Since 1996, PSI/Zimbabwe has collaborated with the Ministry of Health and Child Care (MoHCC) to develop, market and scale health innovations which empower families to lead healthier lives. With local and international partnerships, these innovations have helped to normalize previously stigmatized health seeking behaviors in Zimbabwe — such as condom use, HIV testing, and Voluntary Medical Male Circumcision (VMMC).
With an initial focus on HIV/ AIDS prevention through the social marketing of condoms, the program has now grown significantly to include numerous services. These services include HIV testing services (HTS), screening and treatment for sexually-transmitted infections (STI), VMMC services, tuberculosis (TB) screening, diagnosis and treatment, pre-exposure prophylaxis for HIV (PrEP) provision, and HIV care and treatment services for key populations and the general community. Additionally, services for family planning, cervical cancer screening, and treatment of pre-cancerous lesions are also included, as are services for survivors of sexual violence. PSI/Zimbabwe also supports the MoHCC with long-lasting insecticide-treated net (LLIN) distribution to prevent malaria, and social behavior change communication for all control interventions.
PSI/Zimbabwe estimates that in 2015, its products and services helped avert 2,132,832 DALYs, including, by health area:
- 35,913 Malaria DALYs
- 1,990,406 HIV DALYs
- 104,942 FP DALYs
- 352 TB DALYs
- 706 WASH DALYs
- 512 NCD DALYs
PSI/Zimbabwe’s family planning programs also provided 441,028 couple-years of protection.
PSI/Zimbabwe seeks to improve health in Zimbabwe through the provision of the following services and products:
Voluntary Medical Male Circumcision (VMMC)
VMMC has increased protection against HIV by 60%. PSI/Zimbabwe started the VMMC program in 2009 and has grown from a pilot in five districts to 43 districts. Quality assured VMMC services are offered at three PSI-operated sites, public sector hospitals and clinics. Since inception, PSI/Zimbabwe has contributed over 70% male circumcisions to the national goal of circumcising 1.3 million men by 2018.
Condom Social Marketing
Male condoms are an important part of Zimbabwe’s national HIV prevention strategy and have contributed to a 25% decrease in new infections between 2010 and 2015. Since 1996, PSI/Zimbabwe has been responsible for generating demand for condoms and ensuring accessibility to its branded condom, Protector Plus. PSI/Zimbabwe socially markets an average of 20 million Protector Plus male condoms annually, through a network of over 5,000 retail outlets. Most outlets are situated in areas with high-risk activity and are open outside normal retail hours, giving people access to condoms when they are most likely to need them. PSI/Zimbabwe is moving towards cost recovery to achieve sustainability of the male condom program.
New Start Testing Services
PSI/Zimbabwe introduced New Start centers in 1999. New Start has evolved from offering testing services only, to offering integrated sexual and reproductive health (SRH)/HIV services. This includes a wide range of family planning services, STI screening and treatment, TB symptom screening, diagnosis and treatment, ART, PrEP, cervical cancer screening and treatment of pre-cancerous lesions and services for survivors of sexual violence
HIV Testing Services
HIV testing services provide an entry point to treatment and care, and are crucial to achieving the 90-90-90 target. By 2020, this target is aiming for 90% of people living with HIV to know their status, 90% of all people with a diagnosed HIV infection to receive sustained antiretroviral therapy, and 90% of those on treatment will achieve viral suppression. When New Start centers were introduced in 1999, testing was still taboo and highly stigmatized. At that time, only 160 clients were tested per month through one site. This has now grown to outreach testing of over 30,000 people per month, through a network of 13 sites.
The package of HIV services incorporates testing and counseling, STI and TB symptom screening, screening for hypertension, CD4 cell count testing, counseling and referrals into HIV care and treatment, and other integrated services, including out- of- network referrals. HIV testing services are offered as both client-initiated testing and counseling (CITC) and provider-initiated testing and counseling (PITC), from the other integrated services offered through New Start. Clients now also have the option of accessing HIV testing through provider-delivered HIV testing services (PDHTS) or through HIV self-testing (HIVST). In addition, through the UNITAID/PSI HIV-Self-Testing AfRica (STAR) Project, PSI/Zimbabwe is also distributing HIV self-testing kits through community-based distributors, VMMC clinics, and interpersonal communication agents as well as clinics via peers of key populations.
HIV Care and Treatment Services
PSI’s Antiretroviral Therapy (ART) program is supporting the government’s efforts to reach the 90-90-90 goal in Zimbabwe. In 2013, PSI/Zimbabwe started offering ART services in Bulawayo, Harare and Mutare, as part of the treatment-as-prevention strategy. In 2017, the ART program is providing services in seven districts:
Harare (including Chitungwiza), Bulawayo, Gweru, Mutare, Masvingo, Makoni, and Chipinge. PSI has a robust care and treatment program that provides specialized services to key populations. At the start of 2017, there were over 3,500 key population clients on treatment. PSI’s commitment to fighting HIV saw the
development, approval and roll-out of the Treat All: Identify, Initiate, and Transition strategy. Through this strategy, PSI identifies newly diagnosed HIV-positive clients, and initiates them on ART. Stable clients are then transitioned to the public sector for further management. This strategy is expected to improve the linkage of HIV-positive clients from testing to care and treatment services. There are four ART laboratories (New Africa House, Bambanani, Masvingo and Mutare) that have been set up to support client monitoring in the ART program. Laboratory testing services are available for haematology, chemistry, serology, CD4 and viral load (VL) testing. A dedicated VL testing laboratory has been set up in Chitungwiza to run VL on the Abbott system. Tests that are not available on testing menu are outsourced. All PSI laboratories are enrolled for an external quality assurance program for the various tests that are done.
PSI is offering pre-exposure prophylaxis (PrEP) to people at substantial risk of HIV. The DREAMS program focuses on adolescent girls and young women aged 15 to 24 years. Following significant demand for PrEP services from clients outside the DREAMS target population, PSI/Zimbabwe is expanding the PrEP. Now, people at substantial risk that fall outside the DREAMS age group can access PrEP through the New Start network. By the end of December 2016, just over 400 clients had been enrolled on PrEP through PSI.
Since 2004 PSI/Zimbabwe has been engaged in TB activities including symptom screening using the recommended WHO questionnaire. In 2011, TB diagnosis services were introduced at four New Start centers. There are currently four GeneXpert machines in Harare, Bulawayo, Masvingo, and Mutare for TB screening, as well as detection of drug-resistance TB, in sputum culture. By December 2016, 3,507 active TB cases had been diagnosed. All identified cases were either treated at PSI/Zimbabwe’s New Start sites or were referred to public health institutions for treatment. Client follow-ups are also done on those referred to the public health sector, with 95% successfully starting TB treatment. In 2015, isoniazid preventive therapy (IPT) was introduced at three PSI ART sites (Harare, Bulawayo, and Masvingo) for HIV positive clients. This has not only reduced TB infection among ART clients but also decreased mortality rates. PSI/Zimbabwe reports all TB cases to the National TB Programme.
Contraception and Family Planning Services
Family planning counseling and services are offered through all 13 New Start sites and their associated mobile outreach teams. The New Start centers offer a wide range of short-acting and long-acting reversible contraceptives: oral contraceptives, injectables, implants (Jadelle and Implanon), intrauterine contraceptive device (IUCD), and emergency contraceptive (EC) pills. PSI/Zimbabwe family planning services are branded ProFam. ProFam services are offered through the New Start network and through a partial social franchise (PSF) of 28 public sector health facilities. The ProFam public sector PSF in family planning was launched in 2014, through the United Kingdom’s Department for International Development (DfID)-funded program Sexual and Reproductive Health and HIV Prevention in Zimbabwe. These institutions receive training in long-acting reversible contraceptives, and support in the form of equipment and quality assurance support and supervision. PSI also socially markets EC pills and injectable contraceptives to private pharmacies and clinics.
Sexually Transmitted Infection (STI) Screening and Treatment
PSI/Zimbabwe offers routine STI symptom screening through the counseling and other integrated services at New Start. At five New Start sites, PSI also
provides STI treatment services. Sites that do not offer treatment refer eligible clients for treatment.
Services for Survivors of Sexual Violence
PSI/Zimbabwe serve survivors of sexual violence through five sites in the New Start network as well as through local partner organizations. PSI offers counseling, HIV testing, HIV post-exposure prophylaxis (PEP), pregnancy testing, emergency contraception, STI screening, prophylaxis and treatment, and any other emergency treatment.
Cervical cancer is the most common cancer among women in Zimbabwe, accounting for 33.4% of all cancer cases among black women. It is estimated that more than 2,000 women are diagnosed with cervical cancer in Zimbabwe and about 1,500 die from the condition every year. In 2013, PSI/Zimbabwe launched cervical cancer screening and treatment in to fight the disease. . PSI/Zimbabwe offers cervical cancer screening using Visual Inspection with acetic acid and cervicography (VIAC) and cryotherapy services through seven New Start centers and associated mobile outreach teams. PSI/Zimbabwe also offers the loop electrosurgical excision procedure (LEEP) for more advanced precancerous lesions. Clients with lesions suspicious for cancer are referred for further management. The New Start centers offer high-quality cervical cancer screening and treatment services accessible to women including the urban poor and rural populations. The cervical cancer screening services are integrated into HIV services (HIV testing, care and treatment services), and other sexual and reproductive health services. These include family planning, and STI treatment and services for survivors of sexual violence. Women accessing the other integrated services also fall into the group of women at risk for cervical cancer, due to the associations between unprotected sex, STIs, HIV infection, and cervical cancer. In the integrated service model that New Start offers, clients for cervical cancer screening can either come in primarily for that service or are referred for it from the other services that the site offers. Clients are also offered the other services that the site offers.
PSI/Zimbabwe has adopted the universal approach to distribute long-lasting insecticide-treated nets (LLINs) to households in medium-to-high malaria transmission districts. With support from USAID’s President’s Malaria Initiative and the Global Fund to Fight AIDS, PSI/Zimbabwe piloted continuous distribution using the expanded program on immunization, antenatal care, community and schools. Social behavior change communication activities, such as community sensitization meetings, net hang up campaigns, road shows, radio spots, wall paintings, and vehicle branding are being used to promote the correct and consistent use of the nets. PSI/Zimbabwe is also promoting the school health program. Under this program, children are trained to disseminate malaria messages to their peers, families and communities.
- U.S. Agency for International Development (USAID)
- UK Department for International Development (DfID)
- Bill & Melinda Gates Foundation
- The Global Fund to Fight AIDS, Tuberculosis and Malaria
- Zimbabwe Ministry of Health and Child Care National AIDS Council
- Zimbabwe National Family Planning Council
- Local and international based organizations
- Shaping the Family Planning Market by Strengthening the Public Sector
PSI considers total market approaches to be critical for achieving universal health coverage, especially when it comes to contraception. This program brief presents cases, supported by several different donors, which take into consideration the total family planning market.
- Expanding Access to HIV Self-Testing: A Market Development Approach
PSI envisions a healthy market for HIVST to be one that is supported by multiple buyers and suppliers and that delivers on the 5As (Availability, Assured Quality, Appropriate Design, Awareness, and Affordability) to achieve public health goals. Realizing this vision for the HIVST market will require consideration of two key markets- public and private sectors. While HIV testing has traditionally been driven by the public sector, HIVST opens up the possibility of utilizing private sector pharmacies to expand and extend the reach of testing.
- Perspectives of Parents and Health Care Workers on Early Infant Male Circumcision Conducted Using Devices: Qualitative Findings From Harare, Zimbabwe
This paper presents findings from a qualitative study in Zimbabwe that assessed parental and health care workers’ perspectives of EIMC conducted using devices.
- Safety, Acceptability, and Feasibility of Early Infant Male Circumcision Conducted by Nurse-Midwives Using the AccuCirc Device: Results of a Field Study in Zimbabwe
This paper presents the results of a field study of EIMC conducted in Zimbabwe to determine the safety, acceptability, and feasibility of early infant male circumcision.
- Comparative Cost of Early Infant Male Circumcision by Nurse-Midwives and Doctors in Zimbabwe
This is a comparative cost analysis of early infant male circumcision performed by nurse-midwives and doctors using the AccuCirc device in Zimbabwe.
- Strategy for Identifying Populations at High Risk of HIV Infection in Zimbabwe.
This study was aimed at identifying geographic clusters of HIV based on positivity threshold of 10% countrywide in Zimbabwe. Routine data from the outreach HIV testing and counselling programme administered by PSI Zimbabwe’s New Start Centre network and collected between January and March 2016 was used for this analysis. Results suggest geographic variation in the transmission of HIV in Zimbabwe.
- “Reaching the Higher Hanging Fruits”: Tracking VMMC Uptake and Behavioural Determinants: Results From Multi-Year National Cross-Sectional Surveys in Zimbabwe
In 2009, PSI implemented the national communications strategy to increase demand for VMMC through both mass media and interpersonal communication channels in Zimbabwe. Knowledge about VMMC and uptake and perceived availability of services increased over time reflecting the impact of demand creation and scaling up of services in Zimbabwe. The initial increase in intention to go for VMMC implies that demand creation was effective to motivate early adopters.
- Devices, an Alternative for Surgical Male Circumcision With Adolescents Ages 13-17 Years in Zimbabwe?
The safety and efficacy of the PrePexTM device for voluntary medical male circumcision (VMMC) has been demonstrated in studies in sub-Saharan Africa, leading to the conditional prequalification of the device for use in adults. WHO has recommended that use of the device could extend to eligible 13-17 year-olds, but only under active surveillance. This study presents preliminary findings from active surveillance of the device among adolescents in Zimbabwe.
- Factors That May Explain Post-Op Wound Infections Among Adolescent Voluntary Medical Male Circumcision (VMMC) Clients: Qualitative Findings From Zimbabwe
This study aimed to explore reasons that hinder adolescents ́ proper wound management in order to inform risk-reduction strategies. Data suggested that although wound care instructions were adequately articulated and comprehended during counseling, younger adolescents (10-14) failed to recall these instructions. Involving parents/guardians during some of the counseling for younger adolescents and creating age-appropriate materials on wound care will likely be important factors in curbing these infections.
- Simplified Asset Indices to Measure Wealth and Equity in Health Programs: a Reliability and Validity Analysis Using Survey Data from 16 Countries
Many program implementers have difficulty collecting and analyzing data on program beneficiaries' wealth because a large number of survey questions are required to construct the standard wealth index. We created country-specific measures of household wealth with as few as 6 questions that are highly reliable and valid in both urban and rural contexts.