**3. Results**

#### *3.1. COVID-19 Cases and Deaths and General Effects on Health Services*

COVID-19 cases and deaths as reported to WHO cumulatively increased to 35,994 and 1458, respectively, during the 12 months (see Figure 1).

**Figure 1.** Cumulative number of COVID-19 cases and deaths in Zimbabwe between March 2020 and February 2021 as reported to the World Health Organization.

*From a general services perspective*, there had been heightened economic decline in Zimbabwe in the pre-COVID-19 period, especially towards the end of 2019 and start of 2020. This resulted in a series of health care worker strikes which affected service provision. The introduction of flexible working hours in 2020 helped to restore health service delivery. In March 2020, COVID-19 struck. There was a national lockdown between March and the end of June 2020 and again from 6 January to 28 February 2021. During lockdowns, people were not allowed to leave their places of residence, public transport ceased, there were night curfews, health facilities shortened their working hours, and some health facilities had to close due to either shortage of health care workers or if there was an outbreak of COVID-19 within the facility. Only a few patients were allowed into health facilities at a time, resulting in long waiting queues outside, which may have deterred patients from coming to the health facilities. Between July and September 2020, there was industrial strike action again in the health sector over the lack of personal protective equipment and remuneration. Locum staff brought in to fill the gaps were not familiar with programmatic activities, including recording and reporting. There was widespread community fear about contracting COVID-19 or being diagnosed with COVID-19 at health facilities during the whole period.

*From a TB perspective*, environmental health technicians, responsible for community follow-up of TB patients while on treatment, were repurposed to COVID-19 activities. Between 12 December 2020 and 11 January 2021, GeneXpert cartridges expired in some facilities, and during this time clinic staff did not collect sputum specimens for TB investigation.

*From an HIV perspective*, voluntary male medical circumcision services (VMMC), which provided HIV testing for a large number of male adolescents and men, stopped in March 2020 and remained closed for the next 12 months. There were stock-outs of HIV test kits in July 2020, which remained a challenge intermittently for the next few months.

#### *3.2. TB Case Finding, Diagnosis and Registration*

There was an overall decrease in the numbers of persons presenting with presumptive PTB (40.6%), people diagnosed with bacteriologically confirmed PTB (30.1%) and people being registered for TB treatment (33.7%) in the COVID-19 period compared to the pre-COVID-19 period (Table 1).

\*

**Table 1.** Characteristics of persons with presumptive pulmonary TB and registered TB in 10 health facilities in Harare, Zimbabwe, during pre-COVID-19 and COVID-19 periods.


absolute change (increase or decrease); TB = tuberculosis; PTB = pulmonary tuberculosis; ↑ = increase; ↓ = decrease.

> For presumptive PTB, the overall decrease was greater in children (71.3%) compared with adults (38.6%), but almost similar between males (38.4%) and females (36.0%). The yield of bacteriologically positive PTB in those investigated for presumptive TB increased from 13.5 to 15.9%. The decline in those diagnosed and registered with TB was worse for patients with PTB, and amongs<sup>t</sup> those with pulmonary disease, it was worse for those with clinically diagnosed PTB (46.0%). The proportion of TB patients tested for HIV remained above 90%, although it declined from 95.1 to 90.3%.

> The monthly numbers of persons presenting with presumptive PTB and registered TB in the pre-COVID-19 and COVID-19 periods are shown in Figure 2A,B. The footnotes for the Figures indicate the interventions that were put in place to counteract the downward trends.

> Compared with the pre-COVID-19 period, the decline in presumptive TB in the first 6 months of COVID-19 (March to August 2020) was 35.8%, and this became greater in the second 6 months (September 2020 to February 2021) when the decline was 45.5%. The decline in registered TB in the first 6 months of COVID-19 was 29.9%, which also became greater in the second 6 months when the decline was 37.5%.

#### *3.3. TB Treatment Outcomes*

The overall aggregate treatment outcomes between the pre-COVID-19 and COVID-19 periods are shown in Table 2. There was a decrease in treatment success from 80.9 to 69.3%, mainly due to an increase in patients "not evaluated" (12.1%). Other program outcomes were similar between the two periods.

The monthly treatment success rates in the pre-COVID-19 and COVID-19 periods are shown in Figure 3. Interventions to reverse downward trends are indicated in the footnotes. Compared with the pre-COVID-19 period, the decline in treatment success was 14% in the first 6 months of COVID-19. This improved in the second 6 months when the decline was 7.8%. Treatment success particularly improved in January and February 2021 to 80 and 78%, respectively.

**Figure 2.** (**A**): Monthly numbers of persons presenting with presumptive PTB in 10 health facilities in Harare, Zimbabwe, during pre-COVID-19 and COVID-19 periods. (**B**): Monthly numbers of persons presenting with registered TB in 10 health facilities in Harare, Zimbabwe, during pre-COVID-19 and COVID-19 periods. ↑ = increase; ↓ = decrease. Interventions applied from July 2020 onwards to counteract the decline in numbers included: integrated screening of patients with respiratory symptoms for TB and COVID-19; improved contact tracing of index patients with TB and COVID-19; and strict infection control practices at health facilities which were promoted to try and encourage symptomatic patients to attend.

**Table 2.** Treatment outcomes of patients enrolled in TB treatment in 10 health facilities in Harare, Zimbabwe, during pre-COVID-19 and COVID-19 periods.


\* absolute change (increase or decrease); TB = tuberculosis; ↑ = increase; ↓ = decrease; treatment outcome was considered "treatment success" when the TB patient was either cured or had "treatment completed". The success rate was calculated for the month-wise cohort of TB patients commenced on treatment eight months prior to the reporting month (this takes account of six months of treatment to be completed and another two months to finalize the recording of the final treatment outcome).

**Figure 3.** Treatment success amongs<sup>t</sup> patients enrolled each month in 10 health facilities in Harare, Zimbabwe, during pre-COVID-19 and COVID-19 periods. Enrollment occurred eight months prior to the month of reporting (to allow for 6 months treatment and 2 months of follow-up and record the final outcome); ↑ = increase; ↓ = decrease. The interventions applied from July onwards included: medication refills given for longer periods and synchronized for TB and ART medications; attempts to reduce the outcome "not evaluated".

#### *3.4. HIV Testing and Referral to ART*

There was a large overall decrease in numbers tested for HIV between pre-COVID-19 and COVID-19 periods (Table 3). The overall decrease was greater for children (70.2%) compared with adults (62.4%) and greater for males (79.1%) compared with females (53.6%). There was a small relative increase in the HIV positivity rate from 6.0 to 8.1% and a small decrease in the referral of HIV-positive persons to ART from 95.7 to 91.7% during the COVID-19 period.

**Table 3.** Characteristics of persons tested for HIV and referred to antiretroviral therapy in 10 health facilities in Harare, Zimbabwe, during pre-COVID-19 and COVID-19 periods.


\* absolute change (increase or decrease); ↑ = increase; ↓ = decrease; ART = antiretroviral therapy.

> The monthly numbers tested for HIV in the pre-COVID-19 and COVID-19 periods are shown in Figure 4.

**Figure 4.** Monthly numbers presenting each month for HIV testing in 10 health facilities in Harare, Zimbabwe, during pre-COVID-19 and COVID-19 periods; ↑ = increase; ↓ = decrease. From August 2020 onwards, human resources support was given to the Ministry of Health by PEPFAR partners (President's Emergency Fund for AIDS Relief in Africa) by seconding direct service delivery nurses to affected sites.

The number of people being HIV tested in health facilities was already declining in the pre-COVID-19 period due to a number of factors that included: a shift from general HIV testing to more targeted HIV testing using a screening tool to identify high-risk groups, to identify those with a high lifestyle risk score assessment and to identify those who had not been tested in the previous year; promotion of HIV self-testing, with the referral of only those HIV-positive to the health facilities for confirmation of the result; and a greater focus on index partner testing. As explained in the footnotes of Figure 4, human resources support was provided to clinics from August 2020 onwards to sustain HIV testing services and ART delivery. Compared with the pre-COVID-19 period, the decline in HIV testing

in the first 6 months of COVID-19 was 62.8%, which was greater than the 37.6% decline observed in the second 6 months.
