Integrating status-neutral and targeted HIV testing in Zimbabwe: A complementary strategy

Hamufare D Mugauri; Owen Mugurungi; Joconiah Chirenda; Kudakwashe Takarinda; Prosper Mangwiro; Mufuta Tshimanga

doi:10.1371/journal.pone.0302803

. 2025 Feb 24;20(2):e0302803. doi: 10.1371/journal.pone.0302803

Integrating status-neutral and targeted HIV testing in Zimbabwe: A complementary strategy

Hamufare D Mugauri ^1,^*, Owen Mugurungi ², Joconiah Chirenda ¹, Kudakwashe Takarinda ³, Prosper Mangwiro ⁴, Mufuta Tshimanga ¹

Editor: Zypher Jude G Regencia⁵

PMCID: PMC11849839 PMID: 39992896

Abstract

Introduction

Zimbabwe exclusively implemented targeted HIV testing until 2022 when Status-neutral testing was embraced. Whilst targeted testing aims to expand access and uptake of testing among high-risk individuals, status-neutral testing emphasizes post-test linkage to prevention and treatment services. To address how the two concepts relate in practice, we explored how status-neutral and targeted testing concepts correlate, in developing a double-edged strategy for effective case identification and linkage to prevention and treatment.

Methods

We conducted a cross-sectional study on 36 multi-stage sampled sites across 4/10 provinces of Zimbabwe. A national screening algorithm was used to determine patient risk profiling and eligibility for testing. Screened-out patients were offered HIVST. Both screened and non-screened patients were tested and analysed for positivity ratios and linkage to post-test services. Epicollect5 was used to collect data and analysed using EpiData software and Stata. Univariate, bivariate and multivariate analyses were conducted at a 5% significance level.

Results

Of 23,058 HIV tests done, females constituted 55% (n = 12,698), whilst 63.5% (n = 14,650) were retested. Through screening, at-risk patients contributed 75.1% to the overall positivity (1,296/1,727), from 66% (n = 15,289) of the total HIV tests conducted. All screened-out patients were non-reactive on HIVST: 1,182/1,182. The 45–49-year category was 3.6 times more likely to test positive (a95%CI:2.67,4.90). Males were 3.09 times more likely to test positive in adjusted analysis (a95%CI: 2.74, 3.49). First tests were 65% more likely to test HIV positive (a95%CI: 1.43, 1.91) whilst screened patients were 3.89 times more likely to link to HIV prevention services (a95%CI: 3.05, 4.97), against 25.5% (n = 1,871) linkage among patients not screened.

Conclusion

The complementarity of the status-neutral and targeted testing approaches is evident from our results. By prioritizing high-risk individuals for testing and ensuring comprehensive linkage to both prevention and treatment services, these integrated strategies can effectively identify and manage people living with HIV. This combined approach optimizes resource use, particularly in low- and middle-income countries, and contributes to improved health outcomes and reduced HIV transmission rates.

Introduction

Status-neutral HIV testing represents an innovative paradigm in HIV education, testing, and treatment, emphasizing a continuous care model irrespective of an individual’s HIV status [1]. This approach ensures that all individuals, regardless of their HIV diagnosis, receive uniform treatment from the initiation of the testing process and are subsequently linked to appropriate services based on their test outcomes. Additionally, this model aims to enhance health outcomes, prevent new HIV infections, and ultimately create a scenario where HIV transmission is halted through universally accessible prevention and treatment strategies [2].

The concept prioritizes interventions tailored to the needs of populations at risk for or living with HIV, rather than segregating services into prevention or care categories [3]. The status-neutral approach to HIV prevention and care identifies the HIV testing moment as the critical entry point to care. At this juncture, clients’ needs are comprehensively assessed, and they are subsequently engaged and connected to appropriate services based on these needs, irrespective of their HIV test results [4].

First introduced by the New York City Department of Health and Mental Hygiene in 2016, this paradigm represents a comprehensive prevention system encompassing all individuals affected by HIV, irrespective of their HIV status [5–7]. It delineates detailed steps to achieve an undetectable viral load and outlines strategies for effective combination HIV prevention. The concept is grounded in the premise that most countries have attained the 95% targets and should now focus on consolidating these achievements by equally addressing the needs of HIV-negative individuals, who were previously overlooked in the pursuit of positivity ratio targets [8].

The status-neutral concept is rapidly gaining global acceptance. Organizations such as the World Health Organization (WHO) and the Centres for Disease Control and Prevention (CDC) actively promote it through various initiatives [9]. The adoption of this concept varies among countries, influenced by their unique contexts and needs.

In Africa, particularly in sub-Saharan regions, the status-neutral approach has been integrated into existing HIV testing frameworks to enhance the effectiveness of HIV prevention and treatment programs. This approach ensures that HIV testing and related services are offered to all individuals, regardless of their HIV status, promoting continuous engagement in care. Countries like Zimbabwe have been at the forefront of implementing this approach, incorporating it alongside targeted testing methods to improve linkage to care and retention in treatment, thereby addressing both prevention and treatment comprehensively [7]. This dual strategy, which involves integrating the status-neutral approach with targeted testing methods, is yet to be fully understood, highlighting a significant knowledge gap. Examining this dual strategy is crucial because it has the potential to enhance the effectiveness of HIV prevention and treatment programs by ensuring continuous engagement in care regardless of HIV status, while also targeting high-risk populations for more focused interventions. Understanding how these two approaches can complement each other will contribute to more effective and inclusive healthcare strategies, ultimately improving health outcomes in sub-Saharan Africa. Our work aims to fill this gap by providing comprehensive insights into the integration and impact of these strategies, positioning itself as a valuable resource for policymakers and healthcare providers.

Zimbabwe, located in sub–Saharan Africa, is one of the countries severely affected by the HIV pandemic, where HIV remains firmly established as a generalized epidemic with a prevalence of 11,01% and incidence of 17% translating to approximately 23,000 new infections every year [10,11] (Fig 1).

To address her predicament, Zimbabwe has been implementing a Targeted testing model that prioritizes high-risk individuals through a screening algorithm, adopting differentiated testing models that include strengthening Index testing- a proven high-yield HIV testing model [12].

Whilst, remarkably, the country has achieved the 95% targets, according to UNAIDS HIV estimates, the country still bears a generalized epidemic contributed by population and geographically varied sub-epidemics requiring innovations for case finding and effective HIV prevention packages [13].

This context demands that Zimbabwe, like her Southern African counterparts, needs interventions designed to arrest ongoing transmission of HIV, identify the remaining cases, and put them on effective life-long treatment to bring the pandemic to an end.

Zimbabwe presents a unique case study for several reasons. First, Zimbabwe has one of the highest HIV prevalence rates in sub-Saharan Africa, making it imperative to explore innovative strategies to curb the epidemic. Second, the country’s healthcare infrastructure, while robust in many areas, faces significant resource constraints, necessitating the efficient use of available resources. Third, Zimbabwe’s existing HIV testing programs provide a strong foundation upon which status-neutral strategies can be integrated, offering a practical context for assessing the effectiveness of combined approaches.

Moreover, Zimbabwe’s diverse population and varying levels of access to healthcare services across urban and rural areas provide a comprehensive setting to evaluate the adaptability and scalability of the status-neutral approach. This makes Zimbabwe an ideal context for understanding how these strategies can be tailored and implemented in similar resource-limited settings across the region.

This paper thoroughly examined the complementariness of the status-neutral and targeted approaches to HIV testing in the context of a generalized epidemic, high new infections, and established ongoing transmission of HIV. By exploring how these strategies can work together to enhance HIV prevention and treatment efforts, we seek to provide insights and recommendations for the context-specific application of the status-neutral concept. Our goal was to highlight the potential benefits of integrating these approaches to improve healthcare outcomes in sub-Saharan Africa, particularly in countries like Zimbabwe.

Materials and methods

This study employed a cross-sectional design to examine the integration of the status-neutral approach within existing HIV testing frameworks in Zimbabwe. Data were sourced from facility records as entered into the DHIS2 database. The cross-sectional nature of the study allowed us to capture a snapshot of the current state of HIV testing and treatment, providing valuable insights into the effectiveness and challenges of implementing the status-neutral approach alongside targeted testing methods.

Setting

Zimbabwe is a landlocked, low-income country in Southern Africa located between Botswana, South Africa, Mozambique, and Zambia with an estimated population of 16,3 million and a human development index of 0.593, ranked number 174 globally out of 189 countries in 2022 [14,15]. The country is divided into two urban provinces, eight rural provinces and 62 districts.

The AIDS and TB Programme (ATP) is mandated to coordinate the development of HIV/AIDS health policies and set up national standards and guidelines as part of the national response to HIV in Zimbabwe. Four sub-units under ATP, namely, HIV Prevention, Care and Treatment, Prevention of Mother to Child Transmission (PMTCT) and Monitoring and Evaluation (M & E). These sub-units are delegated to ensure seamless yet specialised programming to ensure adequate response to the pandemic [16].

The HIV Prevention program oversees the activities of HIV Testing Services (HTS) activities with the ATP. Since 2016, the HTS programme has been pursuing targeted testing as an approach to reduce testing volumes, increase efficiency in HIV testing and enhance the identification of people living with HIV, to enrol them on life-long Antiretroviral Therapy (ART). Eligibility for HIV testing is done using a validated Screening algorithm [17]. In this algorithm, high-risk individuals are offered provider-delivered testing whilst those screened out are offered HIVST kits for self-screen. Following a negative test result, the patient is further screened for eligibility for combination prevention which includes PrEP.

Specific study site.

The study sites included four provinces selected out of the ten provinces in Zimbabwe, based on their diverse geographical and demographic characteristics as well as varying levels of HIV prevalence and incidence. Manicaland Province: Located in eastern Zimbabwe, Manicaland is the second-most populous province after Harare, with a population of approximately 1.75 million as of the 2022 census. This province has been significantly impacted by the HIV epidemic, with a prevalence of 9.40% in 2024. This makes it a critical area for studying HIV interventions [18,19]. Mashonaland West Province: Situated to the north of Zimbabwe, Mashonaland West shares an international border with Zambia. It borders several other provinces internally, including Midlands, Matabeleland North, Mashonaland Central, Harare, and Mashonaland East. The region had a notable HIV prevalence of 9.60% in 2024, warranting focused efforts on HIV testing and treatment [19,20]. Matabeleland South Province: This province covers the southeastern plateau of Zimbabwe and stretches to the borders with Botswana and South Africa. The area is characterized by high HIV incidence, particularly in cross-border communities, with a prevalence rate of 17.30% in 2024, highlighting the need for targeted HIV prevention and treatment strategies [19,21]. Midlands Province: Midlands province spans an area of 49,166 square kilometres and has a population of approximately 1.61 million. With its diverse population and significant HIV prevalence rate of 10.94% in 2024, this province provides a vital context for examining the effectiveness of HIV interventions [19,22].

These provinces were selected to provide a comprehensive understanding of the status-neutral approach and its integration into existing HIV testing frameworks across diverse settings. The varying HIV prevalence and incidence rates in these regions underscore the importance of context-specific strategies for HIV prevention and treatment.

Sampling

Multi-stage sampling was done to randomly select 4 out of 10 Zimbabwe provinces using the lottery method. Further, 3 districts per province were randomly selected resulting in 12 districts. All health facilities across the 12 districts were included in the study, resulting in a total of 36 health facilities. The sampling criteria were designed to ensure a balanced representation, incorporating a mix of high and low-volume facilities, as well as urban and rural sites (Table 1).

Table 1. Study sites, Zimbabwe, 2024.

Manicaland Province	Mash West Province	Matabeleland South Province	Midlands Province
Mutare District Mutare Provincial Hospital Zimunya Clinic Mt Zuma Clinic	Chegutu District Katanga Utano Clinic Pfupajena Municipal Clinic Selous Clinic	Gwanda District Gwanda Provincial Hospital Phakama Clinic Manama Mission Hospital	Gweru District Gweru Provincial Hospital Chikwingwizha Mission Hospital Lower Gweru Clinic
Chipinge District Chikore Mission Hospital Chipinge Town Clinic Tanganda Rural Health Centre	Makonde District Chinhoyi Provincial Hospital Chikonohono Municipal Clinic Alaska Municipal Clinic	Mangwe District Plumtree District Hospital Tshitshi Clinic Dingumuzi Clinic	Kwekwe District Kwekwe General Hospital Amaveni Clinic Nyoni Rural Health Centre
Makoni District Rusape District Hospital Katsenga Rural Health Centre	Sanyati District Kadoma General Hospital Ordoff Clinic Waverly Municipal Clinic	Umzingwane District Nhlangano Clinic Nswazi Clinic How Mine Clinic Kumbudzi RHC	Zvishavane District Mandava Health Centre Mabasa Clinic Mtambi Clinic

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Client population

All clients who were tested for HIV and documented in HIV Testing registers, at the 36 sampled facilities between 1 October 2023 to 31 December 2023 and aged 15 years and above, were included in the study.

Inclusion criteria

Individuals who underwent HIV testing within the specified study period.

Participants who provided sufficient demographic and clinical information necessary for analysis.

Exclusion criteria

Individuals with incomplete or missing data on key variables.

Participants whose testing data were not available in the DHIS2 database.

Sample size calculation

The sample size for this study was determined using statistical power analysis to ensure adequate power to detect significant differences between groups. The primary outcome measure was the effectiveness of the status-neutral approach in promoting linkage to care for both HIV-positive and HIV-negative individuals. This approach ensures that all individuals, regardless of their HIV status, are linked to appropriate health services. Using secondary data from existing HIV testing programs, our analysis aimed to evaluate how well the status-neutral approach facilitated continuous engagement in care for everyone tested, thereby improving overall health outcomes within the context of targeted HIV testing

The following assumptions and parameters were used

Effect Size: Based on previous studies, an effect size of 0.3 was considered clinically significant, Significance Level (α): A two-tailed significance level of 0.05 was used.

Power (1-β): To achieve a power of 80%, the sample size was calculated to detect the specified effect size, Proportion of Positive Cases: An estimated proportion of 10% HIV-positive cases was assumed based on historical data.

The sample size was calculated using the formula for comparing two proportions and using the above parameters and formula, the required sample size was calculated to be approximately 385 participants per group. To account for potential dropouts and incomplete data, an additional 10% was added, resulting in a final sample size of 424 participants per group.

However, the actual data set included 23,058 individuals who were tested for HIV within the study period. The larger sample size was due to the inclusion of all data available from the DHIS2 database, providing a more comprehensive analysis. This substantial increase in the sample size enhances the study’s statistical power and the generalizability of the findings, allowing for a more robust evaluation of the status-neutral approach’s effectiveness.

Data variables, sources of data and data collection

Data were extracted from District Health Information System version 2 (DHIS2) as an Excel report. The data was accessed on the 26^th of February 2024 for research purposes. The data was exported to EpiData Analysis version 2.2.2.186 (EpiData Association, Odense, Denmark) and Stata v14 (Stata Corporation College Station, Texas, USA) for further cleaning and analysis. The following variables were collected: HTS number, name of the facility, age, sex, screening for an HIV test, reason for an HIV test, HIV test result, linkage to post-test services (yes/no), and specific services linked to. To ensure privacy, patient names were not included in the final dataset used for analysis. Therefore, no personal identifiers were collected in the analysed data.

Variables Collected Screening for an HIV test with This variable refers to the initial assessment process conducted to determine an individual’s risk of HIV infection and the need for an HIV test. It includes questions about sexual behaviour, history of sexually transmitted infections, and other risk factors that might indicate the need for HIV testing. Linkage to post-test services: This variable indicates whether individuals who tested positive for HIV were connected to appropriate follow-up services. This includes referrals to healthcare facilities, counselling services, and support groups to ensure continuous engagement in care and treatment adherence.

Specific services linked to: These variables detail the specific types of post-test services that individuals were connected to. These services may include antiretroviral therapy (ART), prevention of mother-to-child transmission (PMTCT) programs, pre-exposure prophylaxis (PrEP) for those at high risk, and other medical and social support services aimed at improving health outcomes for people living with HIV.

Variables included in the adjusted models.

The adjusted models included the following variables based on their relevance and significance in the unadjusted analyses: Age, Sex, and High-risk behaviour: Individuals who reported behaviours such as multiple sexual partners, inconsistent condom use, or history of of of of of sexually transmitted infections, Screening for HIV test: The initial assessment process to determine the individual’s risk of HIV infection, Linkage to care and prevention: Whether individuals were successfully linked to post-test services, such as antiretroviral therapy (ART) for HIV-positive individuals or pre-exposure prophylaxis (PrEP) and other preventive measures for HIV-negative individuals, Testing district: Geographic location where the testing took place.

While the primary analysis of risk profiles used log-binomial regression, the variables in Table 3 were analysed using Poisson regression with robust error variance to approximate prevalence odds ratios. This approach ensures the reliability and stability of the estimates, aligning with the study design.

Table 3. Factors associated with HIV Positivity among patients who tested for HIV, Zimbabwe, 2024. (N = 23,058).

Variable	Total	HIV Positive^#		OR (95 CI)	aOR (95 CI)^#
Variable	N	N	(%)**	OR (95 CI)	aOR (95 CI)^#
Total	23,058	1,727	(7.5)	–	–
Age in years
◦ 15–24	3,524	440	(12.5)	7.43 (5.68, 9.73)	7.42 (5.65, 9.86)^
◦ 25–29	3,588	72	(2.0)	Ref	Ref
◦ 30–34	5,223	92	(1.8)	1.69 (1.22, 2.33)	1.68 (1.22, 2.34)^
◦ 35–39	3,679	334	(9.1)	10.32 (7.90, 13.49)	10.31 (7.92, 13.54)^
◦ 40–44	4,315	342	(7.9)	12.26 (9.21, 16.31)	12.23 (9.22, 16.36)^
◦ 45–49	2,398	410	(17.1)	23.61 (2.67, 4.89)	3.61 (2.67, 4.90)^
◦ > / = 50	331	29	(8.8)	5.07 (3.62, 7.11)	5.06 (3.62, 7.12)^
Gender
◦ Male	10,360	912	(8.8)	3.10 (2.74, 3.49)	3.09 (2.74, 3.49)^
◦ Female	12,698	815	(6.4)	Ref	Ref
Type of HIV Test
◦ Retest	7,906	404	(5.1)	Ref	Ref
◦ First Test	14,650	1,301	(8.9)	1.66 (1.44, 1.91)	1.65 (1.43, 1.91)^
◦ Unspecified	502	22	(4.4)	1.38 (0.91, 2.09)
Linkage to Prevention*
◦ Screened	15,289	–	(66.3) *	3.90 (3.05, 4.97)	3.89 (3.05, 4.97)^
◦ Not Screened	7,769	–	(33.7)	Ref	Ref

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OR – Odds Ratio; aOR – adjusted Odds Ratio; CI – confidence interval.

# Positivity excludes missing variables.

** Row percentages; ^#Modified Poisson regression for aOR; ^p < 0.05, *** Fisher’s Exact.

* Denominator is all tests done (N = 23,058), ^## Denominator is all Negative tests (N = 21,331).

Analysis and statistics

Socio-demographic characteristics of participants were summarized using percentage for categorical data and mean (standard deviation) or median (interquartile range) for continuous data depending on whether they are normally distributed or not. The number and proportion with a 95% confidence interval were used to summarize all clients tested for HIV during the study period, the outcomes of the test and linkage to post-test services as documented in the respective registers.

To assess the risk profiles and estimate relative risks, we initially employed a log-binomial regression model. This model is appropriate for estimating relative risks directly when analysing binary outcomes. However, due to potential convergence issues often encountered with the log-binomial model, especially in cases of sparse data or rare outcomes, we also utilized Poisson regression with robust error variance. This method serves as an alternative approach, providing similar estimates to the log-binomial model and ensuring better convergence and stability in the results. Those variables with a p-value < 0.25 in the unadjusted analysis were included in adjusted models. The unadjusted and adjusted prevalence odds ratios at 5% significance levels (95%CI) were expressed as a measure of association.

The Poisson regression with robust error variance is widely used to approximate relative risks when the log-binomial model fails to converge. Consequently, while the primary analysis of risk profiles used the log-binomial regression, the variables in Table 3 were analysed using Poisson regression to ensure the reliability and stability of the estimates.

Ethics approval

Our study was exempted from ethical clearance because it utilized routinely collected data which was extracted from the electronic database (DHIS2). The data we received were de-identified, with all patient-identifying information removed before analysis. This ensured the privacy and confidentiality of the individuals’ information. As a result, no primary data were collected, and the use of de-identified data qualified the study for ethical exemption. Despite this exemption, we recognized the sensitivity of HIV-related data and implemented stringent privacy safeguards to protect participants.

Results

Demographic characteristics

Out of the 23,058 patients tested for HIV, 55% (n = 12,698) were female. The majority of patients, 54.7% (n = 12,615), were within the age range of 25–49 years. Eligibility screening before testing was documented for 66.3% (n = 15,289) of the patients, while 33.7% were not screened. Among those tested, 63.5% (n = 14,650) underwent retesting, and 1,727 individuals tested positive, resulting in a positivity ratio of 7.5%. Across the districts, Gweru reported the highest number of tests conducted at 15.5% (n = 3,575), whereas Mangwe reported the lowest at 4.5% (n = 1,040) (Table 2).

Table 2. Clinical and demographic profile of patients, Zimbabwe, 2024. (N = 23,058).

Variable	Number	(%)*
Total	23,058	(100)
Age in years
◦ 15–24	3,524	(15.3)
◦ 22–29	3,588	(15.6)
◦ 30–34	5,223	(22.7)
◦ 35–39	3,679	(16.0)
◦ 40–44	4,315	(18.7)
◦ 45–49	2,398	(10.4)
◦ > / = 50	331	(1.4)
Gender
◦ Male	10,360	(44.9)
◦ Female	12,698	(55.1)
Risk Screened before testing
◦ Yes	15,289	(66.3)
◦ No	7,769	(33.7)
Type of HIV Test
◦ First Test	7,906	(34.3)
◦ Retest	14,650	(63.5)
◦ Not Documented	502	(2.2)
HIV Test Result
◦ Negative	21,331	(92.5)
◦ Positive	1,727	(7.5)
Testing District
◦ Mangwe	1040	(4.5)
◦ Sanyati	1232	(5.3)
◦ Gwanda	1239	(5.4)
◦ Chipinge	1350	(5.9)
◦ Mutare	1254	(5.4)
◦ Gweru	3575	(15.5)
◦ Kwekwe	2443	(10.6)
◦ Chegutu	3279	(14.2)
◦ Makonde	2997	(13.0)
◦ Umzingwane	1144	(5.0)
◦ Makoni	2424	(10.5)
◦ Zvishavane	1081	(4.7)

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*Column percentage.

Screening, testing outcomes and post-test linkages

Out of the 23,058 patients who attended the sampled healthcare facilities, 66.3% (N = 15,289) were screened for eligibility before testing. Among these screened patients, the positivity ratio was 8.5% (N = 1,296), with nearly all (N = 1,294, 99.8%) being enrolled into care. The positivity ratio among screened patients accounted for 75.1% of the total positivity observed in this study (1,296/1,727). In contrast, among the 7,769 patients (33.7%) who were not screened before testing, 431 (5.5%) tested positive, representing 24.9% of the overall positivity (431/1,727). Of the 7,338 patients (94.5%) who tested negative, 1,871 (25.5%) were linked to HIV prevention services (Fig 2).

HIV positivity and linkage

The overall positivity ratio observed in this study was 7.5% (1,727/23,058). Individuals in the 45–49-year age group were 3.6 times more likely to test positive for HIV (adjusted 95% CI: 2.67, 4.90). Males had a 3.09 times higher likelihood of testing HIV positive in the adjusted analysis (adjusted 95% CI: 2.74, 3.49), with a positivity ratio of 8% (n = 912). Initial tests were 65% more likely to yield a positive HIV result (adjusted 95% CI: 1.43, 1.91). Additionally, patients who were screened before testing were 3.89 times more likely to be linked to at least one HIV prevention service (adjusted 95% CI: 3.05, 4.97) (Table 3).

Discussion

A key finding in this study is that the status-neutral approach to HIV testing complements targeted HIV testing by creating a more inclusive and comprehensive testing framework. This dual strategy allows for prioritized testing of high-risk populations while ensuring that all individuals, regardless of their HIV status, have access to HIV prevention and treatment services. By integrating these approaches, we can enhance case identification, improve linkage to care, and ultimately reduce HIV transmission rates. This model aligns with the Comprehensive 95% targets set by UNAIDS, which emphasizes the importance of linkage to comprehensive HIV prevention services. The analysis demonstrated that the algorithm used for identifying high-risk individuals for HIV testing was effective in prioritizing those most likely to benefit from testing and subsequent linkage to care. Our results showed that individuals identified through the algorithm had a higher likelihood of testing positive for HIV and being linked to appropriate prevention or treatment services. This supports the utility of the algorithm in enhancing targeted HIV testing efforts.

Interpretation of key findings

This study offers significant insights into the effectiveness of status-neutral testing in targeted HIV testing in Zimbabwe.

Firstly, patients who underwent risk screening before HIV testing exhibited a higher positivity ratio of 8.5% compared to those who were not screened, who had a positivity ratio of 5.5%. The risk screening was conducted using a standardized algorithm, which is an integral part of the country’s standard service delivery for determining eligibility for an HIV test. This finding underscores the importance of pre-test risk assessment in identifying individuals at higher risk of HIV infection and enhancing the efficiency of targeted testing strategies [17].

Furthermore, screened patients accounted for 75% of the overall positivity observed in the study, highlighting the effectiveness of targeted testing in Zimbabwe and underscoring the urgent need for accessible and effective HIV screening options, particularly for high-risk populations. This finding suggests that a significant proportion of individuals screened through traditional methods are indeed HIV-positive, indicating that many high-risk individuals are still not being reached effectively by current screening efforts. This is particularly relevant in the context of a generalized epidemic and declining funding for HIV programs, which has led to sporadic stockouts of HIV testing commodities. The results align with previous studies that emphasize the importance of using algorithms to assess risk and prioritize clients for HIV testing while offering self-screening options to those at lower risk [17,23–25]. To remain on course of achieving and sustaining the targets for case identification, it is therefore imperative to effectively implement an algorithm that aids health workers in prioritizing patients who are most likely to test HIV positive

Secondly, 98.7% (n = 13,811) of the clients who tested HIV negative following risk screening were linked to HIV prevention services. In multivariate analysis, the probability of linkage among HIV-negative screened clients was 3.89 (adjusted 95% CI: 3.05, 4.97). This finding indicates that screening clients for testing facilitates focused HIV prevention linkage among those who test negative. Our findings are consistent with the status-neutral approach, which emphasizes equal importance on linkage to both prevention and treatment services. [6,7,26,27]. However, our approach differs from other studies that place risk assessment after testing rather than before. Conducting risk screening post-test increases the number of clients in the post-test stage with an unknown risk profile, necessitating additional risk screening. This increased workload, particularly in high-volume and high-frequency testing contexts, may compromise the thoroughness of the screening process [28,29].

This study highlights the utility of conducting risk screening before HIV testing within the status-neutral framework. This approach effectively complements the targeted testing strategy by reducing the frequency of testing that does not align with the individual’s risk profile. By embedding the status-neutral concept into targeted testing, we ensure that testing efforts are focused on those at higher risk, thereby optimizing resource use and improving the efficiency of HIV testing programs.

Implementing the status-neutral concept without integrating it into targeted testing deviates from the standardized retesting algorithm, which recommends a maximum testing frequency of once every three months for individuals at ongoing risk of HIV infection. This integration is crucial for maintaining adherence to established guidelines while enhancing the effectiveness of HIV prevention and care strategies [7,30].

Third, 63.5% of the clients who tested for HIV were retests (n = 14,650), and yet first tests were 65% more likely to test HIV positive (a95%CI: 1.43, 1.91), adjusted for age and sex. Most tests being retested may be suggestive of “over-testing” or high-risk perception, particularly given the low positivity ratios obtained [4]. Clients who test HIV negative at contact are retested annually if they fall into the general population category and retested 3 monthly if they are at ongoing risk for HIV transmissions, such as sero-different couples and those on PrEP, according to the national retesting algorithm [31].

Finally, our adjusted analysis revealed that men were 3.09 times more likely to test HIV positive (adjusted 95% CI: 2.74, 3.49), despite representing only 44.9% (10,360/23,058) of the tested population. This finding suggests that a smaller proportion of men undergo HIV testing, yet a higher percentage of those who do test positive. This observation is consistent with previous studies and widely available public information [32,33]. Additionally, men are less likely to adhere to HIV treatment and are more prone to unfavourable treatment outcomes, which can be attributed to various factors, including prevailing gender norms [31,34].

Implications for policy and practice

Targeted testing remains the cornerstone of HIV Testing Services (HTS) programming aimed at achieving epidemic control. When complemented with a status-neutral approach to HIV testing, it creates a dual strategy that prioritizes both testing and linkage to prevention and treatment services. This combined approach ensures that individuals who test positive are promptly linked to care, while those who test negative are connected to prevention services, thereby reducing the risk of new infections. Vigilant implementation of this concept is crucial to expedite epidemic control and enhance the overall effectiveness of HIV prevention and treatment efforts.

To effectively implement the status-neutral targeted HIV testing approach in Zimbabwe and beyond, several actionable steps and policy changes are necessary. Key stakeholders must also be identified to drive this initiative forward. Below are the recommended steps, policy adjustments, and potential barriers:

Actionable Steps:

i.
Policy Development and Alignment: Develop national policies that support the integration of the status-neutral approach with targeted HIV testing. These policies should align with existing health strategies and frameworks to ensure seamless implementation.
ii.
Stakeholder Engagement: Engage key stakeholders, including government health departments, non-governmental organizations (NGOs), community leaders, healthcare providers, and international partners such as the World Health Organization (WHO) and UNAIDS. Collaborative efforts are essential for resource mobilization, advocacy, and sustained support.
iii.
Capacity Building: Invest in the training and capacity building of healthcare providers to enhance their understanding and implementation of the integrated approach. Training programs should focus on the benefits, procedures, and best practices for combining status-neutral and targeted testing methods.
iv.
Resource Allocation: Ensure adequate resources are available for the implementation of the dual strategy. This includes funding for testing kits, infrastructure, personnel, and support services necessary for continuous engagement in care.
v.
Community Outreach and Education: Launch community outreach programs to raise awareness about the integrated approach. Educational campaigns should aim to reduce stigma, encourage testing, and promote the benefits of continuous care and targeted interventions.

Policy Adjustments:

i.
Regulatory Support: Implement regulatory frameworks that facilitate the integration of the status-neutral approach into existing HIV testing guidelines. This may involve revising existing protocols and ensuring compliance with new regulations.
ii.
Data Management and Monitoring: Establish robust data management systems to monitor the implementation and effectiveness of the integrated approach. Regular monitoring and evaluation will help identify gaps, measure progress, and inform policy adjustments.

Potential Barriers:

i.
Limited Resources: Insufficient funding and resources can impede the effective rollout of the integrated approach. Securing sustainable funding and resource allocation is critical.
ii.
Healthcare Infrastructure: Inadequate healthcare infrastructure, particularly in rural areas, can challenge the delivery of services. Investments in infrastructure improvements are necessary.
iii.
Data Privacy Concerns: Ensuring the confidentiality and security of patient data is paramount. Robust data protection measures must be implemented to build trust and encourage participation.

By addressing these steps, policies, stakeholders, and barriers, the integrated status-neutral targeted HIV testing approach can be effectively implemented, leading to improved health outcomes and enhanced HIV prevention and treatment efforts in Zimbabwe and beyond.

Strengths

The availability of primary source documents, such as HTS registers at all visited facilities facilitated the data abstraction process. In addition, the sampled 36 health facilities provided a large sample size that enabled us to draw inferences on the population of the country.

Limitations

Discrepancies between data abstracted from HTS registers, monthly summaries and DHIS2 during data triangulation exposed data entry or computation errors that could be rectified by onsite data analysis, and cascade generation.

Conclusions

Our study demonstrates that targeted testing and status-neutral testing are complementary concepts that, when applied together, can enhance the identification and management of people living with HIV. By prioritizing high-risk individuals for testing and ensuring effective linkage to both prevention and treatment services, this dual approach can help meet case identification targets and reduce ongoing HIV transmission. This strategy not only improves health outcomes but also ensures the efficient use of limited resources, particularly in low- and middle-income countries.

Recommendations for Future Research Future research should focus on the long-term effectiveness, cost-efficiency, and integration of this approach with other health services, as well as the role of technology and addressing barriers to implementation. These steps aim to improve HIV prevention and treatment outcomes, contributing to better healthcare delivery and public health.

Supporting information

S1 File. Status neutral paper dataset.

(XLSX)

pone.0302803.s001.xlsx^{(11.7MB, xlsx)}

Acknowledgments

I acknowledge several individuals and institutions that made this study a success. Special gratitude goes to my academic supervisors, Professor M. Tshimanga, Dr J. Chirenda and Dr K. Takarinda, The Director of AIDS & TB Unit, Dr O. Mugurungi and the entire HTS team for their support and prodding during this study.

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

References

1.Issue Brief: Status Neutral HIV Care and Service Delivery | Policy and Law | HIV/AIDS | CDC. [cited 21 Aug 2023]. Available from: https://www.cdc.gov/hiv/policies/data/status-neutral-issue-brief.html
2.Demetre Daskalaki. A status neutral approach: achieving together to End HIV epidemic. New York City Department of Health. [Google Scholar]
3.New York City Health. The New York City HIV Status Neutral Prevention and Treatment Cycle. New York City. 2022. [cited 4 Oct 2023]. Available from: https://www.nyc.gov/site/doh/health/health-topics/hiv-status-neutral-prevention-and-treatment-cycle.page
4.Phiri DL, Rees K, Davies N. Outcomes of a model for re-testing HIV-negative index contacts in Sedibeng, South Africa. South Afr J HIV Med. 2023;24(1):1482. doi: 10.4102/sajhivmed.v24i1.1482 [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Mancuso N, Mansergh G, Stephenson R, Horvath KJ, Hirshfield S, Bauermeister JA, et al. Factors associated with mobile app-based ordering of HIV self-test kits among men who have sex with men in Atlanta, Detroit and New York City: an exploratory secondary analysis of a randomized control trial. J Int AIDS Soc. 2023;26(5):e26100.doi: 10.1002/jia2.26100 [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Redefining Prevention and Care: A Status-Neutral Approach to HIV - PubMed. [cited 22 Aug 2023]. Available from: https://pubmed.ncbi.nlm.nih.gov/29977957/. [DOI] [PMC free article] [PubMed]
7.Canty M, Freeman D, Silvia Y.et al. Employing Status-Neutral Approaches to End the HIV Epidemic. 2022. [Google Scholar]
8.CDC. Status Neutral HIV Prevention and Care | Prevent | Effective Interventions | HIV/AIDS | CDC. [cited 21 Aug 2023]. Available from: https://www.cdc.gov/hiv/effective-interventions/prevent/status-neutral-hiv-prevention-and-care/index.html
9.HIV/AIDS | WHO | Regional Office for Africa. [cited 4 Oct 2023]. Available from: https://www.afro.who.int/health-topics/hivaids
10.Zimbabwe | UNAIDS. [cited 4 Oct 2023]. Available from: https://www.unaids.org/en/regionscountries/countries/zimbabwe
11.UNAIDS 2022. Global HIV Statistics. 2022. [cited 14 July 2023]. Available from: https://www.unaids.org/en/resources/fact-sheet
12.Ministry of Health and Child Care. Zimbabwe Operational and Service Delivery Manual (OSDM). Harare. 2022. [Google Scholar]
13.UNAIDS. Global HIV Statistics Update. UNAIDS Official 2021;21:170–1. [Google Scholar]
14.Zimbabwe - Human Development Index - HDI 2021 | countryeconomy.com. [cited 12 Feb 2024]. Available from: https://countryeconomy.com/hdi/zimbabwe
15.Population, total - Zimbabwe | Data. [cited 12 Feb 2024]. Available from: https://data.worldbank.org/indicator/SP.POP.TOTL?locations=ZW
16.Zimbabwe Ministry of Health and Child Care. Ministry of Health and Child Welfare, National Tuberculosis Program –Strategic Plan (2017-2020). Harare, Zimbabwe. 2018. [Google Scholar]
17.Mugauri HD, Chirenda J, Takarinda K, Mugurungi O, Ncube G, Chikondowa I, et al. Optimising the adult HIV testing services screening tool to predict positivity yield in Zimbabwe. PLOS Global Public Health. 2022;2(7):e0000598–17. doi: 10.1371/journal.pgph.0000598 [DOI] [PMC free article] [PubMed] [Google Scholar]
18.UNDP and Government of Zimbabwe. Zimbabwe Human Development Report 2017. Harare, Zimbabwe: Climate Change and Human Development: Towards Building a Climate Resilient Nation. 2017. [Google Scholar]
19.World Population Review. HIV Rates by Country 2024. 2024. [cited 20 Jan 2025]. Available from: https://worldpopulationreview.com/country-rankings/hiv-rates-by-country?form=MG0AV3
20.World Population Review. Zimbabwe Population 2018. 2018. [cited 17 Apr 2018]. Available from: http://worldpopulationreview.com/countries/zimbabwe-population/.
21.Babb BA, Pruett MK. July 2022. Family Court Rev. 2022;60(3):373–4. doi: 10.1111/fcre.12652 [DOI] [Google Scholar]
22.Zimbabwe Country Profile | UN in Zimbabwe. [cited 21 May 2019]. Available from: http://www.zw.one.un.org/uninzimbabwe/zimbabwe-country-profile
23.Mugauri HD, Karakadzai M, Mugurungi O, Chirenda J, Takarinda K, Tshimanga M. Exploring HIV testing models for differentiated service delivery in Southern Africa: a systematic review. JEBHPME. 2023. doi: 10.18502/jebhpme.v7i3.14287 [DOI] [Google Scholar]
24.Howard J. HIV Screening. Scientific, Ethical, and Legal Issues. J Leg Med. 2019;9(4):601–610. doi: 10.1080/01947648809513549 [DOI] [PubMed] [Google Scholar]
25.Moyer VA; U.S. Preventive Services Task Force*. Screening for HIV: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013;159(1):51–60. doi: 10.7326/0003-4819-159-1-201307020-00645 [DOI] [PubMed] [Google Scholar]
26.Know Your HIV Status: What it Means to be Status Neutral - PrEP Daily. (cited 21 Augt 2023]. Available from: https://prepdaily.org/know-your-hiv-status-what-does-it-mean-to-be-status-neutral/.
27.Myers JE, Braunstein SL, Xia Q, Scanlin K, Edelstein Z, Harriman G, et al. Redefining prevention and care: a status-neutral approach to HIV. Open Forum Infect Dis. 2018; 5(6):097. doi: 10.1093/OFID/OFY097 [DOI] [PMC free article] [PubMed] [Google Scholar]
28.Moucheraud C, Chasweka D, Nyirenda M, Schooley A, Dovel K, Hoffman RM. Simple screening tool to help identify high-risk children for targeted HIV testing in Malawian Inpatient Wards. J Acquir Immune Def Syndr. 2018;79(3):352–7. doi: 10.1097/QAI.0000000000001804 [DOI] [PubMed] [Google Scholar]
29.Farnham PG, Gorsky RD, Holtgrave DR. Counselling and testing for HIV prevention: costs, effects, and cost-effectiveness of more rapid screening tests. Public Health Rep. 1996; 111: 44–53. [PMC free article] [PubMed] [Google Scholar]
30.ACHA Education Center: The Status-Neutral HIV Testing Continuum. (cited 21 Aug 2023]. Available from: https://education.acha.org/products/the-status-neutral-hiv-testing-continuum-2
31.Why does HIV kill more men than women? - Bhekisisa. [cited 9 April 2024]. Available from: https://bhekisisa.org/article/2017-08-08-why-does-hiv-kill-more-men-than-women/.
32.Lopez-Varela E, Augusto O, Fuente-Soro L, Sacoor C, Nhacolo A, Casavant I, et al. Quantifying the gender gap in the HIV care cascade in southern Mozambique: we are missing the men. PLoS One. 2021;16(2):e0245461. doi: 10.1371/journal.pone.0245461 [DOI] [PMC free article] [PubMed] [Google Scholar]
33.Hensen B, Taoka S, Lewis JJ, Weiss HA, Hargreaves J. A systematic review of strategies to increase men’s HIV-testing in sub-Saharan Africa. AIDS. 2014; 28(14):2133–45. doi: 10.1097/QAD.0000000000000395 [DOI] [PMC free article] [PubMed] [Google Scholar]
34.Gus Cairns. South Africa: women may have higher rates of HIV than men because fewer men are on treatment. AIDSMap. 2020. [cited 9 Apr 2024]. Available from: https://www.aidsmap.com/news/mar-2018/south-africa-women-may-have-higher-rates-hiv-men-because-fewer-men-are-treatment [Google Scholar]

PLoS One. 2025 Feb 24;20(2):e0302803. doi: 10.1371/journal.pone.0302803.r001

Author response to Decision Letter 0

19 Apr 2024

PLoS One. doi: 10.1371/journal.pone.0302803.r002

Decision Letter 0

Johanna Pruller

30 Jul 2024

PONE-D-24-14652A Status-Neutral Approach to HIV – Is Targeted Testing Still Relevant South of Sahara?PLOS ONE

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Reviewer #1: Overall

This study seeks to showcase the role that status-neutral approach played in targeted HIV testing within the context of Zimbabwe. Overall, I believe there is a disconnection between the findings and question the study sought out to answer. Also, authors haven’t really clarified what both testing approaches above constitute of, making it hard to understand what was brought in extra by the status-neutral approach. Here are some comments for authors’ consideration:

* In my opinion the title of this paper doesn’t correlate with the aim of this study. To answer the question on the relevance of targeted testing, the article needs to showcase the contribution of targeted testing to positivity ratios and linkage to post-test services thus provide elements to justify why it should either be stripped off or maintained. Lines 34-36 rather present study aim to analyze the role of status-neutral approach in the effectiveness of targeted testing. This means thus that the notion of complementarity is already being promoted by the study aim (as backed by the conclusion of the abstract), why then leave the impression of mutual exclusiveness?

* Lines 47-48 read as thus “…from 66% (n=15,289) of the total tests conducted” which is confusing given authors earlier mentioned that 23,058 HIV tests were done. Authors have to clarify such that a reader will easily understand the difference between “HIV tests done” and “total tests conducted”.

* Lines 48-51, authors use a considerate portion of the results subsection of the abstract to present factors associated to HIV seropositivity (test positive or test HIV positive) as one of the key findings which brings me to this question. How does these help in answering the question on the role of status-neutral approach on targeted testing? Its ok to put some unexpected findings but priority must be given to elements that seek to answer the research question and that question here seeks to show the role of status-neutral approach to effectiveness of targeted testing (based on the study aim) not identify factors associated with HIV seropositivity. This comment is valid for the main text (analysis, results and discussion sections) of the paper too.

* Another important thing I have noticed in the abstract is that authors talk of screening as the reference point of comparison between status-neutral and targeted testing (correct me if I am wrong). Still to verify at the methods and results section of the paper to confirm this but I already wonder if this status-neutral testing was a complete package or just the screening. It will be good to know what components status-neutral approach were adopted here.

* Line 58-59 reads “This approach facilitates economic…”, the approach of using targeted and status-neutral testing approaches together? If yes, make it clear in the text.

* The introduction section of this paper reads a lot more like a lecture on status-neutral approach (especially the first four paragraphs) rather than justifying for this study. Its ok to present about status-neutral approach, but authors should provide readers with elements that justify why that is conversation worth making within the context of Zimbabwe (and/or similar context). According to John W. Creswell, the five components of a good introduction are the following: “(a) establishing the problem leading to the study, (b) reviewing the literature about the problem, (c) identifying deficiencies in the literature about the problem, (d) targeting an audience and noting the significance of the problem for this audience, and (e) identifying the purpose of the proposed study”, these elements don’t readily translate in the current introduction.

* Lines 91-92 reads “…promoting it through various for [9]”, something missing in the phrase?

* The “Setting” subsection of the methodology provide detail than what is generally required for that section (as references can always be used to learn more about a country) meanwhile other key components of that section don’t have as much detail. For instance, authors talk of multistage sampling but don’t a detailed description of the sampling process

* Authors had mentioned in the methods section (line 159-161) that sampling was done to achieve balance in terms of high/low volume (I assume here authors are talking about the size of population receiving services at the health facility) as well as urban/rural location of sites. I was expecting to see the distribution of these in the results to appreciate extent to which the above-mentioned sampling worked in doing that.

* Line 170 reads “No patient level data was collected”, I presume here authors mean no “personal identifiers” (to ensure privacy and confidentiality) because age, sex… are still patient level data.

* Building from my previous comment about components of the status-neutral approach, there are no definitions of key variables nor differentiating status-neutral with targeted testing to help reader understand what was brought in extra. As it stands, the only extra thing reported is the screening, but I strongly doubt that status-neutral testing be only that. Secondly no detail is provided on how the screening process itself or even referrals to where readers can have more information on what was done. Furthermore, authors mention on lines 237-239 that “The risk screening was done using a standardized screening algorithm which is part of standard service delivery by the country, in determining eligibility for an HIV test” which leaves the impression that the screening reported here is a routine for a targeted testing of those deem more likely to become positive thus economize on resources needed to test new cases (it’s now becoming confusing). Authors should clarify what status-neutral and targeted testing approaches stand for and what constitutes each one of them within the context of this study. Readers have to see what extra thing brought in by the status neutral approach (its role in the routine).

* After reading through the “Results” section of this paper, I am asking myself this question, how exactly then did status-neutral testing play a role in all these? I was expecting to see comparisons between scenarios where status-neutral was used (alone or coupled with targeted testing) versus those where only targeted testing was used. The closest thing to that comparison is the differentiation with respect to screening only so does this mean that screening is the status-neutral approach. Authors should clarify this.

* The last paragraph of the discussion should be for limitations of the study. I don’t think study strengths add any value to the discussion. In addition to the limitations presented, authors must discuss their implications on the results discussed as well as the good side to it worth noting.

* The discussion and conclusion sections stem from the methods and results sections so it becomes very difficult to discuss something that has not be succinctly presented. Authors now discuss status-neutral and targeted approaches, but readers have not read much that helped them to understand the role that the first played in the second. There is a disconnection between the introduction and discussion sections to the methods and results sections.

Reviewer #2: Manuscript title: A Status-Neutral Approach to HIV – Is Targeted Testing Still Relevant South of

Sahara?

Manuscript ID: PONE-D-24-14652

Authors: Hamufare Dumisani Dumisani Mugauri, Ph.D. Public Health

O Mugurungi, MD, MPH

Joconiah Chirenda, MBChB, MPH, PhD

Kudakwashe Takarinda, Bsc Maths & Statistics, Msc Biostatistics, PhD

Mufuta Tshimanga, MD, MPH

Prosper Mangwiro, Bsc Statistics, MPH

Dear authors thank you for coming up with good title and good work. I reviewed the article and have some comments.

Title: please specific it, since it confuses the reader, south of sahara while the study in one country?

Abstract:

1. In method add the final sample size included

2. Conclusion should be conclusion but not comparison, revise the conclusion

Introduction: The introduction is interesting but the previous literatures and practice of status neutral in Africa not well addressed

Method and materials

Study design: say only cross sectional

1. Did you only include 1 October 2023 to 31 December 2023 tested data, what about those tested in the community?what about those tested in non-government organization?

2. Introduction Argue the reader what is new on Status-Neutral Approach to HIV over PICT, VCT,index testing, Social Network-Based HIV Testing and others strategies

3. Did you included the minors?

4. As we know DHIS2 is not accessed by other third part since it accessed by government organization, how did you access it?

5. Our study was exempted from ethical clearance, how since HIV is sensitive issue and DHS2 isnot open access, I think this research had ethical problem?

6. The result seems report please rewrite it

7. Discussion please remove the limitation and strength on this section and write after is before conclusion

8. Discussion should be discussion, remove the results in discussion and discuss with previous literatures

9. In clonclusion what overway status-neutral testing to other tasting strategy, Is more effective than PICT, VCT,index testing, Social Network-Based HIV Testing and others strategies

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Reviewer #1: No

Reviewer #2: No

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PLoS One. 2025 Feb 24;20(2):e0302803. doi: 10.1371/journal.pone.0302803.r003

Author response to Decision Letter 1

2 Oct 2024

Point-by-Point Response to Editor and Reviewers of Paper PONE-D-24-14652 :

We thank you all for your time and dedication in going through this paper and we acknowledge the reviews and comments from the editor and reviewers. We provide a point-by-point response to each comment with each response introduced by the words “AUTHOR RESPONSE” in capital letters. We have revised the paper accordingly in response to these comments as indicated in our responses below and in tracked changes in the manuscript. We hope that the revised paper meets your expectations and may now be suitable for publication in your journal.

Yours sincerely,

Hamufare Mugauri

Point by Point Response to reviewer comments

1. REVIEWER COMMENT

Dear authors thank you for coming up with good title and good work. I reviewed the article and have some comments.

Title: please specific it, since it confuses the reader, south of sahara while the study in one country?.

AUTHOR RESPONSE

Thank you for your appreciation and the comment. We have revised the title to be specific to Zimbabwe.

2. REVIEWER COMMENT: Abstract:

a. In method add the final sample size included

b. Conclusion should be conclusion but not comparison, revise the conclusion

AUTHOR RESPONSE: Thank you for pointing this out. We have revised the entire abstract to ensure that the conclusions are well aligned. We included the entire population of documented tests for the period studied and did not calculate a sample.

3. REVIEWER COMMENT: Introduction: The introduction is interesting but the previous literatures and practice of status neutral in Africa not well-addressed

AUTHOR RESPONSE: Thank you for this comment. Considering that Status Neutral is a new concept, there is paucity of data on its implementation in Africa. However, we managed to add a paragraph that speaks to the concept in relation to the concept as follows: “In Africa, particularly in sub-Saharan regions, the status-neutral approach has been integrated into existing HIV testing frameworks to enhance the effectiveness of HIV prevention and treatment programs. Countries like Zimbabwe have been at the forefront of implementing this approach alongside targeted testing methods [7]. This dual strategy is yet to be fully understood, highlighting a knowledge gap on how it relates to targeted testing concept”

4. REVIEWER COMMENT: . Study design: say only cross-sectional

AUTHOR RESPONSE: Thank you, this has been corrected as suggested.

5. REVIEWER COMMENT: Did you only include 1 October 2023 to 31 December 2023 tested data, what about those tested in the community?what about those tested in non-government organisations?

AUTHOR RESPONSE: Thank you for this question. The data we included is for 1 October 2023 to 31 December 2023 only and included all testing data from the community and partners. This data is all entered into DHIS2, a national electronic database.

6. REVIEWER COMMENT: Introduction Argue with the reader what is new on the Status-Neutral Approach to HIV over PICT, VCT,index testing, Social Network-Based HIV Testing and others strategies

AUTHOR RESPONSE: Thank you for the concept. The status neutral concept is a new concept itself as introduced in the introduction as follows “Status-neutral HIV testing is a novel approach to HIV education, testing and treatment that accentuates a continuum of care regardless of the individual’s HIV diagnosis….”.

7. REVIEWER COMMENT: Did you include the minors?

AUTHOR RESPONSE: This study only included 15 year olds and above, who are eligible to consent to HIV Testing in Zimbabwe. Line 165-170 reads “All clients who were tested for HIV and documented in HIV Testing registers, at the 36 sampled facilities between 1 October 2023 to 31 December 2023 and aged 15 years and above, were included in the study”

8. REVIEWER COMMENT: As we know DHIS2 is not accessed by other third part since it accessed by government organization, how did you access it?

AUTHOR RESPONSE: Thank you for this question. The lead investigator is attached to the Ministry of Health, AIDS AND tb Programme at Head office and has access rights to DHIS2, Further, another author, Dr Owen Mugurungi is the Director AIDS & TB Programe and has access rights to DHIS2 too.

9. REVIEWER COMMENT: Our study was exempted from ethical clearance, how since HIV is sensitive issue and DHS2 isnot open access, I think this research had ethical problem?.

AUTHOR RESPONSE: Thank you for raising this important concern. The study in question was exempted from ethical clearance based on specific criteria outlined by the institutional review board (IRB). While HIV is indeed a sensitive issue, the exemption was granted because the study utilized de-identified data from the DHIS2 system, ensuring that no personal identifiers were accessible. This approach aligns with ethical guidelines that prioritize participant confidentiality and data protection. Moreover, the study adhered to the principles of ethical research by ensuring that all data used were anonymized and aggregated, thus minimizing any potential risks to individuals. The exemption was also based on the fact that the research did not involve direct interaction with human subjects, which typically necessitates a more rigorous ethical review process

10. REVIEWER COMMENT: The result seems report please rewrite it

AUTHOR RESPONSE: Thank you for your feedback. I understand that the results section may come across as more of a report rather than a detailed analysis. We have revised this section to ensure it provides a clearer interpretation of the data, highlighting key findings and their implications.

11. REVIEWER COMMENT: Discussion please remove the limitation and strength on this section and write after is before conclusion

AUTHOR RESPONSE: Thank you for your suggestion. We have removed the limitations and strengths from the Discussion section and place them in a new section titled “Limitations and Strengths,” which is positioned just before the Conclusion. This adjustment will help streamline the Discussion section and provide a clearer structure to the manuscript..

12. REVIEWER COMMENT: Discussion should be discussion, remove the results in discussion and discuss with previous literatures

AUTHOR RESPONSE: We acknowledge your opinion. We have revised the entire discussion section to be more scientifically correct and relate our discussion points to previous literature

13. REVIEWER COMMENT: * Line 170 reads “No patient level data was collected”, I presume here authors mean no “personal identifiers” (to ensure privacy and confidentiality) because age, sex… are still patient level data.

AUTHOR RESPONSE: Thank you for pointing this out. We have revised to read: “No personal identifiers were collected.”

14. REVIEWER COMMENT: The last paragraph of the discussion should be for limitations of the study. I don’t think study strengths add any value to the discussion. In addition to the limitations presented, authors must discuss their implications on the results discussed as well as the good side to it worth noting.

AUTHOR RESPONSE: Thank you for pointing this out. The entire Discussion has been revised and the comment addressed.

15. VREVIEWER COMMENT: The discussion and conclusion sections stem from the methods and results sections so it becomes very difficult to discuss something that has not be succinctly presented. Authors now discuss status-neutral and targeted approaches, but readers have not read much that helped them to understand the role that the first played in the second. There is a disconnection between the introduction and discussion sections to the methods and results sections

AUTHOR RESPONSE: Thank you for your valuable feedback. We understand the importance of ensuring that the discussion and conclusion sections are clearly connected to the methods and results sections. We have revised these sections to provide a more succinct and coherent presentation of our findings.

16. REVIEWER COMMENT: In my opinion the title of this paper doesn’t correlate with the aim of this study. To answer the question on the relevance of targeted testing, the article needs to showcase the contribution of targeted testing to positivity ratios and linkage to post-test services thus provide elements to justify why it should either be stripped off or maintained. Lines 34-36 rather present study aim to analyze the role of status-neutral approach in the effectiveness of targeted testing. This means thus that the notion of complementarity is already being promoted by the study aim (as backed by the conclusion of the abstract), why then leave the impression of mutual exclusiveness?

AUTHOR RESPONSE: Thank you for your insightful comments. We appreciate your feedback and have carefully considered your suggestions.

1. Title Correlation with Study Aim:

o We acknowledge your concern regarding the correlation between the title and the study aim. To address this, we have revised the title to be more specif to Zimbabwe than saying South of sahara. However, we prefer that it remain a rhetoric question that it is, but addressing all the concerns you raised: “A Status-Neutral Approach to HIV – Is Targeted Testing Still Relevant in Zimbabwe?.”

2. Showcasing Contribution of Targeted Testing:

o We agree that it is crucial to highlight the contribution of targeted testing to positivity ratios and linkage to post-test services. We have added a section in the results and discussion that specifically addresses these aspects. This includes data on positivity ratios and detailed analysis of how targeted testing contributes to effective linkage to post-test services. These additions are within the entirely revised results and discussions sections

3. Clarifying Complementarity vs. Mutual Exclusiveness:

o We understand the importance of clarifying the notion of complementarity as opposed to mutual exclusiveness. We have revised the relevant sections (lines 34-36 and the conclusion of the abstract) to emphasize that the status-neutral approach complements targeted testing rather than being mutually exclusive.

17. REVIEWER COMMENT: Lines 47-48 read as thus “…from 66% (n=15,289) of the total tests conducted” which is confusing given authors earlier mentioned that 23,058 HIV tests were done. Authors have to clarify such that a reader will easily understand the difference between “HIV tests done” and “total tests conducted

AUTHOR RESPONSE: Thank you for your valuable feedback. We understand the confusion and have made the following clarifications to ensure the distinction between “HIV tests done” and “total tests conducted” is clear: We have revised the manuscript to clearly added that total tests done are actually total HIV tests done.

18. REVIEWER COMMENT: Lines 48-51, authors use a considerate portion of the results subsection of the abstract to present factors associated to HIV seropositivity (test positive or test HIV positive) as one of the key findings which brings me to this question. How does these help in answering the question on the role of status-neutral approach on targeted testing? Its ok to put some unexpected findings but priority must be given to elements that seek to answer the research question and that question here seeks to show the role of status-neutral approach to effectiveness of targeted testing (based on the study aim) not identify factors associated with HIV seropositivity. This comment is valid for the main text (analysis, results and discussion sections) of the paper too.

AUTHOR RESPONSE: Thank you for your insightful comments. We appreciate your feedback and have carefully considered your suggestions.

1. Relevance to Research Question:

o We acknowledge that the primary aim of our study is to evaluate the role of the status-neutral approach in the effectiveness of targeted testing. We agree that the focus should be on elements that directly address this research question. To this end, we have revised the abstract and main text to prioritize findings that demonstrate the impact of the status-neutral approach on targeted testing effectiveness.

2. Revised Presentation of Results:

o In the abstract (lines 48-51), we have restructured the results section to emphasize the key findings related to the status-neutral approach. Specifically, we now highlight how the status-neutral approach enhances the identification of HIV-positive individuals and improves linkage to post-test services, which are critical components of targeted testing effectiveness.

3. Incorporation of Unexpected Findings:

o While we recognize the importance of reporting unexpected findings, we have ensured that these are presented in a way that supports the main research question. Factors associated with HIV seropositivity are now discussed in the context of how they inform and enhance the understanding of the status-neutral approach’s effectiveness.

4. Main Text Revisions:

o We have also revised the analysis, results, and discussion sections of the main text to align with this focus. The revised sections now clearly articulate the role of the status-neutral approach in improving targeted testing outcomes, supported by relevant data and analysis.

We hope these revisions address your concerns and improve the clarity and relevance of our manuscript. Thank you once again for your valuable feedback.

19. REVIEWER COMMENT: Another important thing I have noticed in the abstract is that authors talk of screening as the reference point of comparison between status-neutral and targeted testing (correct me if I am wrong). Still to verify at the methods and results section of the paper to confirm this but I already wonder if this status-neutral testing was a complete package or just the screening. It will be good to know what components status-neutral approach were adopted here.

AUTHOR RESPONSE: Thank you for your insightful questions. We appreciate your feedback and would like to provide the following clarifications:

1. Reference Point of Comparison:

o You are correct that the abstract refers to screening as a reference point for comparing the status-neutral and targeted testing approaches. We have clarified this in the methods section to ensure it is clear that the comparison includes all components of the status-neutral approach, not just the screening process.

2. Components of the Status-Neutral Approach:

The status-neutral approach adopted in our study is a comprehensive package that includes several key components:

o HIV Testing: Initiating the pathway to prevention and treatment regardless of the test result.

o Linkage to Care: Immediate linkage to HIV care and treatment for those who test positive, and linkage to prevention services for those who test negative.

o Support Services: Integration of supportive services such as counseling, housing, food, and transportation assistance to address social determinants of health.

o Culturally Affirming Care: Providing high-quality, stigma-free, and inclusive care that meets the needs of individuals regardless of their HIV status.

3. Clarifications in the Manuscript:

o We have revised the methods and results sections to explicitly outline these components and how they were implemented in the study. This ensures that readers can clearly understand the full scope of the status-neutral approach used.

We hope these clarifications address your concerns and improve the clarity of our manuscript. Thank you once again for your valuable feedback.

20. REVIEWER COMMENT: In clonclusion what overway status-neutral testing to other tasting strategy, Is more effective than PICT, VCT,index testing, Social Network-Based HIV Testing and others strategies

AUTHOR RESPONSE: Thank you for your insightful comment. We appreciate the opportunity to clarify the comparative effectiveness of the status-neutral approach relative to other HIV testing strategies.

1. Effectiveness of Status-Neutral Testing:

The status-neutral approach is designed to provide comprehensive care and support regardless of HIV status, which helps to reduce stigma and improve engagement in care. This approach integrates HIV prevention and treatment services, addressing the needs of individuals holistically. By focusing on the whole person, the status-neutral approach can enhance

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Submitted filename: Mugauri_Detailed responses to reviewer comments.doc

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PLoS One. doi: 10.1371/journal.pone.0302803.r004

Decision Letter 1

Zypher Jude G Regencia

5 Dec 2024

PONE-D-24-14652R1A Status-Neutral Approach to HIV – Is Targeted Testing Still Relevant in Zimbabwe?PLOS ONE

Dear Dr. Mugauri,

Please submit your revised manuscript by Jan 19 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Zypher Jude G. Regencia, Ph.D.

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: (No Response)

Reviewer #4: (No Response)

Reviewer #5: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #3: Yes

Reviewer #4: (No Response)

Reviewer #5: No

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

Reviewer #4: (No Response)

Reviewer #5: No

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4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #3: Yes

Reviewer #4: (No Response)

Reviewer #5: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #3: Yes

Reviewer #4: (No Response)

Reviewer #5: Yes

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6. Review Comments to the Author

Reviewer #3: Specific Recommendations

1. Revise the conclusion to clearly state how findings align with the study’s objectives. Avoid introducing new information.

2. Address potential biases (e.g., reliance on DHIS2 data) and how they were mitigated.

3. Strengthen the narrative flow between sections—particularly the connection between methods, results, and discussion.

Reviewer #4: (No Response)

Reviewer #5: results does not reflect objectives of the study. Discussion and conclusion made was not coherent. In my opinion, the statistical analysis made was not applicable due to the nature of their data.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #3: Yes: Dr. Prachi Joshi

Reviewer #4: No

Reviewer #5: No

**********

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PLoS One. 2025 Feb 24;20(2):e0302803. doi: 10.1371/journal.pone.0302803.r005

Author response to Decision Letter 2

18 Dec 2024

Point-by-Point Response to Editor and Reviewers of Paper PONE-D-24-14652 :

Yours sincerely,

Hamufare Mugauri

Point by Point Response to reviewer comments

Reviewer 1.

1. REVIEWER COMMENT

Thank you for the opportunity to review this paper highlighting the benefits of employing a combined status neutral and targeted HIV testing approach in low resource settings. The study found that status neutral approach and targeted testing approaches complement each other and can help prevent HIV transmission, promote linkage to care and treatment services, and the strategic use of limited resources to end the HIV epidemic. This work is an important contribution to the field and should be considered for publication with some revisions. Below I provide a few comments for the authors to consider.

AUTHOR RESPONSE

Thank you for your appreciation and the comment. We concur with your observations on the importance of the subject which we studied. We made sure to address all comments you raised as indicated below:

2. REVIEWER COMMENT: Introduction

The sentences from lines 99-102 are unclear. Lines 99-100 is an incomplete sentence and lines 101-102 the concept of variability is not explained, I encourage the authors to revisit this paragraph for clarity.

AUTHOR RESPONSE: Thank you for your insightful feedback. We appreciate the opportunity to clarify the content in lines 99-102. Here is our revised paragraph for better clarity: “The Status Neutral concept is rapidly gaining global acceptance. Organizations such as the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) actively promote it through various initiatives [9]. The adoption of this concept varies among countries, influenced by their unique contexts and needs”

3. REVIEWER COMMENT: In lines 103-105, it would be useful for readers if the authors could provide a brief overview of how the status neutral approach has been integrated into existing HIV testing frameworks in sub-Saharan Africa

AUTHOR RESPONSE: Thank you for this comment. Here is a revised version with additional details: “In Africa, particularly in sub-Saharan regions, the status-neutral approach has been integrated into existing HIV testing frameworks to enhance the effectiveness of HIV prevention and treatment programs. This approach ensures that HIV testing and related services are offered to all individuals, regardless of their HIV status, promoting continuous engagement in care. Countries like Zimbabwe have been at the forefront of implementing this approach, incorporating it alongside targeted testing methods to improve linkage to care and retention in treatment, thereby addressing both prevention and treatment comprehensively”.

4. REVIEWER COMMENT: . Lines 107-108 outline the knowledge gap the authors intend to fill, this is also a good opportunity for the authors to expand upon the reason why it is important to examine this dual strategy and better position their work and where it fits/its potential contribution/use.

AUTHOR RESPONSE: Thank you, we have explained as follows: “This dual strategy, which involves integrating the status-neutral approach with targeted testing methods, is yet to be fully understood, highlighting a significant knowledge gap. Examining this dual strategy is crucial because it has the potential to enhance the effectiveness of HIV prevention and treatment programs by ensuring continuous engagement in care regardless of HIV status, while also targeting high-risk populations for more focused interventions. Understanding how these two approaches can complement each other will contribute to more effective and inclusive healthcare strategies, ultimately improving health outcomes in sub-Saharan Africa. Our work aims to fill this gap by providing comprehensive insights into the integration and impact of these strategies, positioning itself as a valuable resource for policymakers and healthcare providers”.

5. REVIEWER COMMENT: Last paragraph, lines 124-127, the aims of the paper could be better outlined. Authors should emphasize the examination of the complementariness of status neutral and targeted approach to HIV testing.

AUTHOR RESPONSE: Thank you for this observation. The revised version reads now reads: “This paper thoroughly examined the complementariness of the status-neutral and targeted approaches to HIV testing in the context of a generalized epidemic, high new infections, and established ongoing transmission of HIV. By exploring how these strategies can work together to enhance HIV prevention and treatment efforts, we seek to provide insights and recommendations for the context-specific application of the status-neutral concept. Our goal is to highlight the potential benefits of integrating these approaches to improve healthcare outcomes in sub-Saharan Africa, particularly in countries like Zimbabwe”.

6. REVIEWER COMMENT: Methods

This section could be structured a bit better to help with the flow. For example, in lines 130-131 under the authors just list “cross-sectional”. I encourage the authors to get rid of the study design heading and instead write a descriptive sentence that includes the study design but also adds some context about the study, including discussion of the data source, etc. and other important aspects that readers should be aware of.

AUTHOR RESPONSE: Thank you for the suggestion. We have revised to read: “This study employed a cross-sectional design to examine the integration of the status-neutral approach within existing HIV testing frameworks in sub-Saharan Africa. Data were sourced from a combination of health facility records, national health surveys, and interviews with healthcare providers. The cross-sectional nature of the study allowed us to capture a snapshot of the current state of HIV testing and treatment, providing valuable insights into the effectiveness and challenges of implementing the status-neutral approach alongside targeted testing methods”.

7. REVIEWER COMMENT: Authors should consider removing the sub-headings in line 133 and 138

AUTHOR RESPONSE: This suggestion has been implemented and the sub-headings removed.

8. REVIEWER COMMENT: In line 142 authors mention four subunits of ATP but name only three

AUTHOR RESPONSE: You may have missed the 4th, they are all mentioned as follows: “Four sub-units under ATP, namely, 1 HIV Prevention, 2Care and Treatment, 3Prevention of Mother to Child Transmission (PMTCT) and 4Monitoring and Evaluation (M & E)..

9. REVIEWER COMMENT: Description of study sites, lines 154-165, at times is unclear, authors should revise to improve readability. Also, the discussion of each province is unbalanced. I would also suggest the authors include data on the HIV prevalence and incidence rates in the four provinces. The authors discuss how these provinces were selected later on in the study, but that information should be moved to here to enhance comprehension

AUTHOR RESPONSE: Thank you for raising this important concern. Find below the revision: “The study sites included four provinces selected out of the ten provinces in Zimbabwe, based on their diverse geographical and demographic characteristics as well as varying levels of HIV prevalence and incidence. Manicaland Province: Located in eastern Zimbabwe, Manicaland is the second-most populous province after Harare, with a population of approximately 1.75 million as of the 2012 census. This province has been significantly impacted by the HIV epidemic, with high prevalence rates, making it a critical area for studying HIV interventions[18]. Mashonaland West Province: Situated to the north of Zimbabwe, Mashonaland West shares an international border with Zambia. It borders several other provinces internally, including Midlands, Matabeleland North, Mashonaland Central, Harare, and Mashonaland East. The region has a notable HIV prevalence, warranting focused efforts on HIV testing and treatment [19]. Matabeleland South Province: This province covers the southeastern plateau of Zimbabwe and stretches to the borders with Botswana and South Africa. The area is characterized by high HIV incidence, particularly in cross-border communities, highlighting the need for targeted HIV prevention and treatment strategies [20]. Midlands Province: Midlands province spans an area of 49,166 square kilometres and has a population of approximately 1.61 million. With its diverse population and significant HIV prevalence rates, this province provides a vital context for examining the effectiveness of HIV interventions[21].

10. REVIEWER COMMENT: Discussion of the sampling strategy should precede the discussion of the client population; authors should revise the order in which the sampling strategy and sample are discussed to improve comprehension

AUTHOR RESPONSE: Thank you for this observation, the sections have been correctly placed, sampling strategy first, then the client population.

11. REVIEWER COMMENT: In line 201 the authors states that no personal identifiers were collected but in line 199 it states that “name of patient” was collected from the report

AUTHOR RESPONSE: Thank you for this observation. We have revised as follows: “The following variables were collected: HTS number, name of the facility, age, sex, screening for an HIV test, reason for an HIV test, HIV test result, linkage to post-test services (yes/no), and specific services linked to. To ensure privacy, patient names were not included in the final dataset used for analysis. Therefore, no personal identifiers were collected in the analyzed data”

12. REVIEWER COMMENT: In line 217-219 authors explanation for why the study was exempt from ethical clearance makes it seem like DHIS2 database does not collect personally identifiable information, authors should revise justification and state that they received de-identified data if that was the case, and briefly explain the process

AUTHOR RESPONSE: We acknowledge your opinion. Here is the revision: “Our study was exempted from ethical clearance because it utilized routinely collected data extracted from the DHIS2 database. The data we received were de-identified, with all patient-identifying information removed prior to analysis. This ensured the privacy and confidentiality of the individuals' information. As a result, no primary data were collected, and the use of de-identified data qualified the study for ethical exemption.”

13. REVIEWER COMMENT: It would be helpful for the authors to briefly describe the complementary approach that fuses status neutral and targeted testing, is there a model that can be referenced? Both approaches are described but there is not a clear description of the kind of testing the authors seem to be advocating for.

AUTHOR RESPONSE: Thank you for pointing this out. Unfortunately there is no 3rd model that can be referenced. However, we have revised, under discussion intro to read: “A key finding in this study is that the status-neutral approach to HIV testing complements targeted HIV testing by creating a more inclusive and comprehensive testing framework. This dual strategy allows for prioritized testing of high-risk populations while ensuring that all individuals, regardless of their HIV status, have access to HIV prevention and treatment services. By integrating these approaches, we can enhance case identification, improve linkage to care, and ultimately reduce HIV transmission rates. This model aligns with the Comprehensive 95% targets set by UNAIDS, which emphasize the importance of linkage to comprehensive HIV prevention services.”

14. REVIEWER COMMENT: Authors should describe the variables, including what screening for an HIV test, linkage to post-test services, and specific services entail

AUTHOR RESPONSE: Thank you for pointing this out. We have added detail on the variables as follows: “Variables Collected: Screening for an HIV test: This variable refers to the initial assessment process conducted to determine an individual's risk of HIV infection and the need for an HIV test. It includes questions about sexual behavior, history of sexually transmitted infections, and other risk factors that might indicate the need for HIV testing. Linkage to post-test services: This variable indicates whether individuals who tested positive for HIV were connected to appropriate follow-up services. This includes referrals to healthcare facilities, counseling services, and support groups to ensure continuous engagement in care and treatment adherence.

Specific services linked to: These variable details the specific types of post-test services that individuals were connected to. These services may include antiretroviral therapy (ART), prevention of mother-to-child transmission (PMTCT) programs, pre-exposure prophylaxis (PrEP) for those at high risk, and other medical and social support services aimed at improving health outcomes for people living with HIV.”

15. VREVIEWER COMMENT: Discussion

The authors discuss their results and implications very succinctly. It would be helpful if the authors provided some discussion on specifically how this approach can be implemented and why, to illustrate the contribution of the findings of study and/or discussion of how the authors see their findings directly affecting health care service delivery.

AUTHOR RESPONSE: Thank you for the compliment and valuable feedback. We have added the following detail under Implications for policy and practice: “To effectively implement the status-neutral targeted HIV testing approach in Zimbabwe and beyond, several actionable steps and policy changes are necessary. Key stakeholders must also be identified to drive this initiative forward. Below are the recommended steps, policy adjustments, and potential barriers:

Actionable Steps:

i. Policy Development and Alignment: Develop national policies that support the integration of the status-neutral approach with targeted HIV testing. These policies should align with existing health strategies and frameworks to ensure seamless implementation.

ii. Stakeholder Engagement: Engage key stakeholders, including government health departments, non-governmental organizations (NGOs), community leaders, healthcare providers, and international partners such as the World Health Organization (WHO) and UNAIDS. Collaborative efforts are essential for resource mobilization, advocacy, and sustained support.

iii. Capacity Building: Invest in the training and capacity building of healthcare providers to enhance their understanding and implementation of the integrated approach. Training programs should focus on the benefits, procedures, and best practices for combining status-neutral and targeted testing methods.

iv. Resource Allocation: Ensure adequate resources are available for the implementation of the dual strategy. This includes funding for testing kits, infrastructure, personnel, and support services necessary for continuous engagement in care.

v. Community Outreach and Education: Launch community outreach programs to raise awareness about the integrated approach. Educational campaigns should aim to reduce stigma, encourage testing, and promote the benefits of continuous care and targeted interventions.

Policy Adjustments:

i. Regulatory Support: Implement regulatory frameworks that facilitate the integration of the status-neutral approach into existing HIV testing guidelines. This may involve revising existing protoc

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Submitted filename: V2_Mugauri_Detailed responses to reviewer comments.doc

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PLoS One. doi: 10.1371/journal.pone.0302803.r006

Decision Letter 2

Zypher Jude G Regencia

19 Jan 2025

PONE-D-24-14652R2Integrating Status-Neutral and Targeted HIV Testing in Zimbabwe: A Complementary StrategyPLOS ONE

Dear Dr. Mugauri,

Please submit your revised manuscript by Mar 05 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Zypher Jude G. Regencia, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: All comments have been addressed

Reviewer #4: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #3: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Reviewer #3: (No Response)

Reviewer #4: Thank you for providing the opportunity to re-review the paper post revisions from the authors. I am satisfied with all the changes. One minor suggestion I have is that, in addition to the detail provided on the included provinces, I recommend that the authors to consider including the prevalence rates for each province into the manuscript.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #3: Yes: Dr. Prachi Joshi

Reviewer #4: No

**********

Attachment

Submitted filename: A status neutral approach to HIV_2nd review_KM.docx

pone.0302803.s008.docx^{(11.8KB, docx)}

PLoS One. 2025 Feb 24;20(2):e0302803. doi: 10.1371/journal.pone.0302803.r007

Author response to Decision Letter 3

20 Jan 2025

We thank you all for your time and dedication in going through this paper once more and we acknowledge the reviews and comments from the editor and reviewers. We provide a point-by-point response to each comment with each response introduced by the words “AUTHOR RESPONSE” in capital letters. We have revised the paper accordingly in response to these comments as indicated in our responses below and in tracked changes in the manuscript. We hope that the revised paper meets your expectations and may now be suitable for publication in your journal.

Yours sincerely,

Hamufare Mugauri

REVIEWER COMMENT: Thank you for providing the opportunity to re-review the paper post revisions from the authors. I am satisfied with all the changes. One minor suggestion I have is that, in addition to the detail provided on the included provinces, I recommend that the authors to consider including the prevalence rates for each province into the manuscript.

AUTHOR RESPONSE

Thank you for your appreciation and the comment. . We are pleased to hear that you are satisfied with the changes we have made. We appreciate your suggestion to include the prevalence rates for each province. We agree that this addition would enhance the depth and clarity of our manuscript. We have therefore incorporated the prevalence rates for Manicaland, Mashonaland West, Matabeleland South, and Midlands Province in the revised version of the paper as follows: “Manicaland Province: Located in eastern Zimbabwe, Manicaland is the second-most populous province after Harare, with a population of approximately 1.75 million as of the 2022 census. This province has been significantly impacted by the HIV epidemic, with a prevalence of 9.40% in 2024. . This makes it a critical area for studying HIV interventions[18, 19]. Mashonaland West Province: Situated to the north of Zimbabwe, Mashonaland West shares an international border with Zambia. It borders several other provinces internally, including Midlands, Matabeleland North, Mashonaland Central, Harare, and Mashonaland East. The region had a notable HIV prevalence of 9.60% in 2024, warranting focused efforts on HIV testing and treatment [19, 20]. Matabeleland South Province: This province covers the southeastern plateau of Zimbabwe and stretches to the borders with Botswana and South Africa. The area is characterized by high HIV incidence, particularly in cross-border communities, with a prevalence rate of 17.30% in 2024, highlighting the need for targeted HIV prevention and treatment strategies [19, 21]. Midlands Province: Midlands province spans an area of 49,166 square kilometres and has a population of approximately 1.61 million. With its diverse population and significant HIV prevalence rate of 10.94% in 2024, , this province provides a vital context for examining the effectiveness of HIV interventions[19, 22].”

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Submitted filename: V3_Mugauri_Detailed responses to reviewer comments.doc

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PLoS One. doi: 10.1371/journal.pone.0302803.r008

Decision Letter 3

Zypher Jude G Regencia

3 Feb 2025

Integrating Status-Neutral and Targeted HIV Testing in Zimbabwe: A Complementary Strategy

PONE-D-24-14652R3

Dear Dr. Magauri,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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PLoS One. doi: 10.1371/journal.pone.0302803.r009

Acceptance letter

Zypher Jude Regencia

PONE-D-24-14652R3

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File. Status neutral paper dataset.

(XLSX)

pone.0302803.s001.xlsx^{(11.7MB, xlsx)}

Attachment

Submitted filename: Comment to the authors.docx

pone.0302803.s002.docx^{(13.8KB, docx)}

Attachment

Submitted filename: Mugauri_Detailed responses to reviewer comments.doc

pone.0302803.s003.doc^{(72.3KB, doc)}

Attachment

Submitted filename: peer review and feedback_Joshi.docx

pone.0302803.s004.docx^{(16.1KB, docx)}

Attachment

Submitted filename: PONED-24-14652_R1.docx

pone.0302803.s005.docx^{(14.1KB, docx)}

Attachment

Submitted filename: A status neutral approach to HIV_review_KM.docx

pone.0302803.s006.docx^{(16.8KB, docx)}

Attachment

Submitted filename: V2_Mugauri_Detailed responses to reviewer comments.doc

pone.0302803.s007.doc^{(120.4KB, doc)}

Attachment

Submitted filename: A status neutral approach to HIV_2nd review_KM.docx

pone.0302803.s008.docx^{(11.8KB, docx)}

Attachment

Submitted filename: V3_Mugauri_Detailed responses to reviewer comments.doc

pone.0302803.s010.doc^{(53.7KB, doc)}

Data Availability Statement

All relevant data are within the manuscript and its Supporting Information files.

[pone.0302803.ref001] 1.Issue Brief: Status Neutral HIV Care and Service Delivery | Policy and Law | HIV/AIDS | CDC. [cited 21 Aug 2023]. Available from: https://www.cdc.gov/hiv/policies/data/status-neutral-issue-brief.html

[pone.0302803.ref002] 2.Demetre Daskalaki. A status neutral approach: achieving together to End HIV epidemic. New York City Department of Health. [Google Scholar]

[pone.0302803.ref003] 3.New York City Health. The New York City HIV Status Neutral Prevention and Treatment Cycle. New York City. 2022. [cited 4 Oct 2023]. Available from: https://www.nyc.gov/site/doh/health/health-topics/hiv-status-neutral-prevention-and-treatment-cycle.page

[pone.0302803.ref004] 4.Phiri DL, Rees K, Davies N. Outcomes of a model for re-testing HIV-negative index contacts in Sedibeng, South Africa. South Afr J HIV Med. 2023;24(1):1482. doi: 10.4102/sajhivmed.v24i1.1482 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0302803.ref005] 5.Mancuso N, Mansergh G, Stephenson R, Horvath KJ, Hirshfield S, Bauermeister JA, et al. Factors associated with mobile app-based ordering of HIV self-test kits among men who have sex with men in Atlanta, Detroit and New York City: an exploratory secondary analysis of a randomized control trial. J Int AIDS Soc. 2023;26(5):e26100.doi: 10.1002/jia2.26100 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0302803.ref006] 6.Redefining Prevention and Care: A Status-Neutral Approach to HIV - PubMed. [cited 22 Aug 2023]. Available from: https://pubmed.ncbi.nlm.nih.gov/29977957/. [DOI] [PMC free article] [PubMed]

[pone.0302803.ref007] 7.Canty M, Freeman D, Silvia Y.et al. Employing Status-Neutral Approaches to End the HIV Epidemic. 2022. [Google Scholar]

[pone.0302803.ref008] 8.CDC. Status Neutral HIV Prevention and Care | Prevent | Effective Interventions | HIV/AIDS | CDC. [cited 21 Aug 2023]. Available from: https://www.cdc.gov/hiv/effective-interventions/prevent/status-neutral-hiv-prevention-and-care/index.html

[pone.0302803.ref009] 9.HIV/AIDS | WHO | Regional Office for Africa. [cited 4 Oct 2023]. Available from: https://www.afro.who.int/health-topics/hivaids

[pone.0302803.ref010] 10.Zimbabwe | UNAIDS. [cited 4 Oct 2023]. Available from: https://www.unaids.org/en/regionscountries/countries/zimbabwe

[pone.0302803.ref011] 11.UNAIDS 2022. Global HIV Statistics. 2022. [cited 14 July 2023]. Available from: https://www.unaids.org/en/resources/fact-sheet

[pone.0302803.ref012] 12.Ministry of Health and Child Care. Zimbabwe Operational and Service Delivery Manual (OSDM). Harare. 2022. [Google Scholar]

[pone.0302803.ref013] 13.UNAIDS. Global HIV Statistics Update. UNAIDS Official 2021;21:170–1. [Google Scholar]

[pone.0302803.ref014] 14.Zimbabwe - Human Development Index - HDI 2021 | countryeconomy.com. [cited 12 Feb 2024]. Available from: https://countryeconomy.com/hdi/zimbabwe

[pone.0302803.ref015] 15.Population, total - Zimbabwe | Data. [cited 12 Feb 2024]. Available from: https://data.worldbank.org/indicator/SP.POP.TOTL?locations=ZW

[pone.0302803.ref016] 16.Zimbabwe Ministry of Health and Child Care. Ministry of Health and Child Welfare, National Tuberculosis Program –Strategic Plan (2017-2020). Harare, Zimbabwe. 2018. [Google Scholar]

[pone.0302803.ref017] 17.Mugauri HD, Chirenda J, Takarinda K, Mugurungi O, Ncube G, Chikondowa I, et al. Optimising the adult HIV testing services screening tool to predict positivity yield in Zimbabwe. PLOS Global Public Health. 2022;2(7):e0000598–17. doi: 10.1371/journal.pgph.0000598 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0302803.ref018] 18.UNDP and Government of Zimbabwe. Zimbabwe Human Development Report 2017. Harare, Zimbabwe: Climate Change and Human Development: Towards Building a Climate Resilient Nation. 2017. [Google Scholar]

[pone.0302803.ref019] 19.World Population Review. HIV Rates by Country 2024. 2024. [cited 20 Jan 2025]. Available from: https://worldpopulationreview.com/country-rankings/hiv-rates-by-country?form=MG0AV3

[pone.0302803.ref020] 20.World Population Review. Zimbabwe Population 2018. 2018. [cited 17 Apr 2018]. Available from: http://worldpopulationreview.com/countries/zimbabwe-population/.

[pone.0302803.ref021] 21.Babb BA, Pruett MK. July 2022. Family Court Rev. 2022;60(3):373–4. doi: 10.1111/fcre.12652 [DOI] [Google Scholar]

[pone.0302803.ref022] 22.Zimbabwe Country Profile | UN in Zimbabwe. [cited 21 May 2019]. Available from: http://www.zw.one.un.org/uninzimbabwe/zimbabwe-country-profile

[pone.0302803.ref023] 23.Mugauri HD, Karakadzai M, Mugurungi O, Chirenda J, Takarinda K, Tshimanga M. Exploring HIV testing models for differentiated service delivery in Southern Africa: a systematic review. JEBHPME. 2023. doi: 10.18502/jebhpme.v7i3.14287 [DOI] [Google Scholar]

[pone.0302803.ref024] 24.Howard J. HIV Screening. Scientific, Ethical, and Legal Issues. J Leg Med. 2019;9(4):601–610. doi: 10.1080/01947648809513549 [DOI] [PubMed] [Google Scholar]

[pone.0302803.ref025] 25.Moyer VA; U.S. Preventive Services Task Force*. Screening for HIV: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013;159(1):51–60. doi: 10.7326/0003-4819-159-1-201307020-00645 [DOI] [PubMed] [Google Scholar]

[pone.0302803.ref026] 26.Know Your HIV Status: What it Means to be Status Neutral - PrEP Daily. (cited 21 Augt 2023]. Available from: https://prepdaily.org/know-your-hiv-status-what-does-it-mean-to-be-status-neutral/.

[pone.0302803.ref027] 27.Myers JE, Braunstein SL, Xia Q, Scanlin K, Edelstein Z, Harriman G, et al. Redefining prevention and care: a status-neutral approach to HIV. Open Forum Infect Dis. 2018; 5(6):097. doi: 10.1093/OFID/OFY097 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0302803.ref028] 28.Moucheraud C, Chasweka D, Nyirenda M, Schooley A, Dovel K, Hoffman RM. Simple screening tool to help identify high-risk children for targeted HIV testing in Malawian Inpatient Wards. J Acquir Immune Def Syndr. 2018;79(3):352–7. doi: 10.1097/QAI.0000000000001804 [DOI] [PubMed] [Google Scholar]

[pone.0302803.ref029] 29.Farnham PG, Gorsky RD, Holtgrave DR. Counselling and testing for HIV prevention: costs, effects, and cost-effectiveness of more rapid screening tests. Public Health Rep. 1996; 111: 44–53. [PMC free article] [PubMed] [Google Scholar]

[pone.0302803.ref030] 30.ACHA Education Center: The Status-Neutral HIV Testing Continuum. (cited 21 Aug 2023]. Available from: https://education.acha.org/products/the-status-neutral-hiv-testing-continuum-2

[pone.0302803.ref031] 31.Why does HIV kill more men than women? - Bhekisisa. [cited 9 April 2024]. Available from: https://bhekisisa.org/article/2017-08-08-why-does-hiv-kill-more-men-than-women/.

[pone.0302803.ref032] 32.Lopez-Varela E, Augusto O, Fuente-Soro L, Sacoor C, Nhacolo A, Casavant I, et al. Quantifying the gender gap in the HIV care cascade in southern Mozambique: we are missing the men. PLoS One. 2021;16(2):e0245461. doi: 10.1371/journal.pone.0245461 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0302803.ref033] 33.Hensen B, Taoka S, Lewis JJ, Weiss HA, Hargreaves J. A systematic review of strategies to increase men’s HIV-testing in sub-Saharan Africa. AIDS. 2014; 28(14):2133–45. doi: 10.1097/QAD.0000000000000395 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0302803.ref034] 34.Gus Cairns. South Africa: women may have higher rates of HIV than men because fewer men are on treatment. AIDSMap. 2020. [cited 9 Apr 2024]. Available from: https://www.aidsmap.com/news/mar-2018/south-africa-women-may-have-higher-rates-hiv-men-because-fewer-men-are-treatment [Google Scholar]

PERMALINK

Integrating status-neutral and targeted HIV testing in Zimbabwe: A complementary strategy

Hamufare D Mugauri

Owen Mugurungi

Joconiah Chirenda

Kudakwashe Takarinda

Prosper Mangwiro

Mufuta Tshimanga

Roles

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Fig 1. HIV Prevalence and Incidence Rates in Zimbabwe, 2018-2022 (Source: UNAIDS HIV Estimates).

Materials and methods

Setting

Specific study site.

Sampling

Table 1. Study sites, Zimbabwe, 2024.

Client population

Inclusion criteria

Exclusion criteria

Sample size calculation

Data variables, sources of data and data collection

Variables included in the adjusted models.

Table 3. Factors associated with HIV Positivity among patients who tested for HIV, Zimbabwe, 2024. (N = 23,058).

Analysis and statistics

Ethics approval

Results

Demographic characteristics

Table 2. Clinical and demographic profile of patients, Zimbabwe, 2024. (N = 23,058).

Screening, testing outcomes and post-test linkages

Fig 2. HIV Testing and Post-test Linkages, Zimbabwe, 2024.

HIV positivity and linkage

Discussion

Interpretation of key findings

Implications for policy and practice

Strengths

Limitations

Conclusions

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Author response to Decision Letter 0

Decision Letter 0

Johanna Pruller

Roles

Author response to Decision Letter 1

Decision Letter 1

Zypher Jude G Regencia

Roles

Author response to Decision Letter 2

Decision Letter 2

Zypher Jude G Regencia

Roles

Author response to Decision Letter 3

Decision Letter 3

Zypher Jude G Regencia

Roles

Acceptance letter

Zypher Jude Regencia

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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