1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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.

7. 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)

8. 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.

9. 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).

10. 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

11. 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

12. 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