What was the problem?
Adolescents living with HIV (ALHIV) face challenges with adherence to, and retention on, treatment and have lower viral suppression rates than adults.
What is the solution?
The Zvandiri program, run by Africaid, began in Zimbabwe in 2004 as a support group for ALHIV. This program provides differentiated or tailored care for children, adolescents and young people living with HIV (aged 6–24 years). Community Adolescent Treatment Supporters (CATS), who are HIV- positive people aged 18-24 years, work between health facilities and the homes of youth living with HIV (YLHIV) to increase uptake of testing, linkage to care, adherence, retention in care, and other services related to sexual, reproductive, and mental health. CATS work with health facilities supervised by the Ministry of Health (MOH), and work closely with social workers, community health workers, and clinic health workers.
CATS support YLHIV through a comprehensive range of services:
- CATS act as positive role models to strengthen existing networks of social protection.
- Monthly community-based support groups facilitate learning, confidence building, and socializing. Community outreach teams provide more advanced care in the homes of YLHIV.
- Clinic-based Zvandiri Centers provide safe spaces for clinical and social services, linking adolescents to other forms of assistance, while educating individuals on sexual and reproductive health (SRH), and life skills.
Through these interventions, the Zvandiri program builds mental, emotional, and physical resilience among its participants.
What was the impact?
Compared to adolescents on antiretroviral therapy (ARV) who did not participate in the Zvandiri program, adolescents supported by CATS were 3.9 times more likely to adhere to treatment than the control group (OR=3.934). At the start of the program, participates kept up with (adhered to) their treatment 44.2% of the time, on average. This improved to 71.8% in a study in Gokwe South, a rural district in northern Zimbabwe. Overall, the study results confirmed programmatic experience.
CATs helped increase understanding of medication and helped motivate adherence. The results confirmed the importance of home visits. The impact of the intervention was also felt by caregivers. Youth with adherence issues and previous loss to follow-up had improved linkage and retention in care. The intervention also showed improvements in psychosocial well-being, self-esteem, self-worth, and confidence. Limitations of the study included the fact there were no objective measures, and anecdotal evidence of referrals was used.
Zvandiri Results as of June 2016
How does it work?
The program centers on improving adherence, retention, and well-being by connecting beneficiaries with a peer support network.
Zvandiri takes several steps to reach out to YLHIV. CATS actively recruit children and adolescents through ‘adolescent corners’ in clinics. Outreach in the community promotes the uptake of HIV testing and counseling, treatment, care, and support. As primary contacts in clinics and the community for children and adolescents, CATS also provide a support system for nurses and providers. Clinic staff members rely on this task-sharing support system and refer children and adolescents to CATS for pre- and post-test counseling, information, disclosure, and treatment adherence support. Those young people often then become Zvandiri clients. Collaborating with other implementing partners has also increased the number of beneficiaries through good coordination of referrals.
Providing a Support System for YLHIV
At the core of the Zvandiri program are its Community Adolescent Treatment Supporters. According to project reports, these role models “have experienced and therefore understand many of the issues around ill-health, anxiety, guilt, fear, shame, rejection, depression, and hopelessness. They have also benefited in terms of personal growth and transformation from Zvandiri, and this enables them to support others effectively. Their lived experience makes them particularly credible to others struggling with a new HIV diagnosis or with treatment, and they have a unique value as normative role models.”
- Monthly community-based support groups – Run by CATS, support groups provide structured activities to:
- build resilience, confidence, and self-esteem,
- develop knowledge and skills related to HIV, to promote adherence, and
- improve sexual and reproductive health (SRH).
Participants can share experiences, make new friendships, and develop support networks. Groups are an opportunity to evaluate beneficiaries’ well-being. Support groups may include youth and young parents’ groups to meet the needs of young people with HIV.
- Community Outreach Teams – Multi-disciplinary teams, made up of HIV clinicians, nurses, counselors, social workers, psychologists, and a network of CATS provide home-based clinical monitoring, counseling, adherence support, and ensure retention in care. The multi-disciplinary teams refer to clinics when patients require laboratory investigations, opportunistic infection (OI) management, or experience adverse events including antiretroviral (ARV)-related toxicities.
- Clinic-based Zvandiri Centers – Established in 2013 at four clinics in Harare, Zvandiri centers provide an adolescent-focused environment for young people to access HIV- and SRH-related information, counseling, peer support, life-skills training, and recreational activities. Provider discomfort and knowledge gaps are commonly-cited reasons for decreased HIV testing and linkage to ART among children and adolescents. Facility-based CATS work with clinical providers to improve adolescent-friendliness at health facilities, addressing this systems-level challenge. Run by trained CATS and supervised by clinic staff, the centers refer young people to other services including HIV testing and counseling, family planning, treatment for sexually transmitted infections, prevention of mother-to-child transmission (PMTCT), mental health, and socio-economic services (e.g., for school fees).
Scaling up: from local engagement to national integration
From young people living with HIV to national ministry structures, Africaid involved stakeholders in the design of the program, which helped to foster its adoption. Communities were at the center of efforts to recruit CATS, maximizing their support and ownership of the project. This model serves as an illustrative example of patient involvement and empowerment. It has been extended to adults as well. The training and engagement of expert clients to improve linkage to care, adherence support, and defaulter tracing among adult PLHIV in the PEPFAR Zimbabwe portfolio is largely modeled after the success of the Zvandiri program.
Zvandiri’s achievements attracted the attention of decision-makers who wanted to scale up the program. Implementation followed a phased approach starting with the 36 PEPFAR-supported districts. Since this model had already been recognized by the Ministry of Health & Child Care (MoHCC) and the World Health Organization (WHO) as a best practice, there was ready support for the roll-out in health facilities.
Local organizations often develop innovative strategies perfectly suited to their respective contexts. Rapidly scaling up these strategies to the national level, however, requires significant capacity building of these organizations. This is particularly true in administrative areas, such as financial management and human resources, as well as monitoring and evaluation. National roll-out of this program has required a massive expansion of CATS and district-level Zvandiri mentors. Africaid has had to significantly increase its management capacity and strengthen its operational systems to ensure beneficiaries receive the services they need. Rapid scale-up also runs the risk of prioritizing quantity over quality. The Zvandiri intervention is novel and innovative in catering to the holistic needs of each individual children and adolescents living with HIV. The pressure to grow rapidly and meet targets should never overshadow the need for high-quality services, which in the case of at-risk children and adolescents may include daily text messages, weekly home visits, and caregiver support.
Zvandiri has been adopted by the Government of Zimbabwe and is currently being expanded by the Ministry of Health with PEPFAR support (currently in 24 districts and growing to 38 districts in fiscal year 2018). It is now expanding further to include focused support for disabled children and adults living with HIV, young mothers living with HIV, as well as mental health, and SRH services.
Findings will be made available in the future from two randomized control trials:
- A cluster randomized trial of the Zvandiri Programme, a multi-component, community-based programme to improve adherence and retention in care among children and adolescents living with HIV in Zimbabwe (MoHCC, CeSSHAR, ViiV Healthcare); and
- The peer support intervention, which supports HIV-positive adolescents in Zimbabwe to improve HIV care continuum outcomes among adolescents with virological failure (MoHCC, UZCHS, JSI/USAID)
International AIDS Society. Clinical Models of HIV Care for Adolescents. 18 July 2016.
Enhancing Psychosocial Support for HIV Positive Adolescents in Harare, Zimbabwe. Mavhu W, et al. (2013) PLOS ONE 8(7): e70254.
“My story”—HIV positive adolescents tell their story through film, In Children and Youth Services Review. Willis L et al., Volume 45, 2014, Pages 129-136, ISSN 0190-7409.
Best Practices for Adolescent- and Youth-Friendly HIV Services, Gage A, Measure 2017.
Revised by the PEPFAR Solutions Team, May 2018