THE CENTRE FOR SEXUAL HEALTH AND HIV/AIDS RESEARCH (CESHHAR) ZIMBABWE
Africaid’s Zvandiri (‘As I am’) programme is a model of differentiated clinical service delivery for children and adolescents living with HIV in Zimbabwe developed in response to an identified need for tailored support services for these key populations.
Zvandiri combines community support groups, community outreach, Community Adolescent Treatment Supporters (CATS) and child and adolescent-focused Zvandiri Centres to directly influence children and young people’s experience of the HIV continuum of care. Integral to this is intensive ongoing support for adolescent and young people’s psychosocial well-being and mental health, wider sexual and reproductive health, economic empowerment and linkage to education and child protection services. The Zvandiri programme also includes an intervention for caregivers. Alongside delivering improved rates of viral suppression, through its close links with national public and private health and child welfare systems, it aims to build capacity within both the government systems and in family carers and other community members.
Through funding by ViiV Healthcare’s Positive Action Adolescents legacy programme, a cluster randomised controlled trial to evaluate the programme was conducted by the Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) in Zimbabwe, in collaboration with the Ministry of Health and Child Care (MoHCC), Liverpool School of Tropical Medicine, London School of Hygiene and Tropical Medicine and the University of Zimbabwe College of Health Sciences. The results of the trial showed that community-based intervention programmes are effective in improving viral suppression among adolescents with HIV and add to the growing body of evidence supporting the World Health Organization’s (WHO) recommendations for community-based interventions to aid antiretroviral treatment (ART) adherence and retention in care.
Following the success of the trial, ViiV Healthcare provided further investment to support Africaid with the dissemination of its findings, and to enable CeSHHAR to carry out additional analysis of the trial results. It is hoped that if linked programmes across Sub-Saharan Africa can learn from this initiative, they will make a substantial contribution to the UNAIDS 90-90-90 targets.1
The Zvandiri programme responded to the recognition that, whilst paediatric ART was being rolled out in Zimbabwe, there was little if any provision for children and adolescents’ broader psychosocial and treatment needs. Since its inception, Zvandiri has evolved a unique model of integrated, community-based psychosocial support and health services for HIV positive children and young people and is now scaling up to other provinces across Zimbabwe.
The objectives of the Zvandiri trial were to provide evidence on whether enhancing community-based support for children and adolescents on ART through the Zvandiri programme could:
i) reduce the cumulative incidence of ART treatment failure;
ii) improve retention in care;
iii) reduce the prevalence of anxiety and depression;
iv) reduce rates of non-disclosure of HIV status when compared to usual care;
v) be more cost-effective than usual care.
Sixteen clinics were randomised to receive either enhanced ART adherence support through the Zvandiri programme or usual adherence support. Adolescents aged 13 – 19 living with HIV were recruited at each site and were followed for 96 weeks.2
Adolescents attending clinics allocated to the usual care arm received ART and adherence support as set out in the MoHCC guidelines. Adherence support was provided by adult counsellors and nursing staff. After ART initiation, adolescents were seen monthly, with CD4 monitoring at six monthly intervals. MoHCC was only able to finance targeted viral load testing.2
Adolescents attending clinics offering enhanced Zvandiri intervention received additional support as outlined in the following ‘What Zvandiri Did’ section.
The primary hypothesis was that the Zvandiri programme would be more effective than usual care in reducing the proportion of adolescents who die or fail treatment (defined as viral load ≥1,000 copies/ml) at 96 weeks. The secondary hypotheses was that the Zvandiri programme would i) improve retention in care and adherence to ART, and ii) reduce psychological distress over the 96-week follow-up period.2
The study aimed to generate evidence of the Zvandiri model’s effectiveness, with children and adolescents living with HIV experiencing better HIV treatment, retention and prevention outcomes than those attending facilities without Zvandiri support.
To learn more about CeSHHAR visit www.ceshhar.org
Adolescents attending clinics receiving the enhanced Zvandiri programme intervention received MoHCC usual care. In addition, one to three trained and supported CATS were allocated to the clinic to provide adherence counselling and support to adolescents in their clinic visits as well as on-going individualised community-based support.
The CATS are 18-23 year olds, living with HIV, who demonstrated commitment and competence in supporting their peers and are known to be adherent to ART. They were recruited from the clinic in partnership with the clinical staff or from a local support group, and received a small stipend. They also received capacity building support, including two weeks of MoHCC-endorsed training to equip them with counselling and community outreach skills plus knowledge specific to adolescents living with HIV. CATS also provided peer-to-peer support for each other (through a WhatsApp group and via Skype) with oversight from a professional counsellor.
As well as individualised support, adolescents were invited to attend a monthly support group at the health facility, facilitated by a support group leader in conjunction with the CATS. Adolescents identified as being at critical risk of harm could then be immediately referred for mental health services and/or management with the Department of Social Services. Caregivers of the adolescents were also invited to attend a caregiver support group.
In addition to the capacity building support provided to CATS, the programme offered PhD funding to support local young scientists to conduct additional analysis of the results.
To learn more about the Zvandiri model visit www.africaid-zvandiri.org
Adolescents living with HIV face challenges to their wellbeing and ART adherence and have poor treatment outcomes.
The results of this trial, which studied 500 adolescents living with HIV2, found that the prevalence of virologic failure/death among adolescents in the Zvandiri programme was 42% lower than among those solely receiving standard HIV care at rural clinics.2 This suggests peer-supported community-based differentiated service delivery can substantially improve HIV virological suppression in adolescents with HIV.
The data also showed that the programme successfully impacted adolescents’ lives through a focus on shared experiences, role modelling, and supportive friendship. Their understanding of their treatment also improved - as did the understanding of their caregivers – which allowed them to better adhere to their treatment.
Adolescents with HIV credited the Zvandiri programme for relieving their sense of isolation and reducing their fear of the present and future implications of their HIV status. Further, community adolescent treatment supporters stationed in clinics were able to positively influence the attitudes of health-care workers towards adolescents with HIV, so creating a more open and receptive environment in which people living with HIV could disclose their HIV status.
The trial’s cost analysis suggested that incorporation of the Zvandiri intervention into current standard of care would increase the cost of providing HIV treatment to adolescents by about three times. However, potential economies of scale and corresponding lower unit costs could be achieved through provision of both ART and differentiated intervention to larger numbers. These increased costs should be viewed objectively and take into consideration the economic consequences of poor viral suppression in adolescents, who compared to children and adults, have higher rates of treatment failure, morbidity and mortality.2
Overall, the findings indicate that the effectiveness of the comprehensive Zvandiri wraparound programme is in line with approaches advocated in the 2019 UNAIDS Global AIDS update.3 It is hoped further analysis and dissemination of the results could help inform cost-effective strategies to optimise the public health impact of ART and maximise the overall wellbeing of adolescents with HIV.
- UNAIDS. 90-90-90: Treatment for all. 2020. Available at: https://www.unaids.org/en/resources/909090 Last accessed: June, 2020.
- The Lancet HIV. Effect of a differentiated service delivery model on virological failure in adolescents with HIV in Zimbabwe (Zvandiri): a cluster-randomised controlled trial. Last accessed: June, 2020.
- UNAIDS. Global AIDS update: communities at the centre. 2019. Available at: https://www.unaids.org/en/resources/documents/2019/2019global-AIDS-update Last accessed: June, 2020.