A detailed geographic analysis of Zimbabwe’s HIV epidemic indicates the greatest concentrations of people living with HIV who lack treatment are in the country’s main cities and urban settlements.
The micro-level data, generated to identify areas in the country where targeted HIV prevention and care services could have the greatest impact, has earmarked Bulawayo, Harare, Ruwa and Chitungwiza as priority areas.
Zimbabwe has one of the worst HIV epidemics in the world. Around 13% of adults are living with HIV and more than 41,000 people become newly infected every year. Despite this, the country has made significant progress towards UNAIDS 90-90-90 targets. According to Zimbabwe’s Ministry of Health and Child Care, 85% of people living with HIV are aware of their status, 95% of whom are on antiretroviral treatment (ART), and 86% of those on treatment are virally suppressed.
However, the complex nature of Zimbabwe’s epidemic, coupled with dwindling international and domestic resources for the country’s HIV response, means efforts need to become increasingly targeted if progress is to be maintained. Despite this, most information about HIV in the country is gathered at a district or provincial level, obscuring important localised aspects of the epidemic.
Researchers obtained data from the 2015 Zimbabwe Demographic and Health Survey of more than 9,000 women and 7,000 men, which they cross-referenced with the 2016 Zimbabwe Population-Based HIV Impact Assessment report and other studies. This information was used to produce HIV prevalence maps, which were then combined with population density maps to pinpoint areas with high concentrations of people living with HIV yet poor ART coverage and viral suppression levels.
Consistent with other studies, the analysis found HIV to be most prevalent in the southwest of the country, between the provinces of Matabeleland North and South, although high numbers of men and women living with HIV were also found in northern and eastern Zimbabwe. The most concentrated levels of people living with HIV were found in HIV ‘hotspots’, urban settings such as Harare, Norton, Chitungwiza, Ruwa and Bulawayo.
More than 230,000 men and 350,000 women were found to be lacking treatment and care. A significant fraction of these people (22%) live in HIV hotspots, which occupy just 2% of Zimbabwe’s landmass. The cities of Harare and Bulawayo alone are home to around 113,000 and 33,000 people living with HIV who are not on treatment, respectively.
ART coverage and HIV spending was found to be slightly lower in provinces with higher HIV prevalence.
The analysis suggests sexual behaviour continues to drive Zimbabwe’s epidemic. For both men and women, behavioural factors such as having a higher number of lifetime sexual partners, low condom use and having sex at a younger age were identified as having a distinct geographical distribution associated with locations where HIV prevalence is higher than in other parts of the country.
The maps illustrated a similar geographical variation of HIV prevalence for men and women, although HIV positive women were found to be more dispersed across the country than HIV positive men.
Areas linked to commercial transport corridors, increased diamond mining activities, and mobility between the neighbouring countries of Botswana, Mozambique and South Africa were identified as particular HIV hotspots for men.
In remote, poorer areas, a higher percentage of women were found to be engaging in sexual contact from an early age, placing them at increased risk of HIV.
As well as identifying areas underserved for HIV treatment and care in Zimbabwe, these results may also help inform the design of tailored HIV prevention programmes, particularly in hotspot areas. For instance, the analysis suggests that providing voluntary medical male circumcision in places where mining and migration are common or providing pre-exposure prophylaxis (PrEP) for young women in poor, remote areas could have a significant impact on HIV transmission rates.