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ORIGINAL ARTICLE
Open Access

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 and Ajay M.V. Kumar
Global Health: Science and Practice December 2019, 7(4):575-584; https://doi.org/10.9745/GHSP-D-19-00210
Talent Tapera
aAfricaid Zvandiri, Harare, Zimbabwe.
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  • For correspondence: talent.tapera@gmail.com
Nicola Willis
aAfricaid Zvandiri, Harare, Zimbabwe.
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Kudakwashe Madzeke
aAfricaid Zvandiri, Harare, Zimbabwe.
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Tanyaradzwa Napei
aAfricaid Zvandiri, Harare, Zimbabwe.
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Mather Mawodzeke
aAfricaid Zvandiri, Harare, Zimbabwe.
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Stanley Chamoko
aAfricaid Zvandiri, Harare, Zimbabwe.
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Abigail Mutsinze
aAfricaid Zvandiri, Harare, Zimbabwe.
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Teddy Zvirawa
aAfricaid Zvandiri, Harare, Zimbabwe.
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Beatrice Dupwa
bMinistry of Health and Child Care, Harare, Zimbabwe.
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Aveneni Mangombe
bMinistry of Health and Child Care, Harare, Zimbabwe.
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Anesu Chimwaza
bMinistry of Health and Child Care, Harare, Zimbabwe.
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Talent M. Makoni
bMinistry of Health and Child Care, Harare, Zimbabwe.
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Winnie Mandewo
cElizabeth Glaser Pediatric AIDS Foundation, Harare, Zimbabwe.
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Mbazi Senkoro
dNational Institute for Medical Research, Muhimbili Centre, Dar es Salaam, Tanzania.
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Philip Owiti
eInternational Union Against Tuberculosis and Lung Disease, Paris, France.
fNational Tuberculosis, Leprosy and Lung Disease Program, Nairobi, Kenya.
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Jaya Prasad Tripathy
eInternational Union Against Tuberculosis and Lung Disease, Paris, France.
gInternational Union Against Tuberculosis and Lung Disease, South-East Asia Office, New Delhi, India.
hAll India Institute of Medical Sciences, Nagpur, India.
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Ajay M.V. Kumar
eInternational Union Against Tuberculosis and Lung Disease, Paris, France.
gInternational Union Against Tuberculosis and Lung Disease, South-East Asia Office, New Delhi, India.
iYenepoya Medical College, Yenepoya, Mangaluru, India.
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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 SupportEnhanced 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)

    CharacteristicsNo. (%)
    Age (years)
    0–42495 (16.4)
    5–92814(18.5)
    10–143170 (20.8)
    15–193830 (25.2)
    20–242914 (19.1)
    Gender
    Male6597 (43.3)
    Female8626 (56.7)
    Type of Contact
    Sibling6229 (40.9)
    Sexual partner290 (1.9)
    Children8704 (57.2)
    Province
    Bulawayo1567 (10.3)
    Harare685 (4.5)
    Manicaland4489 (29.5)
    Mashonaland Central1076 (7.1)
    Mashonaland East179 (1.2)
    Masvingo1362 (8.9)
    Matabeleland South1871 (12.3)
    Midlands3994 (26.2)
    • View popup
    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 Testing15,223 (100.0)
    Contacts tested for HIV12,114 (79.6)
    Contacts tested who were HIV-positive1,193 (9.8)
    HIV-positive contacts who initiated ART1,153 (96.6)
    ART Outcomes
    3 months
    Alive on ART1,153 (100.0)
    6 months
    Alive on ART1,151 (99.8)
    Died2 (0.2)
    12 Months (n=569a)
    Alive on ART566 (99.5)
    Died2 (0.4)
    Lost to follow-up1 (0.2)
    Viral suppression (<1000 copies/ml)1,037b (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.

    • View popup
    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

    CharacteristicTotal Referred for HIV TestingNot Tested for HIVCrude RR(95% CIa)Adjusted RRb(95% CIa)
    No.No. (%)
    Total152233109 (20.4) 
    Age (years)
    0–42495864 (34.6) 13.63 (10.82–17.18)12.72 (10.01–16.17)
    5–92814775 (27.5) 10.84 (8.59–13.68)10.41 (8.19–13.23)
    10–143170867 (27.4) 10.77 (8.54–13.58)10.20 (8.03–12.96)
    15–193830529 (13.8) 5.43 (4.28–6.90)5.21 (4.08–6.65)
    20–24291474 (2.5) RefRef
    Gender
    Male65971456 (22.1) 1.15 (1.08–1.22)1.05 (0.98–1.13)
    Female86261653 (19.2) RefRef
    Type of contact
    Sibling62291289 (20.7) RefRef
    Sexual partner29012 (4.1) 0.19 (0.11–0.34)0.51 (0.29–0.91)
    Children87041808 (20.8) 1.00 (0.94–1.06)1.04 (0.96–1.12)
    Province
    Masvingo136255 (4.0) RefRef
    Bulawayo1567365 (23.3) 5.76 (4.38–7.58)7.27 (5.47–9.67)
    Harare6852 (0.3) 0.07 (0.01–0.29)0.08 (0.02–0.36)
    Manicaland44891321 (29.4) 7.28 (5.60–9.47)7.36 (5.62–9.65)
    Mashonaland Central107675 (7.0) 1.72 (1.23–2.42)1.73 (1.22–2.45)
    Mashonaland East1799 (5.0) 1.24 (0.62–2.47)1.34 (0.66–2.72)
    Matabeleland South1871812 (43.4) 10.74 (8.25–13.99)11.84 (9.00–15.57)
    Midlands3994470 (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.

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Global Health: Science and Practice: 7 (4)
Global Health: Science and Practice
Vol. 7, No. 4
December 23, 2019
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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
Global Health: Science and Practice Dec 2019, 7 (4) 575-584; DOI: 10.9745/GHSP-D-19-00210

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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
Global Health: Science and Practice Dec 2019, 7 (4) 575-584; DOI: 10.9745/GHSP-D-19-00210
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