Effect of a differentiated service delivery model on virological failure in adolescents with HIV in Zimbabwe (Zvandiri): a cluster-randomised controlled trial

Abstract

Background Adolescents living with HIV face challenges to their wellbeing and antiretroviral therapy adherence and have poor treatment outcomes. We aimed to evaluate a peer-led differentiated service delivery intervention on HIV clinical and psychosocial outcomes among adolescents with HIV in Zimbabwe. Methods 16 public primary care facilities (clusters) in two rural districts in Zimbabwe (Bindura and Shamva) were randomly assigned (1:1) to provide enhanced HIV care support (the Zvandiri intervention group) or standard HIV care (the control group) to adolescents (aged 13-19 years) with HIV. Eligible clinics had at least 20 adolescents in pre-ART or ART registers and were geographically separated by at least 10 km to minimise contamination. Adolescents were eligible for inclusion if they were living with HIV, registered for HIV care at one of the trial clinics, and either starting or already on ART. Exclusion criteria were being too physically unwell to attend clinic (bedridden), psychotic, or unable to give informed assent or consent. Adolescents with HIV at all clinics received adherence support through adult counsellors. At intervention clinics, adolescents with HIV were assigned a community adolescent treatment supporter, attended a monthly support group, and received text messages, calls, home visits, and clinic-based counselling. Implementation intensity was differentiated according to each adolescent's HIV vulnerability, which was reassessed every 3 months. Caregivers were invited to a support group. The primary outcome was the proportion of adolescents who had died or had a viral load of at least 1000 copies per μL after 96 weeks. In-depth qualitative data were collected and analysed thematically. The trial is registered with Pan African Clinical Trial Registry, number PACTR201609001767322.

Scaling up peer‐led community‐based differentiated support for adolescents living with HIV: keeping the needs of youth peer supporters in mind to sustain success

“…Community-based peer support models have not proven to be consistently effective for children, adolescents and young people living with HIV [13]. However, the Zvandiri trial, a cluster-randomized trial which evaluated a theoretically informed peer-led differentiated service delivery intervention on HIV in Zimbabwe [14,15], found 42% lower prevalence of virological failure or death at 96 weeks among participants receiving the Zvandiri intervention than among those solely receiving standard HIV care at rural clinics [16,17]. A detailed explanation of the intervention and trial is outlined in related publications [15,18].…”

Thetha Nami: Participatory development of a peer-navigator intervention to deliver biosocial HIV prevention for adolescents and young men and women in rural South Africa

“…In this area of high youth unemployment, the peer-navigator intervention was seen as bene cial not only to the community but also the peer navigators themselves by providing training, work and income. The bene ts of participating in peer mentorship programmes on the peers themselves has been described in other programmes [31] and suggests the Thetha Nami programme can be a vehicle to accelerate some of the sustainable development goals amongst adolescents [34].…”

“…Whilst Thetha Nami has features in common with the HIV status neutral approaches in high income settings [29] and calls to integrate PrEP with sexual health services [13], the use of community-based participatory research enabled the peernavigators to adapt the biosocial intervention to their own rural setting. Moreover, by using the needs assessment tool to tailor health promotion they can differentiate support at an individual level, with those with greater need receiving the greatest amount of peer support [30,31].…”

Young people are experts and leaders in the HIV response

“…For example in 2019 young researchers led a trial to evaluate the effectiveness of the Zvandiri model for HIV-related and psychosocial support services for adolescents living with HIV in rural districts of Zimbabwe [4]. The study found that adolescents receiving Zvandiri services and Ministry of Health and Child Care services were 42% more likely to be virologically suppressed than adolescents receiving Ministry of Health and Child Care services alone.…”