A community-based, peer-led intervention Improving Adherence, Retention in Care and Psychosocial Well-being among adolescents on ART in Rural Zimbabwe A community-based, peer-led intervention An operations research study to measure the effectiveness of the CATS service in Gokwe South District, Zimbabwe N. Willis, C. Dziwa, M. Mawodzeke, C. Chitiyo, S. Munyonho, A. Milanzi, I. Yekeye, M. Chemhuru, P. Mtshali, B. Mohr, V. James ICASA, 2015

Background AIDS-related deaths in adolescents continue to increase worldwide Poor linkage and retention in care, sub-optimal adherence and limited attention to service delivery for this age group The specific needs of adolescents are now recognised in the new WHO guidelines Limited research to demonstrate which service delivery interventions improve clinical and psychosocial outcomes for this age group.

Background Zvandiri integrates community based prevention, treatment, care and support within facility care for 6-24 yr olds with HIV Combines Community outreach, Community Adolescents Treatment Supporters (CATS), Support Groups and adolescent friendly health facilities Zvandiri has been widely documented but research data was lacking

Study Objectives To measure the effectiveness of a community-based, adolescent-led treatment support and psychosocial intervention in improving retention in care adherence psychosocial well-being amongst adolescents on ART in a rural district of Zimbabwe

Weekly CATS visit at home Linkage to other services Study Design Sesame Clinic   Gokwe South District OI Clinic 50 Standard of Care 3 monthly clinic Visit Clinical Monitoring Management of OIs CD4 count ARVs (if CD4 <350) Counselling and Adherence Support PLUS Weekly CATS visit at home Monthly Support Group Pill boxes  Linkage to other services 25 CONTROL ARM INTERVENTION ARM Krima Clinic

Methods Ethical Clearance from the Medical Research Council of Zimbabwe Stakeholder Meetings Identification of 2 intervention clinics and 1 control arm clinic with MoHCC 10 ALHIV selected and trained as CATS by Africaid and MoHCC 17-23 yrs old, on ART, attending the intervention clinic, adhering well, completed schooling, consent/assent Recruitment of intervention (50) and control (50) arm Intervention delivered over 12 months (Dec 2014 – Nov 2015) Qualitative and quantitative data collected monthly to measure retention in care, self-reported adherence and psychosocial well-being.

Results ADHERENCE Research Arm Baseline Count (N) Endline Difference (95% CI) P value (95% CI) Odds Ratio (95% CI) Intervention 44.2% 52 71.8% 39 27.6 (7.0%,48.2%) 0.0087 3.934 (1.404, 11.02) Control 48.9% 47 39.3% 28 9.6% (-13.7%,32.9%) 0.419   The CATS intervention resulted in a statistically significant improvement in adherence from 44.2% at baseline to 71.8% at endline (p-value=0.0087). The intervention group are 3.9 times more likely to adhere to treatment compared to the control group (OR=3.934). “The hospital O.I department is not youth friendly; adolescents come to collect their medication seat on a bench with adults and the elderly. This usually disheartens the adolescent. And he/she might end up not coming to the hospital to collect medication. The CATs programme has been particularly helpful, especially the support groups, in getting adolescents to adhere well to medication.” (District Medical Officer-Gokwe South District) “There are no adolescents who have problems of not taking pills in the CATS program, but other adolescents who are not in the CATs programme face difficulties as they do not have the right support and usually end up falling sick because they do not take pills correctly.”(Caregiver FGD-Krima Health Centre)

Results PSYCHOSOCIAL WELLBEING Confidence, Self Esteem and Self Worth Research Arm Baseline (Mean Score) Count (N) Endline Difference (95% CI) P value (95% CI) Intervention 2.21 52 2.70 39 0.49 (0.313,0.667) <0.001 Control 2.45 47 2.60 28 0.15 (-0.018,0.318) 0.078 The intervention group reported a statistically significant increase in confidence, self esteem and self worth by 0.49 points. Stigma Research Arm Baseline Count (N) Endline Difference (95% CI) P value (95% CI) Intervention 2.79 37 2.77 39 0.02% (-0.188%,0.228%) 0.848 Control 2.52 24 3.03 17 0.51% (0.13,0.89%) 0.01 The intervention group reported a decline in stigma though not statistically significant while the Control group experienced a statistically significant increase in stigma levels. Quality of Life Research Arm Baseline Count (N) Endline Difference (95% CI) P value (95% CI) Intervention 3.16 52 3.450 39 0.29 (0.031,0.549) 0.028 Control 3.61 47 3.35 28 0.26 (0.61,0.459) 0.011 The intervention group reported a statistically significant improvement in the quality of life by 0.29 points. The control group experienced a statistically significant decline in the quality of life by 0.26 points.

Results LINKAGE TO RETENTION AND CARE Research Arm Baseline (Mean Score) Count (N) Endline (Mean Score) Difference (95% CI) P value (95% CI) Intervention 3.28 52 3.640 39 0.36 (0.209,0.511) <0.001 Control 3.40 47 3.13 28 0.27 (0.128,0.412) The intervention group reported a statistically significant improvement in linkage to services and retention to care by 0.36 points. The control group reported a statistically significant decline of 0.27 points in the linkage to services and retention to care. “CATS link adolescents to HIV testing and counselling, management of opportunistic infections, family planning information access ( e.g. why use condoms), clinical assistance (e.g. admission). Support groups resulted in adolescents feeling comfortable in accessing services and generally linkages to services has improved.” (DMO, Gokwe South District) “The CATS programme has resulted in reduced loss to follow up since each CAT has a number of children he or she looks after and checks up on.” (Acting Sister in Charge, Sesame Health Centre).

Limitations There was an inadequate number of eligible participants in the clinics for the control arm. It was therefore agreed with MoHCC to recruit the control arm from the district OI clinic The results are based on self report rather than biological markers

Conclusion This adolescent led intervention was effective in improving self-reported adherence, psychosocial well-being and retention in rural district in Zimbabwe. Further research of effectiveness is now required with biological markers

Thank you The CATS team in Gokwe South District Adolescents and their families who took part in the study The Ministry of Health and Child Care Sesame Health Centre, Krima Health Centre, and Gokwe South District Hospital National AIDS Council Gokwe South Rural District Council Bristol Myers Squibb Foundation, Secure the Future programme NEDICO ICASA