Understanding the impact of the COVID-19 pandemic and its control measures on women and children: A Zimbabwe case study.

COVID-19 presented countries with unprecedented health policy challenges. For low-income countries in particular, policymakers had to contend with both the direct threats posed by COVID-19 as well as the social, educational, and economic harms associated with lockdown and other infection prevention and control measures. We present a holistic and contextualised case study of the direct and indirect impacts of COVID-19 on women and children, with some assessment of their uneven distribution across socio-economic, age and gender groups. We used different types of primary and secondary data from multiple sources to produce a holistic descriptive analysis. Primary data included: qualitative data obtained from 28 in-depth interviews of key informants, six focus group discussions; and 40 household interviews. We also extracted data from government reports and announcements, the District Health Information Software version 2 (DHIS2), newspaper articles and social media, as well as from published research articles. Our findings show that the direct and indirect adverse impacts of COVID-19 were compounded by many years of severe political economic challenges, and consequent deterioration of the healthcare system. The indirect effects of the pandemic had the most severe impacts on the poorest segment of society and widened age and gender inequalities. The pandemic and its accompanying infection prevention and control measures negatively affected health service delivery and uptake. The management of COVID-19 presented enormous challenges to policymakers and public health specialists. These included managing the greatest tension between direct and indirect harms; short-term and long-term effects; and the unequal distribution of harms across different segments of society.

Regulation of HIV self-testing in Malawi, Zambia and Zimbabwe: a qualitative study with key stakeholders.

INTRODUCTION: HIV self-testing (HIVST) is being introduced as a new way for more undiagnosed people to know their HIV status. As countries start to implement HIVST, assuring the quality and regulating in vitro diagnostics, including HIVST, are essential. We aimed to document the emerging regulatory landscape and perceptions of key stakeholders involved in HIVST policy and regulation prior to implementation in three low- and middle-income countries. METHODS: Between April and August 2016, we conducted semi-structured interviews in Malawi, Zambia and Zimbabwe to understand the relationships between different stakeholders on their perceptions of current and future HIVST regulation and the potential impact on implementation. We purposively sampled and interviewed 66 national-level key stakeholders from the Ministry of Health and the regulatory, laboratory, logistical, donor and non-governmental sectors. We used a thematic approach to analysis with an inductively developed common coding framework to allow inter-country comparison of emerging themes. RESULTS: In all countries, the national reference laboratory was monitoring the quality of HIVST kits entering the public sector. In Malawi, there was no legal mandate to regulate medical devices, in Zambia one regulatory body with a clear mandate had started developing regulations and in Zimbabwe the mandate to regulate was overlapping between two bodies. Stakeholders indicated that they had a poor understanding of the process and requirements for HIVST regulation, as well as lack of clarity and coordination between organizational roles. The need for good collaboration between sectors, a strong post-market surveillance model for HIVST and technical assistance to develop regulators capacity was noted as priorities. Key informants identified technical working groups as a potential way collaboration could be improved upon to accelerate the regulation of HIVST. CONCLUSION: Regulation of in vitro diagnostic devices, including HIVST, is now being recognized as important by regulators after a regional focus on pharmaceuticals. HIVST is providing an opportunity for each country to develop similar regulations to others in the region leading to a more coherent regulatory environment for the introduction of new devices.

Applying user preferences to optimize the contribution of HIV self-testing to reaching the "first 90" target of UNAIDS Fast-track strategy: results from discrete choice experiments in Zimbabwe.

INTRODUCTION: New HIV testing strategies are needed to reach the United Nations' 90-90-90 target. HIV self-testing (HIVST) can increase uptake, but users' perspectives on optimal models of distribution and post-test services are uncertain. We used discrete choice experiments (DCEs) to explore the impact of service characteristics on uptake along the testing cascade. METHODS: DCEs are a quantitative survey method that present respondents with repeated choices between packages of service characteristics, and estimate relative strengths of preferences for service characteristics. From June to October 2016, we embedded DCEs within a population-based survey following door-to-door HIVST distribution by community volunteers in two rural Zimbabwean districts: one DCE addressed HIVST distribution preferences; and the other preferences for linkage to confirmatory testing (LCT) following self-testing. Using preference coefficients/utilities, we identified key drivers of uptake for each service and simulated the effect of changes of outreach and static/public clinics' characteristics on LCT. RESULTS: Distribution and LCT DCEs surveyed 296/329 (90.0%) and 496/594 (83.5%) participants; 81.8% and 84.9% had ever-tested, respectively. The strongest distribution preferences were for: (1) free kits - a $1 increase in the kit price was associated with a disutility (U) of -2.017; (2) door-to-door kit delivery (U = +1.029) relative to collection from public/outreach clinic; (3) telephone helpline for pretest support relative to in-person or no support (U = +0.415); (4) distributors from own/local village (U = +0.145) versus those from external communities. Participants who had never HIV tested valued phone helplines more than those previously tested. The strongest LCT preferences were: (1) immediate antiretroviral therapy (ART) availability: U = +0.614 and U = +1.052 for public and outreach clinics, respectively; (2) free services: a $1 user fee increase decreased utility at public (U = -0.381) and outreach clinics (U = -0.761); (3) proximity of clinic (U = -0.38 per hour walking). Participants reported willingness to link to either location; but never-testers were more averse to LCT. Simulations showed the importance of availability of ART: ART unavailability at public clinics would reduce LCT by 24%. CONCLUSIONS: Free HIVST distribution by local volunteers and immediately available ART were the strongest relative preferences identified. Accommodating LCT preferences, notably ensuring efficient provision of ART, could facilitate "resistant testers" to test while maximizing uptake of post-test services.

Can Schools Support HIV/AIDS-Affected Children? Exploring the 'Ethic of Care' amongst Rural Zimbabwean Teachers.

How realistic is the international policy emphasis on schools 'substituting for families' of HIV/AIDS-affected children? We explore the ethic of care in Zimbabwean schools to highlight the poor fit between the western caring schools literature and daily realities of schools in different material and cultural contexts. Interviews and focus groups were conducted with 44 teachers and 55 community members, analysed in light of a companion study of HIV/AIDS-affected pupils' own accounts of their care-related experiences. We conceptualise schools as spaces of engagement between groups with diverse needs and interests (teachers, pupils and surrounding community members), with attention to the pathways through which extreme adversity impacts on those institutional contexts and social identifications central to giving and receiving care. Whilst teachers were aware of how they might support children, they seldom put these ideas into action. Multiple factors undermined caring teacher-pupil relationships in wider contexts of poverty and political uncertainty: loss of morale from low salaries and falling professional status; the inability of teachers to solve HIV/AIDS-related problems in their own lives; the role of stigma in deterring HIV/AIDS-affected children from disclosing their situations to teachers; authoritarian teacher-learner relations and harsh punishments fuelling pupil fear of teachers; and lack of trust in the wider community. These factors undermined: teacher confidence in their skills and capacity to support affected pupils and motivation to help children with complex problems; solidarity and common purpose amongst teachers, and between teachers and affected children; and effective bridging alliances between schools and their surrounding communities-all hallmarks of HIV-competent communities. We caution against ambitious policy expansions of teachers' roles without recognition of the personal and social costs of emotional labour, and the need for significant increases in resources and institutional recognition to enable teachers to adopt support roles. We highlight the need for research into how best to create opportunities for teacher recognition in deprived and disorganised institutional settings, and the development of more culturally appropriate notions of caring.

It's harder for boys? Children's representations of their HIV/AIDS-affected peers in Zimbabwe.

This study examines whether children in rural Zimbabwe have differing representations of their HIV/AIDS-affected peers based on the gender of those peers. A group of 128 children (58 boys, 70 girls) aged 10-14 participated in a draw-and-write exercise, in which they were asked to tell the story of either an HIV/AIDS-affected girl child, or an HIV/AIDS-affected boy child. Stories were inductively thematically coded, and then a post hoc statistical analysis was conducted to see if there were differences in the themes that emerged in stories about girls versus stories about boys. The results showed that boys were more often depicted as materially deprived, without adult and teacher support, and heavily burdened with household duties. Further research is needed to determine whether the perceptions of the children in this study point to a series of overlooked challenges facing HIV/AIDS-affected boys, or to a culture of gender inequality facing HIV/AIDS-affected girls - which pays more attention to male suffering than to female suffering.

A good patient? How notions of 'a good patient' affect patient-nurse relationships and ART adherence in Zimbabwe.

BACKGROUND: While patient-provider interactions are commonly understood as mutually constructed relationships, the role of patient behaviour, participation in interactions, and characteristics, particularly ideals surrounding notions of 'good' and 'bad' patients, are under-examined. This article examines social representations of 'a good patient' and how these representations affect patient-healthcare provider relationships and antiretroviral treatment (ART) for people living with HIV. METHODS: Using thematic network analysis, we examined interview and focus group transcripts involving 25 healthcare staff, 48 ART users, and 31 carers of HIV positive children, as well as field notes from over 100 h of ethnographic observation at health centres in rural Zimbabwe. RESULTS: Characteristics of a good patient include obedience, patience, politeness, listening, enthusiasm for treatment, intelligence, physical cleanliness, honesty, gratitude and lifestyle adaptations (taking pills correctly and coming to the clinic when told). As healthcare workers may decide to punish patients who do not live up the 'good patient persona', many patients seek to perform within the confines of the 'good patient persona' to access good care and ensure continued access to ART. DISCUSSION: The notion of a 'good ART patient' can have positive effects on patient health outcomes. It is one of the only arenas of the clinic experience that ART patients can influence in their favour. However, for people not conforming to the norms of the 'good patient persona', the productive and health-enabling patient-nurse relationship may break down and be detrimental to the patient. CONCLUSION: We conclude that policy makers need to take heed of the social representations that govern patient-nurse relationships and their role in facilitating or undermining ART adherence.

Factors shaping the HIV-competence of two primary schools in rural Zimbabwe.

We present multi-method case studies of two Zimbabwean primary schools - one rural and one small-town. The rural school scored higher than the small-town school on measures of child well-being and school attendance by HIV-affected children. The small-town school had superior facilities, more teachers with higher morale, more specialist HIV/AIDS activities, and an explicit religious ethos. The relatively impoverished rural school was located in a more cohesive community with a more critically conscious, dynamic and networking headmaster. The current emphasis on HIV/AIDS-related teacher training and specialist school-based activities should be supplemented with greater attention to impacts of school leadership and the nature of the school-community interface on the HIV-competence of schools.

Re-thinking children's agency in extreme hardship: Zimbabwean children's draw-and-write about their HIV-affected peers.

We compare two analyses of the same 'draw-and-write' exercises in which 128 Zimbabwean children represented their HIV-affected peers. The first, informed by the 'New Social Studies of Childhood', easily identified examples of independent reflection and action by children. The second, informed by Sen's understandings of agency, drew attention to the negative consequences of many of the choices available to children, and the contextual limits on outcomes children themselves would value: the support of caring adults, adequate food, and opportunities to advance their health and safety. Conceptualisations of agency need to take greater account of children's own accounts of outcomes they value, rather than identifying agency in any form of independent reflection and action per se.

Children's representations of school support for HIV-affected peers in rural Zimbabwe.

BACKGROUND: HIV has left many African children caring for sick relatives, orphaned or themselves HIV-positive, often facing immense challenges in the absence of significant support from adults. With reductions in development funding, public sector budgetary constraints, and a growing emphasis on the importance of indigenous resources in the HIV response, international policy allocates schools a key role in 'substituting for families' (Ansell, 2008) in supporting child health and well-being. We explore children's own accounts of the challenges facing their HIV-affected peers and the role of schools in providing such support. METHODS: Contextualised within a multi-method study of school support for HIV-affected children in rural Zimbabwe, and regarding children's views as a key resource for child-relevant intervention and policy, 128 school children (10-14) wrote a story about an HIV-affected peer and how school assisted them in tackling their problems. RESULTS: Children presented harrowing accounts of negative impacts of HIV on the social, physical and mental well-being of peers, and how these manifested in the school setting. Whilst relationships with fellow learners and teachers were said to provide a degree of support, this was patchy and minimal, generally limited to small-scale and often one-off acts of material help or kindness (e.g. teachers giving children pens and exercise books or peers sharing school lunches), with little potential to impact significantly on the wider social drivers of children's daily challenges. Despite having respect for the enormity of the challenges many HIV-affected peers were coping with, children tended to keep a distance from them. School was depicted as a source of the very bullying, stigma and social exclusion that undermined children's opportunities for well-being in their lives more generally. CONCLUSIONS: Our findings challenge glib assumptions that schools can serve as a significant 'indigenous' supports of the health and well-being of HIV-affected children in the absence of a very significant increase in outside training, support and additional resources. Schools are an extension of communities, with members of school communities subject to many of the same deprivations, anxieties and prejudices that drive the health-limiting exclusion, impoverishment and stigmatisation of HIV-affected children in their households and wider communities.

Social capital and HIV competent communities: the role of community groups in managing HIV/AIDS in rural Zimbabwe.

Community involvement is increasingly identified as a "critical enabler" of an effective HIV/AIDS response. We explore pathways between community participation and HIV prevention, treatment and impact mitigation in Zimbabwe, reviewing six qualitative studies in Manicaland. These find that community group membership is often (not always) associated with decreased HIV incidence, reduced stigma and improved access to some services, particularly amongst women. Participation in formal community groups (e.g., church or women's groups) and informal local networks (e.g., neighbours, families) provides opportunities for critical dialogue about HIV/AIDS, often facilitating renegotiation of harmful social norms, sharing of previously hidden personal experiences of HIV/AIDS, formulation of positive action plans and solidarity to action them. However, implementation of new plans and insights is constrained by poverty, social uncertainty and poor service delivery. Furthermore, dialogue may have negative effects, spreading false information and entrenching negative norms. The extent that formal groups and informal networks facilitate externally imposed HIV/AIDS interventions varies. They potentially provide vital practical and emotional support, facilitating service access, treatment adherence and AIDS care. However, they may sometimes play a negative role in prevention activities, challenging stereotypes about sexuality or gender. There is an urgent need for greater recognition of the role of indigenous community groups and networks, and the inclusion of "strengthening local responses" as a key element of interventions and policy. Such efforts require great sensitivity. Heavy-handed external interference in complex indigenous relationships risks undermining the localism and bottom-up initiative and activism that might be central to their effectiveness. Cautious efforts might seek to enhance the potentially beneficial effects of groups, especially for women, and limit potentially damaging ones, especially for men. Efforts should be made to facilitate contexts that enable groups to have beneficial effects, through nesting them within wider comprehensive responses, and supporting them through strong partnerships with service providers.

The role of community conversations in facilitating local HIV competence: case study from rural Zimbabwe.

BACKGROUND: This paper examines the potential for community conversations to strengthen positive responses to HIV in resource-poor environments. Community conversations are an intervention method through which local people work with a facilitator to collectively identify local strengths and challenges and brainstorm potential strategies for solving local problems. METHODS: We conducted 18 community conversations (with six groups at three points in time) with a total of 77 participants in rural Zimbabwe (20% HIV positive). Participants were invited to reflect on how they were responding to the challenges of HIV, both as individuals and in community groups, and to think of ways to better support openness about HIV, kindness towards people living with HIV and greater community uptake of HIV prevention and treatment. RESULTS: Community conversations contributed to local HIV competence through (1) enabling participants to brainstorm concrete action plans for responding to HIV, (2) providing a forum to develop a sense of common purpose in relation to implementing these, (3) encouraging and challenging participants to overcome fear, denial and passivity, (4) providing an opportunity for participants to move from seeing themselves as passive recipients of information to active problem solvers, and (5) reducing silence and stigma surrounding HIV. CONCLUSIONS: Our discussion cautions that community conversations, while holding great potential to help communities recognize their potential strengths and capacities for responding more effectively to HIV, are not a magic bullet. Poverty, poor harvests and political instability frustrated and limited many participants' efforts to put their plans into action. On the other hand, support from outside the community, in this case the increasing availability of antiretroviral treatment, played a vital role in enabling communities to challenge stigma and envision new, more positive, ways of responding to the epidemic.

Building adherence-competent communities: factors promoting children's adherence to anti-retroviral HIV/AIDS treatment in rural Zimbabwe.

Given relatively high levels of adherence to HIV treatment in Africa, we explore factors facilitating children's adherence, despite poverty, social disruption and limited health infrastructure. Using interviews with 25 nurses and 40 guardians in Zimbabwe, we develop our conceptualisation of an 'adherence competent community', showing how members of five networks (children, guardians, community members, health workers and NGOs) have taken advantage of the gradual public normalisation of HIV/AIDS and improved drug and service availability to construct new norms of solidarity with HIV and AIDS sufferers, recognition of HIV-infected children's social worth, an ethic of care/assistance and a supporting atmosphere of enablement/empowerment.

Masculinity as a barrier to men's use of HIV services in Zimbabwe.

BACKGROUND: A growing number of studies highlight men's disinclination to make use of HIV services. This suggests there are factors that prevent men from engaging with health services and an urgent need to unpack the forms of sociality that determine men's acceptance or rejection of HIV services. METHODS: Drawing on the perspectives of 53 antiretroviral drug users and 25 healthcare providers, we examine qualitatively how local constructions of masculinity in rural Zimbabwe impact on men's use of HIV services. RESULTS: Informants reported a clear and hegemonic notion of masculinity that required men to be and act in control, to have know-how, be strong, resilient, disease free, highly sexual and economically productive. However, such traits were in direct conflict with the 'good patient' persona who is expected to accept being HIV positive, take instructions from nurses and engage in health-enabling behaviours such as attending regular hospital visits and refraining from alcohol and unprotected extra-marital sex. This conflict between local understandings of manhood and biopolitical representations of 'a good patient' can provide a possible explanation to why so many men do not make use of HIV services in Zimbabwe. However, once men had been counselled and had the opportunity to reflect upon the impact of ART on their productivity and social value, it was possible for some to construct new and more ART-friendly versions of masculinity. CONCLUSION: We urge HIV service providers to consider the obstacles that prevent many men from accessing their services and argue for community-based and driven initiatives that facilitate safe and supportive social spaces for men to openly discuss social constructions of masculinity as well as renegotiate more health-enabling masculinities.

A 'good hospital': nurse and patient perceptions of good clinical care for HIV-positive people on antiretroviral treatment in rural Zimbabwe--a mixed-methods qualitative study.

BACKGROUND: Antiretroviral treatment for HIV is gradually being made available across sub-Saharan Africa. With antiretroviral treatment, HIV can be approached as a chronic, manageable condition rather than a shorter-term issue of palliative care. This treatment involves repeated interaction between health staff and patients for ongoing check-ups and prescription refills. OBJECTIVE: This study aimed to understand patient and healthcare staff perceptions of good clinical antiretroviral treatment care. DESIGN: Over 100 h of ethnographic observation at healthcare sites; interviews and focus groups with 25 healthcentre workers (mostly nurses), 53 HIV-positive adults taking ARVs and 40 carers of children on ART. The data were analyzed using thematic content analysis. SETTING: Three healthcare sites providing free antiretroviral drugs in rural Zimbabwe, where the adult HIV infection rate is approximately 20%. RESULTS: Contrary to reports of poor antiretroviral treatment adherence and task-oriented rather than patient-oriented nursing, our study found great patient commitment to adherence, outstanding nurse dedication and a pervasive sense of hope about coping with HIV. Within this context however there were some situations where patients and nurses had different expectations of the medical encounter, leading to stress and dissatisfaction. Patients and staff both emphasized the importance of nurse kindness, understanding, confidentiality and acceptance (i.e. treating HIV patients 'like normal') and patient adherence to medical directions. However, nurses at times overlooked the negative effects of long wait times and frequent hospital visits. Further, nurses sometimes conflated medical adherence with general patient obedience in all aspects of the nurse-patient relationships. Patients and staff were frustrated by the ambiguity and unpredictability surrounding key elements of hospital visits such as how much patients had to pay for service, how long it would take to be served, and whether drugs or the doctor's services would be available.

"We, the AIDS people. . .": how antiretroviral therapy enables Zimbabweans living with HIV/AIDS to cope with stigma.

We studied the impact of antiretroviral treatment availability on HIV/AIDS stigma through interviews with 118 antiretroviral treatment users, HIV/AIDS caregivers, and nurses in Zimbabwe. Treatment enables positive social and economic participation through which users can begin to reconstruct their shattered sense of social value. However, stigma remains strong, and antiretroviral treatment users remain mired in conflictual symbolic relationships between the HIV/AIDS people and the untested. To date, the restoration of users' own sense of self-worth through treatment has not reduced fear and sexual embarrassment in framing community responses to people living with HIV/AIDS. Much remains to be learned about the complex interaction of economic and psychosocial dimensions of poverty, treatment availability, and conservative sexual moralities in driving HIV/AIDS stigma in specific settings.