Less isolated, less fearful: peer-led programme for HIV-positive adolescents has significant impact
An evaluation of Zvandiri, a teen-led programme for HIV-positive adolescents in Zimbabwe, finds it significantly improves treatment outcomes and boosts self-esteem
The two-year randomised control trial, which began in 2015, involved around 500 13 to 19-year-olds on antiretroviral treatment (ART) in rural Bindura and Shamva. Roughly half received standard of care adherence support from an adult counsellor, while the other half received standard support plus a combination of peer-led support through Zvandiri.
Overall, a 42% lower prevalence of treatment failure or death was observed among Zvandiri participants compared to those receiving standard adherence support. Researchers attributed this to the multi-component, differentiated design of the programme, which not only created a more supportive peer network, but also a more receptive household environment.
In 2013, the World Health Organization recognised Zvandiri (meaning “as I am”) as a best practice programme. Its central component is the community adolescent treatment supporters (CATS), HIV-positive young people (aged 18 to 24) who are on effective treatment and are trained to provide HIV positive teenagers with adherence counselling and support in clinics, support groups and through home visits.
At the end of this trial, more than a third (36%) of adolescents receiving standard support had an unsuppressed viral load or had died, compared to a quarter (25%) of adolescents in the Zvandiri programme. Zvandiri adolescents also reported positive psychological outcomes, such as feeling less isolated and being less fearful of the present and future implications of living with HIV.
The type and frequency of contact with the Zvandiri programme was determined by each teenager’s HIV vulnerability, which in this trial was assessed every three months. Those deemed to be at lower risk of treatment failure received monthly home visits from a CATS plus a weekly, personalised text message about their treatment, and also attended a monthly support group. Additional home visits and messages were arranged if participants missed clinic appointments or support group meetings, or if participants showed signs of mental health or protection issues. The guardians or parents of all Zvandiri adolescents were also invited to a monthly support group.
At enrolment, all trial participants completed a questionnaire and had a viral load test and were then followed-up after weeks 42 to 60 and at week 96. Between 2017 and 2018, in-depth interviews were also conducted with participants, caregivers, healthcare workers, support group leaders (nurses, teachers or social workers) and the CATS.
Despite the benefits of the Zvandiri programme, 17 teenagers in the Zvandiri group and 11 in the control group died during the study. Six of the deaths in the Zvandiri group and eight in the control group were found to be the result of caregivers ordering adolescents to cease ART, acting upon faith healers' instructions. This suggests that teen-focused adherence programmes need to target faith healers as well as caregivers.
A cost-analysis of Zvandiri was also conducted alongside the main trial. This found that, although incorporating the intervention into current care would increase the cost of HIV treatment in the short term, it was likely to be more beneficial in the long term due to the economic cost of ill-health and death brought about by poor treatment.
In 2019, the Zvandiri programme was expanded to the trial’s control group and also introduced in Eswatini, Mozambique, Nigeria, Rwanda, Tanzania and Uganda. There are now around 960 CATS working with 65,500 beneficiaries in 600 clinics.
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