The Republic of Zimbabwe has made significant strides towards meeting the ambitious UNAIDS 95-95-95 targets, which aim to achieve a 95% reduction in new HIV infections, 95% access to ART, and 95% viral suppression by 2030. Despite these positive health outcomes, regional heterogeneity in the different UNAIDS 95-95-95 targets was observed in this study. Spatial analysis revealed contrasting patterns between the HIV prevalence and the UNAIDS 95-95-95 targets. Specifically, high HIV prevalence was mostly concentrated in the southern part of the country, primarily between the provinces of Matabeleland North and South. Conversely, lesser UNAIDS 95-95-95 target outcomes were mostly concentrated in the north and northwestern part of the country, including the provinces of Mashonaland West, parts of Midlands and Matabeleland North. These findings have important implications for decision-making and resource allocation, as targeted interventions tailored to the specific needs of these regions and vulnerable communities could help to improve UNAIDS 95-95-95 target outcomes and ultimately advance progress towards ending the HIV epidemic.

Our study elucidates pronounced disparities within the HIV care continuum across varied demographic groups and geographical regions throughout the nation. Progress towards achieving the “95-95-95” targets reveals heterogeneous progress among the diverse regions of the country, with each component of the “95 s” manifesting distinct geographical distributions that may diverge markedly from the patterns of local HIV prevalence. These results highlight the critical need for tailored regional strategies to bridge the identified gaps in the HIV care continuum, as each “95” showcases a specific geographical pattern that might not align with the broader trends of HIV prevalence. Such findings suggest that aggregate national reporting on the “95-95-95” targets might not capture the granularity required, and subnational regions may demand specialized healthcare interventions to advance towards the articulated HIV treatment ambitions.

In response to the intranational variations in HIV prevalence, testing coverage, and ART linkage, Zimbabwe has adopted an approach that prioritizes district-specific needs. This approach has been instrumental in refining HIV testing services, fortifying the linkage to ART via community-centric initiatives, and confronting distinct challenges such as the high mobility of artisanal miners and transnational issues prevalent in districts adjacent to Zambia and Mozambique²². The incorporation of the Southern African Development Community (SADC) HIV and AIDS Cross Border Initiative into Zimbabwe’s strategic response acknowledges and addresses the economic tribulations influencing HIV control efforts within the country.

In the context of several African countries, including Zimbabwe, HIV testing facilities are predominantly located in areas with high HIV prevalence, where HIV screening is mandatory to curb the epidemic in these high HIV burden areas^4,23. Consequently, PLHIV in low HIV prevalence areas may face limited access to HIV testing facilities, resulting in an increased number of PLHIV unaware of their status in these areas. In this study, we found that percentage of HIV-positive individuals who were unaware of their status were higher in areas with low HIV prevalence, while those from high HIV prevalence areas were mostly aware of their HIV status. High percentage of population unaware of their HIV positive status was clustered in Hurungwe and Gokwe North districts, while other districts displayed no significant clusters. Likewise, we found that two-third of the districts had less than 90% of the PLHIV aware of their status, indicating that most of the districts were experiencing slower progress towards meeting the first 95 target. VL suppression patterns contrasted greatly between male and female population. While virally unsuppressed males were concentrated in low HIV prevalent areas, females were more common in high HIV prevalent areas which also resembles the patterns of the third 95% of total population. Multivariate clustering analysis identified similar estimates combining the three 95% for general population between the clusters, which was like patterns for female population. Male population had varied estimates for the three 95% between the clusters and the slowest progress in male population also dominated the total population estimates. Those areas located in coal mining regions of northern Zimbabwe where HIV prevalence was low and male population was the majority^24,25.

Our study also identified some areas lagging progress towards the UNAIDS 95-95-95 targets in border regions, where migrant labor and population movement is high. Migrant workers from neighboring countries, such as Malawi, Mozambique, and Zambia, encounter significant difficulties in accessing adequate healthcare facilities and routine HIV treatment services, which are vital for HIV diagnosis and control^26,27. Additionally, high poverty levels in these border regions further hinder access to healthcare in Zimbabwe, as the cost of the treatment because of the declining economy might be inconvenient for people living with poverty^28,29. Lower quality of health service provision in the northern border region also induced the hotspots of gaps in the three 95%³⁰. Contrasting patterns of hotspots of missing viral load suppression for male and female population might be the result of migration. Influx of internal immigration of males was higher in the hotspots of unsuppressed male population which infer lower linkage to healthcare³¹.

The findings from our study highlight the need to expand HIV testing and treatment services beyond areas of high HIV prevalence to better address regional disparities in HIV care continuum outcomes. Extensive studies need to be conducted in the identified hotspots of the care continuum estimates of this research to understand the drivers behind the poor progress. Additionally, investigating coldspots of these estimates having similar demographic and spatial characteristics may help us to design interventions.

Individual level regression analysis estimated no significant differences between males and females in terms of achieving the three 95 targets, which was inconsistent with other studies conducted in Zimbabwe, Italy, Venezuela, Cameroon, and Central Haiti, using nationally representative and clinical case study data^{32,33,34,35,36}, as in all of those studies, males were identified as latecomers to HIV/AIDS care. However, the spatial distribution of males who were unaware of their HIV status and females who were unaware of their HIV status presented different intensity in this study. Almost two thirds of the 91 districts in Zimbabwe had less than 90% males who knew their HIV positive status, while only one-third of the districts had less than 90% females who knew their HIV positive status. Most of the districts had less than 95% diagnosed population both for males and females. Like diagnosis males also had low percentage of having VLS, as more than half of the districts had less than 90% VLS for males, while only one-fifth of the districts had less than 90% VLS for females. These estimations provide the idea that males had low progress towards the targets in different districts. Additionally, hotspots of males with no VLS were identified in coldspots of HIV prevalence, while hotspots of females with no VLS were located predominantly in hotspots of HIV prevalence. Further research can be conducted on those hotspots to identify the drivers behind this difference for males and females.

Likewise, we found that younger individuals with HIV had lower odds of being aware of their HIV status, receiving ART, and achieving viral suppression, while older individuals were more likely to be tested for HIV, more inclined to receive ART and routine checkup, and had better viral control with lower viral loads^37,38,39,40. Secondary education was associated with higher likelihood of not being on ART and not having VLS which was inconsistent with some studies where they found that educated people were more likely to be tested, be on ART and achieve VLS^41,42,43. However, school going adolescents found the school environment as a barrier keeping up with medication because of lack of privacy and stigma, which might be the cause of higher odds of not being on ART and not having VLS for people with secondary education rather than people with no education or primary education^44,45.

Achieving the UNAIDS’s ambitious 95-95-95 targets in resource-constrained countries like Zimbabwe requires a well-designed plan that targets high-risk and underserved communities with a high burden of infection and slow progress towards these targets⁴⁶. However, providing HIV treatment facilities to everyone on a national basis might not be feasible, and thus, intervention programs should be implemented at the sub-national and local level. In this regard, it is particularly critical to identify communities with low first 95 prevalence areas and ensure regular access to healthcare and HIV testing by decentralizing HIV treatment services in Zimbabwe, thereby overcoming barriers to linkage to care. Along with hotspots of HIV prevalence it is important to also emphasize in treatment services in hotspots of the undiagnosed, not on ART and no VLS. Having different spatial patterns for each metrics for the total population, and male and female population, HIV services should be operated differently in places based on the particular needs of the community. It is important to note that sociocultural behaviors associated with HIV, healthcare access, and funding for HIV treatment vary across local communities, leading to spatial heterogeneity of HIV prevalence and the distribution of the 95-95-95 targets with distinctive clusters as showing in this study⁴⁷. Therefore, tailored HIV testing and treatment programs need to be implemented independently to balance the spatial disparity of progress towards the UNAIDS 95-95-95 targets, ultimately addressing the spatial heterogeneity for each of the targets observed in the country.

Likewise, the impact of migration and mobility on the spread of HIV in African nations has been widely acknowledged, and therefore, ongoing intervention initiatives must include migrant workers from border regions⁹. These workers face challenges such as a lack of stable habitats and limited access to treatment, highlighting the need for a system that can link them to treatment, which is critical for achieving viral suppression. Furthermore, improving the involvement of migrant workers in HIV treatment facilities is essential, as it becomes increasingly difficult to attain viral suppression after an extended period of HIV infection. It would be recommended that areas with low progress towards UNAIDS 95-95-95 targets should be provided with additional funding for HIV treatment. In 2012, the majority of HIV funds in Zimbabwe were spent at the national level, which may not have helped provinces with low progress towards achieving the UNAIDS 95-95-95 targets⁴⁸. Instead, it may be more effective to allocate funds at the subnational and local levels, considering the unique strategies required in each community informed by the local progress in the UNAIDS targets. To eradicate HIV from an area, financial resources are necessary to provide better services, improve infrastructure, and conduct continuous monitoring of PLHIV. Additionally, community-based HIV testing may be a viable alternative to testing in healthcare facilities, as it is often better received in the community. By increasing testing in the community, individuals who are not infected can also be reached and educated on HIV and initial treatments⁴⁹.

Our study has several limitations that need to be considered when interpreting the results. Firstly, we used data from a cross-sectional population survey, namely the PHIA survey, which may not represent the entire population. For instance, some high-risk subpopulations such as female gender workers, injection drug users, men who have sex with men, and migratory people may have been under-represented due to absence or non-participation^50,51. Additionally, self-reported data may have been subject to recall errors or false information by respondents who may not have been aware of the survey⁵⁰. Furthermore, because Zimbabwe shares borders with South Africa, Botswana, Zambia, and Mozambique, estimating the population in border areas can be challenging. Migrant people, in particular, are difficult to capture due to their dynamic nature, which may lead to an underestimation or double counting of their numbers, potentially affecting the study findings.

Although ART uptake and viral suppression rates are greater than HIV diagnosis, it should be noted that the cascade from PLHIV is not homogenous as the percentage of people unaware of their HIV status is high, it may result in lower estimates for other cascade indicators. Additionally, the number of people on ART may not be an accurate measurement, as the PHIA survey does not capture the regularity or adherence to ART. Finally, the spatial displacement procedure of households to protect the confidentiality of respondents may have also affected the estimates at the sub-national level. This is because households may have been displaced a few kilometers away from their actual location, leading to changes in the estimates. Therefore, these limitations should be considered when interpreting the findings of our study.

Incorporating more granular metrics, such as those delineated by the UNAIDS 95-95-95 targets, unveils a detailed landscape of the current status of the HIV epidemic and identifies the precise requirements of communities that could be led behind. These strategies are crucial for reaching the UNAIDS 95-95-95 targets and for sustaining HIV care beyond the achievement of these targets. Geospatial targeting, within the framework of the UNAIDS 95-95-95 strategy, could significantly bolsters HIV surveillance and public health initiatives. Utilizing the results from this data-centric approach described in this study, health authorities can implement precision public health measures, such as “Test and Start” strategies, with greater efficacy, thereby ensuring immediate initiation of antiretroviral therapy upon HIV diagnosis⁵². The expansion of testing access, through rapid tests and an increased number of testing sites, is vital for the successful deployment of this strategy. Identifying geospatial areas in dire need facilitates the strategic delivery of these interventions, not only aiding in the achievement of the 95-95-95 targets but also enhancing surveillance by providing precise data on the impact of interventions, thus guiding future public health decisions.

Expanding community-based testing directly correlates with the first 95 target, aiming to diagnose 95% of all HIV-positive individuals. This strategy is especially effective in rural and hard-to-reach areas identified in our study, where healthcare facility access is limited. Deploying mobile HIV testing units in these regions can significantly improve accessibility and early detection of HIV⁵³. Furthermore, to target the first 95 (testing) within identified hotspots effectively, strategies should include partner services and contact tracing to leverage the networks of known HIV-positive individuals, integrating HIV testing within other health services to capitalize on routine care encounters, and initiating workplace HIV testing programs in sectors with heightened mobility or risk.

Enhancing ART delivery is crucial for targeting the second 95. Introducing home-based ART delivery, especially in the second 95% hotspot areas identified, ensures consistent access to medication. Strategies to improve linkage to care through immediate ART initiation programs at diagnosis, mobilizing community health workers for follow-up, and deploying mobile clinics in hotspots for on-site ART initiation are key. Partnering with local community health workers for direct ART delivery to patients’ homes reduces barriers to treatment access. Investing in healthcare infrastructure is vital, with the construction and outfitting of local health centers in underserved regions not only providing HIV care but also enhancing overall healthcare services.

Technological advancements, such as digital health tools and electronic medical records, support the second and third 95 targets by improving treatment initiation and monitoring VLS, particularly in these hard-to-reach hotspot areas^54,55. Telemedicine services can facilitate ART initiation for newly diagnosed individuals through remote consultations, overcoming geographical and logistical barriers. The implementation of robust patient tracking systems is essential, with the development of digital health records and smartphone apps for healthcare providers enabling efficient tracking of patient visits, ART adherence, and viral load results. This technological integration facilitates timely interventions and follow-ups, ensuring continuity of care.

In summary, our study emphasizes the relevance of understanding the spatial structure of the HIV epidemic linked to the UNAIDS 95-95-95 targets, advocating for health policymakers and practitioners to implement a comprehensive strategy. This strategy should not only cater to high-prevalence areas but also broaden its scope to encompass extensive treatment and prevention methods. This methodology represents an anticipatory move towards the enduring management of the HIV epidemic, not only in Zimbabwe, but in SSA in general, rather than merely reacting to the shortcomings of existing approaches. The versatility of the 95-95-95 targets within the varied regional landscapes of country level specific like in Zimbabwe, provides a malleable blueprint for crafting customized interventions, guaranteeing that every community is included in our unified effort to fight the HIV epidemic. It is crucial to prioritize and invest in effective strategies that address the sociodemographic constraints and geographic heterogeneity identified in this study to ensure equitable access to HIV prevention and treatment services for all individuals in Zimbabwe. By doing so, significant progress can be made toward achieving the 95-95-95 targets and ultimately working toward ending the HIV/AIDS epidemic as a public health threat by 2030, in line with the global Sustainable Development Goals. Further research is necessary in these low-progress areas to gain a better understanding of how to achieve the targets within the desired timeframe and to ensure that no one is left behind.