Peer-led community intervention substantially reduces treatment failure among adolescents living with HIV in rural Zimbabwe

A peer-led, community-based intervention with multiple components resulted in a 42% reduction in virological failure or death among adolescents living with HIV in rural Zimbabwe compared to adolescents following standard public sector care at 96 weeks follow-up.

These findings from an international team led by Dr Webster Mavhu of the Centre for Sexual Health and HIV/AIDS Research in Harare were published this month in The Lancet Global Health.

As a result of this cluster-randomised controlled trial – undertaken in a real-world, resource-constrained setting – the Zvandiri intervention has been scaled up in Zimbabwe and adapted and implemented in Eswatini, Mozambique, Nigeria, Rwanda, Tanzania and Uganda.

Background

The numbers of adolescents living with HIV will continue to grow as those infected perinatally survive into adolescence. Adolescents have the highest rates of dropping out of HIV treatment and care, resulting in higher rates of treatment failure, disease and death.

The World Health Organization (WHO), even in the absence of strong evidence, recommends community-based interventions for adolescents to support antiretroviral therapy (ART) adherence and retention in care. WHO considers Zvandiri (‘As I am’) a best practice programme.

The intervention’s goal is to improve the wellbeing of adolescents living with HIV and their engagement with services across the HIV prevention and care continuum.

The authors evaluated its effectiveness on HIV-related clinical and psychosocial outcomes among adolescents living with HIV in Zimbabwe. They also conducted a process evaluation, involving in-depth interviews with trial participants, caregivers and those implementing the interventions, as well as observation of meetings.

The study

Sixteen public primary care facilities in two rural districts (Bindura and Shamya) with the lowest ART coverage (29%) among adolescents were randomly assigned to provide enhanced HIV care support (the Zvandiri intervention group) or standard HIV care (control group) to adolescents aged 13-19 years living with HIV. Adult counsellors at all clinics provided adherence support.

At the intervention clinics adolescents were assigned a community adolescent treatment supporter (an HIV-positive peer aged 18-24 years) who provided adherence counselling, ran a monthly support group and offered community-based support.

The frequency of contact was based on individual assessment. Adolescents with well-controlled HIV and good attendance had monthly home visits and weekly individualised text messages with motivational reminders regarding adherence and appointments. Additional home visits occurred when appointments were missed.

Adolescents with more complex situations had enhanced care. This involved two home visits a week, weekly phone calls and daily text messages.

Caregivers were invited to a 12-session caregiver support group.

Results

From 2016 to 2017, 212 adolescents were recruited at the intervention sites and 284 at control sites.  Median age was 15 years and just over half were female (52%). The vast majority (81%) were orphans and almost half (47%) had a viral load over 1000.

The primary outcome was the proportion of adolescents who had died or had a viral load over 1000 after 96 weeks. This occurred in 25% of adolescents (52 of 209) in the intervention group and 36% of adolescents (97 of 270) in the control group.

The intervention had a favourable effect on all secondary outcomes (related to retention, mental health and quality of life), although the differences were not statistically significant.

Cost analysis suggests incorporation of the intervention would triple costs. Economies of scale may be achieved through providing ART and the intervention to greater numbers of adolescents.

Process evaluation data showed that the multi-component intervention addressed the difficult contexts in which adolescents deal with adherence. It provided adolescents with a supportive peer network and a more receptive household, the authors note. Adolescents were able to benefit from continual support to drive and sustain behaviour change.

The intervention:

• Improved the quality of adolescents’ lives through its focus on shared experiences, role modelling and supportive friendship.
• Improved the HIV and treatment literacy of adolescents and their caregivers. This helped adolescents better manage adherence and build self-esteem.
• Fostered more sympathetic household environments, with caregivers better educated and more responsive to meeting adolescents’ nutritional and physical needs.
• Led to adolescents feeling better cared for, less isolated and less worried about the implications of their HIV status.

Having the community adolescent treatment supporters in local clinics had a positive influence on other healthcare workers, creating a more open and receptive environment.

Contextual issues

Implementing the intervention where there is high youth unemployment, a weak economy, persistent HIV stigma, faith healing and an overwhelmed healthcare system is especially difficult. Faith healers, prevalent throughout sub-Saharan Africa, sometimes advised caregivers to tell young people to stop ART. More work with both caregivers and faith healers is essential.

Previous studies have shown how text-messaging supports adherence. However, in this rural setting electricity cuts and mobile network problems meant messages were not always sent. Adolescent treatment supporters also used coded messages for each adolescent so that messages would not result in unintentional disclosure. Sixty-eight per cent of the adolescents had not disclosed their HIV status for fear of rejection.

Lessons learnt

Given the evidence of this differentiated service delivery model’s effects, the authors of a commentary highlight five important lessons.

1. The importance of community investment: quality HIV programming needs funding for community involvement, including treatment literacy, community-based provision of services and community-led monitoring.
2. Investment in peer cadres: Zvandiri’s community adolescent treatment supporters are paid and receive training and mentorship.
3. The value of investing in group models of service delivery: in Zvandiri support groups, peers could share and discuss.
4. Recognition of and response to the changing needs of people with HIV: Zvandiri includes differentiation between a general and intensified package during times of increased risk of treatment failure.
5. The need for continuous innovation by researchers to simplify delivery of care.

Dr Mavhu and colleagues believe these findings support further scale-up across the region and can “inform policies and standards of care for young people with HIV in Zimbabwe, regionally and internationally.”

They conclude “community-based interventions are likely to make a substantial contribution to the UNAIDS 90-90-90 targets if they offer differentiated services, are youth-led and are multi-component.”