Integrated psychosocial, economic strengthening, and clinical service-delivery to improve health and resilience of adolescents living with HIV and their caregivers: Findings from a prospective cohort study in Zambia

Abstract

Background Children and youth are profoundly impacted groups in Zambia’s HIV epidemic. To evaluate delivery of integrated psychosocial, economic strengthening, and clinical services to HIV-affected households through the Zambia Family (ZAMFAM) Project, a prospective cohort study compared socio-economic, psychosocial, and health outcomes among ZAMFAM beneficiaries to non-beneficiaries. Methods In July–October 2017, 544 adolescents living with HIV (ALHIV) aged 5–17 years and their adult caregivers were recruited from Central (ZAMFAM implementation sites) and Eastern (non-intervention sites) Provinces. Structured interviews at baseline and one-year follow-up assessed household characteristics, socio-economic wellbeing, and health service utilization. Poisson regression with generalized estimating equations measured one-year changes in key health and socio-economic indicators, comparing ZAMFAM beneficiaries to non-beneficiaries. Results Overall, 494 households completed two rounds of assessment (retention rate: 91%) Among ALHIV, improvements in current antiretroviral therapy use over time (Adjusted Prevalence Rate Ratio [aPRR] = 1.06, 95% Confidence Interval [95% CI]: 1.01–1.11) and reductions in non-household labor (aPRR = 0.44, 95% CI: 0.20–0.99) were significantly larger among ZAMFAM beneficiaries than non-beneficiaries. For caregivers, receiving ZAMFAM services was associated with significant reductions in HIV-related stigma (aPRR = 0.49, 95% CI: 0.28–0.88) and perceived negative community attitudes towards HIV (aPRR = 0.77, 95% CI: 0.62–0.96). Improvements in caregiver capacity to pay for unexpected (aPRR = 1.54, 95% CI: 1.17–2.04) and food-related expenses (aPRR = 1.48, 95% CI: 1.16–1.90), as well as shared decision-making authority in household spending (aPRR = 1.41, 95% CI: 1.04–1.93) and self-reported good or very good health status (aPRR = 1.46, 95% CI: 1.14–1.87), were also significantly larger among ZAMFAM beneficiaries. Conclusions Significant improvements in caregivers’ financial capacity were observed among households receiving ZAMFAM services, with few changes in health or wellbeing among ALHIV. Integrated service-delivery approaches like ZAMFAM may yield observable socio-economic improvements in the short-term. Strengthening community-based delivery of psychosocial and health support to ALHIV is encouraged.

Integrating HIV services and other health services: A systematic review and meta-analysis

“…One study provided quantitative comparative outcomes related to the third UNAIDS ‘getting to zero’ target of ‘zero discrimination’ [ 3 ]. In this study, the integrated delivery of clinical HIV services and psychosocial interventions for adolescents in Zambia was significantly associated with reduced stigma (adjusted prevalence rate ratio 0.49 [95% CI 0.28–0.88]) and reduced negative community attitudes towards HIV (adjusted prevalence rate ratio 0.77 [95% CI 0.62–0.96]) [ 145 ].…”

“…Another important objective on the global HIV agenda is ‘zero discrimination’ [ 3 ]: We explicitly searched for outcomes of integration interventions related to discrimination and stigma, but found only 1 article that provided quantitative evidence [ 145 ]. However, emerging evidence suggests that interventions explicitly aimed at achieving ‘zero discrimination’ may produce greater population health benefits in jurisdictions with highly unequal access to care [ 170 , 171 ].…”

Models of lifelong care for children and adolescents with chronic conditions in low-income and middle-income countries: a scoping review

“… 27 Finally, in the Zambian ZAMFAM intervention primary caregivers of HIV patients were linked to village loan groups to help them meet financial and nutritional needs. 28 …”

“…A comprehensive care approach to address a patients’ full range of physical, mental and social health service needs was included in the model for mental health, in both models for diabetes, and in 7 of the 11 models for HIV (table 2). 18–21 23–28 Nine models used multidisciplinary care teams, for example, physicians and specialists to manage complex clinical care, nurses and trained community health workers to manage long-term follow-up and routine care, and social workers or case managers to address family, social and community support. Similarly, the use of a case manager to oversee and manage patients’ engagement with each aspect of care—physician visits, nurse follow-up visits and social worker support was used in eight studies 19–22 24 25 27 28…”

Receipt of a combined economic and peer support intervention and clinical outcomes among HIV-positive youth in rural Rwanda: A retrospective cohort

“…Although there is some evidence that peer support programs can improve clinical outcomes among youth with HIV, substantial heterogeneity between programs and infrequent evaluations of existing peer support groups remain a substantial barrier to understanding and improving the implementation of these interventions [15]. Similarly, although economic challenges are often cited as a barrier to treatment adherence, very few youth-focused intervention have assessed the impact of providing economic support on treatment outcomes [16][17][18][19]. Furthermore, although interventions designed to promote treatment adherence and clinical outcomes among youth are commonly include multiple complementary components [20], only two previous studies have combined peer support and economic incentives to support youth with HIV, and both were small pilot studies designed to assess feasibility and safety rather than effectiveness [21,22].…”