The perceived impact of extreme weather events on care for people with HIV or tuberculosis and HIV in Zimbabwe: a survey-based multicentre cross-sectional observational study and formative evaluation.

BACKGROUND: The growing threat to health systems posed by extreme weather events (EWEs) disproportionately affects people living with HIV and tuberculosis disease in high-burden, low-resource settings. In Zimbabwe, for example, the 2023-24 El Niño-induced drought intensified food insecurity and reduced access to clinics and medication for such vulnerable populations. We aimed to conduct a formative evaluation to assess the perceived impact of climate change and EWEs on HIV and tuberculosis determinants and service delivery and identify potential climate-adaptive health-service strategies.

METHODS: In this survey-based multicentre cross-sectional observational study with a formative evaluation supplemented by qualitative data, we surveyed people living with HIV from Sept 19 to Dec 19, 2024, across 321 clinics in Zimbabwe to describe their perceived impact of EWEs on their health. Participants were recruited using convenience sampling. The inclusion criteria were being diagnosed with HIV, being older than 18 years, and receiving HIV care at Organization for Public Health Interventions and Development (OPHID) clinics during the study period. Individuals who were not receiving HIV care at an OPHID clinic or who were younger than 18 years were excluded. A client satisfaction survey was used to collect data from in-person surveys. The survey included questions related to the general effects of EWEs, such as drought, extreme heat, and flooding; how EWEs had affected HIV or tuberculosis care; and what, if any, services were currently available or should be made available to mitigate climate impacts on health. We also conducted six focus group discussions (FGDs; five to eight participants per group) between March 12 and May 12, 2024, across the Bulilima, Mangwe, and Matobo districts. We used a convenience sampling approach to select patients who had visited the health facility for medical check-ups, medication resupply, or viral load testing, as recorded in clinical registers and verified by clinical staff. Eligible participants for the FGDs were adults (≥18 years) with HIV, or with current or previous tuberculosis treatment, receiving care at the study facility during the recruitment period; those under 18 years or not receiving care at the facility were excluded. Participants' sex was self-reported at enrolment. Quantitative data were analysed descriptively, whereas FGD data were analysed using a modified framework approach. The main outcomes were the perceived impact of climate change and EWEs on HIV and tuberculosis determinants and service delivery outcomes, as reported by affected communities, and community-prioritised mitigation strategies to feasibly address climate-sensitive determinants and barriers to care.

FINDINGS: Among 1804 eligible participants approached across 15 districts, all completed the survey and were included in the analysis. Most survey participants (1363 [75·6%] of 1804 participants) reported noticing changes in climate over the past 5 years; of these 1363 participants, 900 (66·0%) were female and 1024 (75·1%) participants reported disruptions to their HIV care during the time they noticed changes in climate. Survey respondents reported that climate-related disruptions were associated with increased food insecurity (reported by 877 [85·6%] of 1024 participants) and water shortage (667 [65·1%] of 1024 participants). Qualitative analysis confirmed that the barriers to HIV and tuberculosis care from EWEs included widespread food insecurity, crop failures, and livestock deaths, with consequent effects on income leading to challenges in paying for food and transportation to clinics. Participants highlighted the need for expanded services that facilitate social and economic wellbeing, including nutrition support, water access, transportation, and income-generating activities, and decentralised models of health-care delivery.

INTERPRETATION: Extreme heat and drought affect food and water security and have financial implications, creating challenges for patients to access care in Zimbabwe. Our findings underscore the urgent need for integrated, climate-adaptive strategies to maintain HIV and tuberculosis care in such climate-vulnerable regions.

FUNDING: Nina Ireland Program in Lung Health.