Effects of a Peer-Led Intervention on HIV Care Continuum Outcomes Among Contacts of Children, Adolescents, and Young Adults Living With HIV in Zimbabwe

Talent Tapera; Nicola Willis; Kudakwashe Madzeke; Tanyaradzwa Napei; Mather Mawodzeke; Stanley Chamoko; Abigail Mutsinze; Teddy Zvirawa; Beatrice Dupwa; Aveneni Mangombe; Anesu Chimwaza; Talent M. Makoni; Winnie Mandewo; Mbazi Senkoro; Philip Owiti; Jaya Prasad Tripathy; Ajay M.V. Kumar

doi:10.9745/GHSP-D-19-00210

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FIGURE 1.
The Zvandiri Model of Care Involving the Community Adolescent Treatment Supporters in Zimbabwe
Abbreviations: ART, antiretroviral therapy; CATS, community adolescent treatment supporters; HTS, HIV testing services; PLHIV, people living with HIV; PMTCT, prevention of mother-to-child transmission of HIV; PSS, psychosocial support; SRHR, sexual and reproductive health and rights; SMS, short message service; TB, tuberculosis.

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TABLE 1.

Description of Community Adolescent Treatment Supporters in the Africaid Zvandiri Program in Zimbabwe

Who are CATS?	Adolescent and young adults living with HIV (18–24 years old) trained and mentored by MOHCC and Africaid as peer counselors
Who appoints CATS?	Health care facility staff identify PLHIV (18–24 years old) with the potential (willing, competent, and motivated) to be CATS and then appoint them in consultation with the authorities in the MOHCC and Africaid. CATS should have completed secondary school and must have consent from their caregivers to enroll.
How many CATS per health facility?	Although the number of CATS per health facility depends on the number of children, adolescents, and young adults living with HIV who need support, the aim is to at least have 1 male and 1 female CATS per health facility. Each CATS should support between 30 and 60 children, adolescents, and young adults living with HIV at any given point in time.
What training do they receive?	All CATS receive 2 weeks of MOHCC-endorsed training on knowledge related to pediatric and adolescent HIV (HIV, ART, adherence support, disclosure, sexual and reproductive health, protection, psychosocial support, and mental health) and skills in counseling and community outreach. The training combines theory and practical components, which includes hands-on mentorship (‘shadowing’) by senior CATS for a period of time before they are independently able to provide support. Training is participatory and uses case studies and role plays. They also receive technical support from district-based Zvandiri mentors employed by Africaid. This initial training is then followed by continued on-site training and mentorship.
What are their responsibilities?	Cofacilitate monthly support groups and ART refill groups Conduct home visits for counseling, monitoring, and support Send SMS reminders and phone calls for adherence and clinic visits and check-ins Provide counseling in clinic and link to other services as needed Refer children, adolescents, and young adults living with HIV (particularly severe cases) and link to other service providers including OI/ART, mental health, social protection, disability, SRHR, and PMTCT Perform community outreach visits in partnership with other cadres from health and social protection Cofacilitate caregiver workshops
Who supervises and mentors CATS?	A nurse or primary counselor at the clinic supervises CATS with additional supervision and mentorship by the district Zvandiri mentor. A district-level monthly meeting is conducted to mentor and review progress of CATS.
What remuneration and incentives do they receive?	Fixed allowance of US$20 per month Bicycles to facilitate home visits and/or reimbursement of bus fare Monthly airtime allowance for SMS reminders and calls

Abbreviations: ART, antiretroviral therapy; CATS, community adolescent treatment supporter; MOHCC, Ministry of Health and Child Care; OI, opportunistic infection; PLHIV, people living with HIV; PMTCT, prevention of mother-to-child transmission of HIV; SMS, short messaging service; SRHR, sexual and reproductive health and rights.

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TABLE 2.

Components and Levels of Support Provided by CATS to Children, Adolescents, and Young Adults Living With HIV in the Africaid Zvandiri Program, Zimbabwe

	Standard Zvandiri Support	Enhanced Zvandiri Support
Eligibility criteria	Undetectable viral load or CD4 count >500 cells/ml in the last 6 months Attended all scheduled clinic visits in the last 3 months Psychologically stable Safe	A detectable viral load or CD4 count <500 cells/ml in the last 6 months Failed to attend scheduled clinic visits in the last 3 months Psychological distress Abuse or neglect Started ART in the past 3 months Reported nonadherence Pregnant
CATS-led interventions	Monthly home visit Weekly SMS reminders Clinic-based counseling Referrals and linkages, particularly for severe cases, to other service providers	Home visit every 2 weeks Daily SMS reminders Clinic-based counseling Referrals and linkages, particularly for severe cases, to other service providers
CATS-supported interventions	Monthly support group Caregiver workshop	Monthly support group Caregiver workshop Adherence workshop Community outreach with CHWs/CCCWs

Abbreviations: CATS, community adolescent treatment supporters; CHWs, community health workers; CCCWs, child case care workers.

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TABLE 3.

Demographic Characteristics of the Household Contacts and Sexual Partners of Index People Living With HIV Identified by Community Adolescent Treatment Supporters in 24 Districts of Zimbabwe, October 2017–September 2018 (N=15,523)

Characteristics	No. (%)
Age (years)
0–4	2495 (16.4)
5–9	2814(18.5)
10–14	3170 (20.8)
15–19	3830 (25.2)
20–24	2914 (19.1)
Gender
Male	6597 (43.3)
Female	8626 (56.7)
Type of Contact
Sibling	6229 (40.9)
Sexual partner	290 (1.9)
Children	8704 (57.2)
Province
Bulawayo	1567 (10.3)
Harare	685 (4.5)
Manicaland	4489 (29.5)
Mashonaland Central	1076 (7.1)
Mashonaland East	179 (1.2)
Masvingo	1362 (8.9)
Matabeleland South	1871 (12.3)
Midlands	3994 (26.2)

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TABLE 4.

HIV Care Cascade Among Household Contacts and Sexual Partners of Index PLHIV Identified by Community Adolescent Treatment Supporters in 24 Districts of Zimbabwe, October 2017–September 2018 (N=15,223)

	No. (%)
HIV Testing Outcome
Contacts Referred for HIV Testing	15,223 (100.0)
Contacts tested for HIV	12,114 (79.6)
Contacts tested who were HIV-positive	1,193 (9.8)
HIV-positive contacts who initiated ART	1,153 (96.6)
ART Outcomes
3 months
Alive on ART	1,153 (100.0)
6 months
Alive on ART	1,151 (99.8)
Died	2 (0.2)
12 Months (n=569^a)
Alive on ART	566 (99.5)
Died	2 (0.4)
Lost to follow-up	1 (0.2)
Viral suppression (<1000 copies/ml)	1,037^b (99.3)

Abbreviations: ART, antiretroviral therapy; PLHIV, people living with HIV.
↵a Number of contacts eligible for 12-month assessment; People whose duration between ART start date and censor date was less than 12 months were considered not eligible for assessment.
↵b Among 1,044 contacts who had a viral load test at 6 months or later after starting ART.

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TABLE 5.

Factors Associated With Not Testing for HIV Among Household Contacts and Sexual Partners of Index PLHIV Identified by Community Adolescent Treatment Supporters in 24 Districts of Zimbabwe, October 2017–September 2018

Characteristic	Total Referred for HIV Testing	Not Tested for HIV	Crude RR(95% CI^a)	Adjusted RR^b(95% CI^a)
Characteristic	No.	No. (%)	Crude RR(95% CI^a)	Adjusted RR^b(95% CI^a)
Total	15223	3109 (20.4)
Age (years)
0–4	2495	864 (34.6)	13.63 (10.82–17.18)	12.72 (10.01–16.17)
5–9	2814	775 (27.5)	10.84 (8.59–13.68)	10.41 (8.19–13.23)
10–14	3170	867 (27.4)	10.77 (8.54–13.58)	10.20 (8.03–12.96)
15–19	3830	529 (13.8)	5.43 (4.28–6.90)	5.21 (4.08–6.65)
20–24	2914	74 (2.5)	Ref	Ref
Gender
Male	6597	1456 (22.1)	1.15 (1.08–1.22)	1.05 (0.98–1.13)
Female	8626	1653 (19.2)	Ref	Ref
Type of contact
Sibling	6229	1289 (20.7)	Ref	Ref
Sexual partner	290	12 (4.1)	0.19 (0.11–0.34)	0.51 (0.29–0.91)
Children	8704	1808 (20.8)	1.00 (0.94–1.06)	1.04 (0.96–1.12)
Province
Masvingo	1362	55 (4.0)	Ref	Ref
Bulawayo	1567	365 (23.3)	5.76 (4.38–7.58)	7.27 (5.47–9.67)
Harare	685	2 (0.3)	0.07 (0.01–0.29)	0.08 (0.02–0.36)
Manicaland	4489	1321 (29.4)	7.28 (5.60–9.47)	7.36 (5.62–9.65)
Mashonaland Central	1076	75 (7.0)	1.72 (1.23–2.42)	1.73 (1.22–2.45)
Mashonaland East	179	9 (5.0)	1.24 (0.62–2.47)	1.34 (0.66–2.72)
Matabeleland South	1871	812 (43.4)	10.74 (8.25–13.99)	11.84 (9.00–15.57)
Midlands	3994	470 (11.8)	2.91 (2.21–3.82)	3.32 (2.51–4.40)

Abbreviations: CI, confidence interval; PLHIV, people living with HIV; Ref, reference group; RR, risk ratio.
↵a Factors with confidence intervals not including 1 were statistically significant (P<.05).
↵b Adjusted for age, sex, province, and type of contact.