WHAT WAS THE PROBLEM?
In Kenya, adolescents and young people living with HIV (AYPLHIV) account for approximately 20% (303,700) of all people living with HIV (Spectrum Estimates, 2015; Kenya HIV Estimates 2015 Report). AYPLHIV (aged 10-24) face especially complex challenges dealing with a chronic illness amidst the physical, emotional, and psychological development changes of transitioning from childhood to adulthood. The HIV epidemic among adolescents and young people (AYP) is characterized by relatively high HIV incidence and sub-optimal treatment outcomes, including a relatively high loss to follow-up, low adherence to treatment, and low viral suppression.
WHAT IS THE SOLUTION?
Operation Triple Zero (OTZ) engages AYPLHIV as active stakeholders and partners in their health by promoting a responsive service delivery model. AYPLHIV joining OTZ clubs are offered a comprehensive HIV treatment literacy package, and are empowered to be self-health managers. Further, they commit to a simple treatment goal of achieving “three zeroes”: zero missed appointment, zero missed drugs/medications, and zero viral load (VL). OTZ empowers participants to take charge of their health, take control of their decisions, receive support from fellow peers, and identify with peers who are doing well.
WHAT WAS THE IMPACT?
Self-reported adherence has improved significantly across programs increasing from 88% in October 2017 to 96% in February 2018 (Figure 1).
Preliminary data for clients aged 10-24 years old from six PEPFAR/CDC supported implementing partners (IPs) show a substantial improvement in viral suppression (Figure 2). Of 2742 AYPLHIV, viral suppression increased from 71% (range 67%-82%) to 82% (range 71%-96%) after 6 months of enrollment in OTZ.
HOW DOES IT WORK?
The target population is AYPLHIV aged 10-24 years old. The intervention is tailored to nurture both intrinsic and extrinsic developmental assets to promote positive behaviors resulting in better health outcomes. Intrinsic assets among AYPLHIV are enhanced through providing comprehensive treatment literacy and goal setting, promoting resilience, and enabling positive peer interactions, independence, and connectedness. Comprehensive HIV treatment literacy training ensures in-depth understanding of body changes as a result of HIV infection, HIV prevention, and antiretrovirals (ARVs). The training also clarifies desired antiretroviral treatment goals, including improved quality of life, per national guidelines. Extrinsic assets are nurtured by providing knowledge and skills to healthcare workers (HCWs) and caregivers to support AYPLHIV. The combination of both intrinsic and extrinsic assets ultimately results in empowered, confident AYPLHIV who are self-health mangers.
AYPLHIV were engaged in designing numerous aspects of the OTZ initiative, including defining the mandate of OTZ clubs; designing the OTZ logo, motto and pledge; translating the OTZ pledge and motto into local languages; developing content for OTZ modules; and participating in OTZ talent shows and activities. At the facility-level, AYPLHIV identified as OTZ graduates (referred to as “champions”) enroll new members, provide psychosocial support to newly identified HIV-positive AYP, provide support to AYPLHIV with high viral loads (VL >1000c/ml) through pairing, coordinate OTZ clubs, and oversee various OTZ activities, including social media.
The OTZ initiative supports AYPLHIV and civil society in HIV programming. In the PEPFAR Regional Planning Meeting for the Fiscal Year 2019 Country Operational Plans, one of the key recommendations from civil society representatives was the nationwide scale up of OTZ, indicating their buy-in and continued engagement.
The OTZ initiative builds on the existing APOC without additional policy changes to date. However, PEPFAR will be supporting the national program to review and revise APOC and caregiver literacy trainings. We envision incorporating asset-based programming into these activities.
OTZ has been rapidly scaled up, moving from one facility with 70 OTZ members in 2016 to over 400 facilities with over 40,000 members by March 2018. The main proponents of OTZ have been PEPFAR, civil society, and the Kenyan government.
OTZ is a facility-based initiative driven by partners in collaboration with county and facility leads. To bring the initiative to scale, partners engage with counties, identify facilities ready to implement, and carry out individualized or joint sensitization meetings.
At the facility-level, sites are sensitized and begin enrollment of AYPLHIV into OTZ. Both group and individual enrollment is encouraged. The overall goal at the facility-level is to enroll all, or nearly all, AYPLHIV into OTZ.
MANAGEMENT & OVERSIGHT
Monitoring: The team developed a logic model to guide implementation and performance measurement of OTZ goals (Figure 3). To track processes and outcomes of OTZ, an M&E plan was developed. Indicators were designed to track completion of processes, and measurement of inputs and outputs, along with short-term, intermediate, and long-term outcomes. Documenting implementation activities, processes, and outcomes was done in an M&E template and reviewed regularly to inform progress.
Cost of innovative solution: OTZ is integrated into the implementation of the APOC for AYPLHIV, which decreases costs. However, the program will need to plan for the availability of clinic space to accommodate OTZ activities, including indoor games, training and engagement of peer leads as champions, printing of information, education and communication materials, and extended working hours. Motivational activities, including retreats and awards for best performing sites, certificates for achievers and most improved, and exchange visits to best performing sites, also require additional resources. Adolescent resource centers equipped with appropriate tools for treatment literacy and improved life skills also require funding. The use of weekend staff (and clinic hours) varied by IP.