs host meetings and events.

 

Drop in Centres (DIC)
Funding Source: Elton John AIDS Foundation, GFATM
Funding Period: January 2018 to December 2020

There are two DICs in Harare and Bulawayo providing safe spaces for the sex worker community. The DICs provides a safe space for sex workers to rest, socialise, discuss issues and organise. Computers and internet connectivity are available for the sex worker community to use.

 

Mental Health and the Friendship Bench
Funding Source: USAID through PSI
Funding Period: October 2019 to September 2020

In response to the high prevalence of common mental disorders (CMD) amongst sex workers (SAPPH-IRe endline 2016 1219/2883 – 41.3%, Size Estimation 2017 1389/2707 – 48.3%), CeSHHAR has partnered with the Friendship Bench Project to pilot the Friendship Bench within the Sisters’ programme. The Friendship Bench is problem solving therapy delivered by trained lay health workers. Fifteen lay mental health counsellors – Friendship Bench Buddies – were trained in November 2019 by the Friendship Bench Project following a Theory of Change workshop to determine how the intervention should be delivered. The bench will piloted will be in Harare at Mbare Hostels Clinic and at the DIC from January 2020.

 

Empowering sex workers in Zimbabwe through self-help groups
Funding Source: Bill and Melinda Gates Foundation through LSTM
Funding Period: November 2016 to May 2019

• We explored the feasibility and applicability of self help groups (SHG) to empower FSW
• We hypothesized that SHG would empower FSW financially, socially and psychologically
• FSW involved in SHG were drawn from a pilot of systematised peer led outreach (microplanning) which is data guided and seeks to improve FSW linkages with health services.
• Harare was divided into 50 hotspots based on the volume of sex work in an area and 50
empowerment workers were each responsible for one hotspot, and a caseload of 50 SW.
The SHG and microplanning pilot was conducted between April 2017 and May 2019.
1. 55 SHG were running by end of April 2019, 16 running with minimal support from the
programme.
• Popular activities in SHG were, ISALs, establishment of child care services, grocery
rounds, general buying and selling of goods
2. A total of 570 FSW were involved in SHG and all linked to health services
3. 14 SHG were trained in Internal Saving and Lending Scheme (ISALs)- 240 FSW benefited.
4. 2568 SW were micro-planned enrolled into micro planning and tracked according to their risk status, 951 (37%) linked to health services.

 

Educational Assistance Program
Funding Source: Institute of Tropical Medicine, Antwerp
Funding Period: October 2017 to December 2021

Young women who sell sex (YWSS) in Zimbabwe have frequently had to drop out of school as a result of financial/social shocks further increasing their vulnerability to HIV as well as reducing their opportunity for alterna?ve/future employment. As a structural intervention, second chance education could potentially lessen the vulnerability of HIV acquisition among YWSS. Second Chance Education is offered through two pathways:
i. Second Chance Secondary Education- beneficiaries are integrated into mainstream
education
ii. Vocational training-short courses mostly for a dura?on of 3 to 10 months with work
placement
• The package of support includes school fees, uniforms, stationery and transport money
where applicable.
• In 2019 stipends were added to support basic expenses such as rentals for beneficiaries
who:
– Maintain an attendance record of at least 80%
– Participate in self help groups and
– Attend quarterly clinic visits
• Between May 2018 to December 2019 the programme cumulatively enrolled 159
beneficiaries
• 4 Self help groups were established ( Hopely, Stoneridge, Epworth & Mbare)
• 22 YWSS sat for public examinations ( 5 Advanced level & 17 Ordinary level)
• 43 YWSS completed vocational training courses.

 

Spotlight – addressing gender based violence
Funding Source: UNFPA
Funding Period: September 2019 to December 2021

Spotlight initiatives are implemented to sensitise key populations and the general community on sexual and gender based violence (SGBV). Implementation is through key population led community based organisations (CBOs). These include Zimbabwe Rainbow Community (ZRC), Women Against All forms of Discrimination (WAAD), Trans and Intersex Rising Zimbabwe (TIRZ) and TransSmart.
The Spotlight Initatve is implemented through a number of activities:
• Community activism of key population-led CBOs advocating for prevention of GBV
against male, female, trans* sex workers including
– Commemoration of 16 days of activism in five priority provinces
– CBOs campaigns around their commitment to combating SGBV
– Social fairs to sensitise communities on public health issues
• CBO Capacity building
– Training of CBO members as paralegals
– Training of CBO members as case care workers
• Engagement with YWSS ( 15-24 yrs.)
– Self-help groups
– Educational Assistance- vocational training
• Young Sisters Community mobilisation meetings
– Interactive health education sessions with young sex workers

 

Addressing sex worker mobility
Funding Source: PEPFAR/USAID
Funding Period: October 2019 to September 2021

Mobility among sex workers is high with movement for work and non-work reasons. A recent systematic review found that female sex worker mobility was associated with delayed access to HIV care and treatment interruptions, and this varied by context and outcome. In Zimbabwe, among a representative sample of 2,883 sex workers from 14 sites, evidence suggested reduced viral suppression among FSW working away from ‘home’ for more than 31 days at mines/farms/growth points. Overall 17% of all FSW reported travelling outside Zimbabwe. Border crossing points are sex work hotspots attracting high numbers of sex workers, providing the opportunity to reach high numbers of FSW and link them to services, including those who are crossing into neighboring countries to work. Mobile populations including sex workers often face challenges in accessing care when abroad resulting in treatment interruptions, loss to follow-up and treatment failure. An intervention to strengthen access to comprehensive HIV services among mobile Female Sex Workers across national borders in Zimbabwe, Botswana,
Mozambique and Zambia is being implemented funded by PEPFAR through USAID and
supported by the Ministry of Health and Child Care, National AIDS Council and PSI Zimbabwe.

It is supported by enhanced data monitoring to op?mise uptake of prevention and care and ensure continued engagement undisrupted by travel. Improvement of HIV services for mobile populations will be achieved through:
1. A cross-border and regional referral system implemented through a coordinated
approach involving all stakeholders in Zimbabwe, Botswana, Mozambique and Zambia.
2. Discussions about travel and travel preparedness forming a routine part of all
consultations including provision of ‘safe travel packs’ containing buffer supplies of ART
(or potentially PrEP) plus a transfer letter.
3. Measurement of successful transfer/linkage and retention

 

Building resilience through self-help groups for adolescent sex workers with young children in Zimbabwe
Funding Source: BMGF Grand Challenges Programme
Funding Period: January 2018 to December 2019

Programme highlights
• 7 self-help groups established for young women aged 16-19, who were pregnant or
new mothers, and were involved in selling sex
• 65 women (71%) retained through to the end of the programme
• 72% attended half or more of the 12 participatory sessions, 67% attended at least 8,
and 13% completed all sessions
• Interactive activities covered healthy pregnancy and parenting, sexual and reproductive health, emotional and mental well-being, managing risks, and planning for the future
• 14 young women were referred into vocational training to continue their education,
taking courses in nursing assistance, hotel and catering, and beauty therapy /
hairdressing

AMETHIST

Differentiated Prevention and Care to Support the Virtual Elimination of risk of acquisition and or transmission of HIV Among Sex Workers in Southern Africa – AMETHIST (Adapted Microplanning: Eliminating Transmissible HIV In Sex Transactions)

Funding Source: Wellcome Trust

Funding Period: October 2019-December 2024

The overall goal for this study is to develop and evaluate a micro-planning intervention for Africa, considering the heterogeneity of FSWs and their experiences and deepen the understanding of how to optimise the implementation and determine population impact and cost-effectiveness.

The study is being conducted at the 57 static and outreach sites where the National Sex Work Program is being implemented. Findings will help to inform health care policy in Africa. The study has several sub-studies that will be conducted at different time points over the course of five years:

  1. The study will commence with an expanded analysis of program data. Since its inception in 2009, the Sisters with a Voice Program has been collecting program data from program beneficiaries for different purposes, from different locations and at different time periods. We will conduct an analysis of this program data and findings will be used to refine the intervention.
  2. A series of quantitative and qualitative sub-studies will be conducted to explore and understand how sex workers transition in and out of sex work and what are the implications of these transitions on their engagement into prevention, treatment, care and support services.
  3. We are evaluating the use of microplanning as an HIV prevention and care differentiated community support model for FSWs in Zimbabwe in an impact evaluation. The impact evaluation is nested within the Sisters with a Voice Program. In this study 22 outreach sites were randomised to either receive the enhanced microplanning intervention and self-help groups or standard care. Microplanning activities commenced in June 2019.
  4. We will refine an existing individual based micro simulation model to predict the impact and cost-effectiveness of intervention to increase engagement with treatment and care services
  5. In order to understand whether findings obtained from the Zimbabwean context can be translated into other African settings, we will describe the patterns and life course of sex work in Malawi and rural KwaZulu-Natal (KZN), South Africa, where the contexts of sex work are different from Zimbabwe.

 

Engaging Young People in the Development of Digital Mental Health Innovation in Africa

Funding Source: UKRI

Funding Period: May 2020 – Apr 2021

 The chief aim is to develop a robust framework for responsible and relevant digital mental health interventions for young people in African countries. The transdisciplinary network will have a group of young people at its core, who will co-create all its work and outputs.

Project activities will include:

  • Intensive training and capacity-building opportunities for early career researchers (ECR) and young people (e.g. workshops; visiting scholar programmes);
  • Meetings and workshops to facilitate the transfer of knowledge among stakeholders;
  • Literature reviews to critically assess and synthesize existing work, identify gaps, and formulate research questions
  • Community engagement to inform empirical questions
  • Young people to co-create a sustainable engagement strategy to involve-ing other young people, with a focus on representation from vulnerable groups, such as Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, and Intersex.(LGBTQ+); sexual violence survivors; those living with HIV/AIDS

Young people will be at the core of the Network, integrated with expert groups of researchers in ethics and social sciences; service providers (app developers, mental health practitioners and researchers); religious congregations; policy and governance decision-makers. This will ensure that the network outputs reflect the needs of young people and that the framework is scalable and sustainable as it is co-produced with young people, researchers, service providers, and policy makers.

 

Pilot study to assess the feasibility and utility of recent infection testing for HIV within an outreach programme for female sex workers in Zimbabwe
Funding Source: Bill and Melinda Gates Foundation
Funding Period: October 2019 to December 2022

The overall goal of this study is to distinguish between recent and long-standing HIV infection among female sex in Zimbabwe. The first phase of the pilot study commenced in June 2018 and was completed in 2019. An analysis of DBS samples collected from participants from previous studies was conducted. In addition samples were collected prospectively from newly diagnosed HIV positive sex workers at six National Sex Work static sites: Harare, Bulawayo, Gweru, Karoi, Masvingo and Mutare. A total of 103 (4.12%) from 2499 analysed DBS samples were recently infected . Factors associated with recent infection after adjustment were age at start of sex work (p<0.001), STI symptoms in past year . Of the 366 newly diagnosed HIV positive FSW, 33
(10.5%) had been recently infected. We received additional funding to recruit an additional 600 women in 2020 and we are anticipating to repeat recency testing annually until 2022. The study will now be extended from the initial 6 to all the 57 static and outreach sites and will include male and transgender key populations in addition to female sex workers.

 

Improving access to HIV services for sex workers in Zimbabwe: field study and mathematical modeling
Funding source: AIDSfonds through Dept. of Public Health, Erasmus Medical Center
Rotterdam, The Netherlands
Funding period: December 2017 to January 2022

The main objective of this study is to determine the impact of improved access to services for key populations in Zimbabwe including female , male and transgender sex workers through mathematical modeling and secondary data analyses. The project, a collaborative research initiative between CeSHHAR and the Department of Public Health, Erasmus Medical Center Rotterdam, The Netherlands is analyzing routine data collected for the National Sex work Program on female sex workers, male and transgender sex workers.
To date, a total of 100 male and transgender sex workers have been enrolled in the study.
Progress towards developing a mathematical model to allow for incorporating male and
transgender sex workers as part of the HIV transmission dynamics has been made.

 

Impact Evaluation of DREAMS in Zimbabwe –focusing on impact in young women who sell sex

Funding Source: Bill and Melinda Gates Foundation subcontracted by London School of Hygiene and Tropical Medicine

Funding Period: January 2016 to December 2019

DREAMS is a combined package of interventions that aims to reduce the risk of HIV among the most vulnerable adolescent girls and young women (AGYW). The package combines strategies to reduce the biological risk of infection, through the provision of condoms, STI treatment and oral pre-exposure prophylaxis (PrEP) to AGYW at highest risk of infection. DREAMS encourages AGYW to use and access these services through the provision of socioeconomic empowerment interventions, including transport vouchers and cash transfers, with strategies to change community-level norms around violence against AGYW and access to school, social and financial assets. This impact evaluation aims to estimate the impact of the DREAMS combined package (which includes an offer of PrEP) on the risk of HIV infection among AGYW at highest risk of HIV in Zimbabwe. The overall aim of this impact evaluation is to estimate the impact of the DREAMS combination package of HIV prevention interventions, which includes an offer of PrEP, on HIV incidence among YWSS in Zimbabwe, including young women who engage in transactional sex and therefore at high risk of entry into sex work.