Leaving no one behind? Addressing inequitable HIV outcomes by attending to diversity: A qualitative study exploring the needs of LGBTQI+ young people living with HIV in Zimbabwe.

Leaving nobody behind in the fight to end the HIV epidemic as a public health threat depends on addressing inequities in optimal HIV outcomes. Consistently overlooked in research, policy and programming are young lesbian, gay, bisexual, transgender, queer/questioning and intersex (LGBTQI+) people who are living with HIV. This study engaged young LGBTQI+ people in Zimbabwe to better understand their experiences of living with HIV and the support they need. Between September 2022 and February 2023, we conducted qualitative research with 14 LGBTQI+ young people (18-24 years), (two focus group discussions and in-depth interviews with 5/14). All 14 participants were accessing a LGBTQI+ HIV support group at Zvandiri ('As I Am'), a well-established community-based HIV program. We conducted thematic analysis and key findings informed the collaborative development of internal activities to further enhance inclusivity of LGBTQI+ young people within Zvandiri's programs. There was consensus among participants that being LGBTQI+ and living with HIV leads to "double stigma and double trouble", involving physical and verbal harassment, social exclusion and family rejection. Participants concealed their LGBTQI+ identity and HIV status in most situations, and many withheld their HIV status in LGBTQI+ social spaces, including community-led LGBTQI+ services. This negatively impacted their psychosocial well-being and social connectedness. Participants described positive experiences of Zvandiri. Interacting with others living with HIV in a destigmatising environment promoted self-acceptance. However, reflecting their prevailing experiences, participants were cautious about revealing their sexuality and/or gender identity at Zvandiri outside of their support group. Ensuring equitable access to HIV care, including mental health support, relies on understanding the challenges experienced by those most marginalised. Critically important is understanding the impact of intersectional stigma on LGBTQI+ young peoples' social lives, and their access to services. Community-based HIV support programs are well-positioned to support and advance this group's health rights.

Intersecting Epidemics: The Predictors of Continued Utilization of HIV Care and Treatment Services During the COVID-19 Outbreak Among People Living with HIV in ZIMBABWE.

Globally, there have been considerable achievements towards HIV care and treatment. AIDS-related deaths have been reduced by 60% since the peak in 2004. Potentially, the fight against the HIV epidemic was made more difficult with the outbreak of COVID-19. Thus, this study examined the implications of COVID-19 in the utilization of HIV care and treatment services among people living with HIV on antiretroviral therapy (ART) in Zimbabwe. The study aimed to identify the critical factors defining the utilization of HIV services at the advent of COVID-19 using the fifth revision of the Anderson Behavioral Model of Healthcare Utilization. The study utilized a concurrent triangulation design of which only one data collection phase was used. The quantitative data was collected from 2,157 people living with HIV on antiretroviral viral therapy through a structured interviewer-administered questionnaire. On the other hand, qualitative data was collected through in-depth interviews. Regarding accessing ART refills, the study findings revealed that adolescents aged 15-19 (aOR = 2.16; 95% CI: 1.18-3.96) had higher odds of utilizing ART refills compared to their counterparts who were aged 20-24. Living in a rural area was associated with higher odds of utilizing the ART refill service (aOR = 2.20; 95% CI: 1.49-3.24). Regarding accessing viral load monitoring adults aged 25-39 (aOR = 0.41; 95% CI: 0.26-0.66) were less likely to utilize viral load monitoring compared to young people aged 20-24. Being vaccinated for COVID-19 was significantly associated with higher odds of utilizing the viral load monitoring service (aOR = 1.97; 95% CI: 1.36-2.87) than those not yet vaccinated. Living in a rural area was associated with higher odds of utilizing viral load monitoring (aOR = 1.50; 95% CI: 1.09-2.08). Regarding tuberculosis preventative therapy, adults aged 25-39 (aOR = 0.30; 95% CI: 0.20-0.47) were less likely to utilize tuberculosis preventative therapy compared to young people aged 20-24. Being vaccinated for COVID-19 was significantly associated with higher odds of utilizing tuberculosis preventative therapy (aOR = 1.59; 95% CI: 1.12-2.25) than those not yet vaccinated. Living in a rural area was associated with higher odds of utilizing tuberculosis preventive therapy (aOR = 1.58; 95% CI: 1.19-2.08). Regarding tuberculosis screening being vaccinated for COVID-19 was significantly associated with higher odds of utilizing tuberculosis screening services (aOR = 1.89; 95% CI: 1.41-2.54) than those not yet vaccinated. Although the severity of the COVID-19 pandemic has dwindled, COVID-19 appears to come and go in waves, and a few countries are still recording relatively high cases. It is therefore likely that the factors associated with utilization of HIV services identified by the study such as age, residence, type of health facility, vaccination of COVID-19 and fear of contracting COVID-19, among others, need to be included when planning to improve access to health utilization.

"They test my blood to know how much blood is in my body": the untapped potential of promoting viral load literacy to support adherence and viral suppression among adolescents living with HIV.

INTRODUCTION: Achieving sustained HIV viral suppression is a key strategy to optimize the health and wellbeing of those living with HIV. Sub-optimal adherence to antiretroviral therapy (ART) in adolescents and young people living with HIV (AYPLHIV) in Southern Africa, due to a range of social and contextual factors, including poor mental health, has presented a substantial challenge to meeting targets aimed towards improving treatment outcomes and reducing transmission. With the increasing availability of viral load (VL) testing in Southern Africa, there is an opportunity to better understand the relationship between VL literacy, wellbeing and adherence among adolescents. METHODS: We conducted qualitative interviews with 45 AYPLHIV aged 10-24 years in three districts (urban, peri-urban and rural) in Zimbabwe between March and August 2021. The sample was purposively selected to represent a range of experiences related to HIV status disclosure, gender, marital status and treatment experience. Separate workshops were conducted with 18 healthcare workers (HCWs) and 20 caregivers to better understand existing support mechanisms to AYPLHIV accessing ART. We used thematic analysis to examine adolescent VL literacy, treatment support networks, experiences of clinic interactions, VL testing procedures and barriers to adherence. RESULTS: VL literacy was consistently under-developed among participants. Comprehension of phrases commonly heard during clinic visits, such as TND (target not detected) and "high" and "low" VL, were better understood by older participants. VL testing was predominantly understood as a clinical procedure that enables HCWs to monitor treatment adherence. Absent throughout the interviews were descriptions of how viral suppression improves health and quality of life, likely fosters wellbeing and enhances self-esteem, enables participation in education and social activities, and eliminates the risk of onward transmission. CONCLUSIONS: It is imperative that we reconsider how routine VL monitoring is communicated to and understood by AYPLHIV. Reframing ART, including VL test results, in terms of the psychosocial benefits that viral suppression can generate is likely to be crucial to motivating AYPLHIV to maintain optimal treatment engagement and develop self-management approaches as they move into adulthood. Access to accurate information tailored to individual concerns and circumstances can support AYPLHIV to achieve wellbeing.

Wakakosha "You are Worth it": reported impact of a community-based, peer-led HIV self-stigma intervention to improve self-worth and wellbeing among young people living with HIV in Zimbabwe.

Introduction: Self-stigma-negative self-judgements or core beliefs-can result in feelings of shame, worthlessness and self-blame, and impacts social interaction, mental health and health service utilization among people living with HIV (PLHIV). Few interventions target self-stigma among PLHIV and, to our knowledge, none until now for adolescents and young people LHIV (AYPLHIV) in sub-Saharan Africa. We present qualitative findings on the perceived impact of a self-stigma intervention (Wakakosha, "You are Worth it"). Methods: The Wakakosha intervention adopted inquiry-based stress reduction (IBSR) at its core-a unique way of identifying and questioning deeply rooted self-stigma, combined with mindfulness, meditation and creativity. The intervention consisted of 16 × 3 hour group sessions. Supporting the intervention was a 156-page activity journal. We utilized a qualitative enquiry to explore the perceived impact of the intervention at various time points between November 2021 and November 2022, with 62 participants (n = 32 female). Discussions explored experiences of being involved in the intervention and any reports on changes in relation to self-stigma and shame. Additionally, we reviewed intervention documentation and creative elements. A thematic analysis guided generation of themes across all data sources. Results: Both intervention participants and coaches described the transformative effect of the intervention, detailing their experiences before and after. Main themes that emerged were positive changes around: self-confidence, self-agency, sense of purpose/meaning, body positivity, improved communication and personal/family relationships and, forgiveness. The intervention also transferred a set of practical skills on self-inquiry, mindfulness, meditation and creativity that continued to be used in participants' daily lives. Conclusion: The Wakakosha intervention, using IBSR supported by music, creativity, writing and mindfulness techniques, showed potential for reducing self-stigma and improving self-worth among AYPLHIV. It also transferred practical skills to intervention participants and peer coaches, building their capacity to support others and deal with life challenges beyond HIV. The next phase is to continue supporting the young people to ensure fidelity as the peer coaches deliver the intervention to others. Study results indicate that culturally and practically, interventions to reduce self-stigma and/or improve self-worth operate at various levels and need to be designed and assessed at each level.

Let's talk about U=U: seizing a valuable opportunity to better support adolescents living with HIV.

The clinical knowledge that people living with HIV who maintain an undetectable viral load and therefore cannot transmit HIV sexually, known as Undetectable equals Untransmittable (U=U), has reached a critical mass of adults, but it is relatively silenced within adolescent HIV care and support. We argue that understanding the full range of opportunities enabled by viral suppression, including the elimination of transmission risk, could transform adolescents' understanding of living with HIV, incentivise optimal treatment engagement and support and sustain their positive mental health. However, the reluctance to discuss U=U with adolescents means that we are not providing them with adequate access to the information and tools that would help them to succeed. We need to recognise, value, and invest in the mediating role of building viral load literacy, illustrated by conveying U=U in ways that are meaningful for adolescents, to accelerate viral suppression. Rather than protect, rationing access to information on U=U only increases their vulnerability and risk to poor HIV and mental health outcomes.

Assessing Engagement of Adolescents and Young Adults (AYA) in HIV Research: A Multi-method Analysis of a Crowdsourcing Open Call and Typology of AYA Engagement in Sub-Saharan Africa.

Engagement of adolescents and young adults (AYA) in HIV research is increasing in many settings. We organized a crowdsourcing open call to solicit examples of how AYA have been engaged in HIV research in Africa and to develop an engagement typology. We formed a steering committee, promoted the open call, organized judging and recognized finalists. We used a multi-methods approach to identify emerging themes and measure engagement. We received 95 entries from individuals in 15 countries; 74 met the eligibility criteria. More than three-quarters of entries were from AYA (55/74, 74%). Four themes characterized AYA engagement: (1) AYA were co-creators in the HIV research process. (2) AYA were involved in community-level capacity building. (3) AYA were co-leaders in minor risk research. (4) AYA used digital methods to enhance engagement. Our open call identified diverse methods of AYA engagement, which can enhance strategies used to reach AYA in African HIV studies.

Conceptualisation and psychometric evaluation of positive psychological outcome measures used in adolescents and young adults living with HIV: a mixed scoping and systematic review protocol.

INTRODUCTION: Sub-Saharan Africa bears the greatest burden of HIV. Concomitant mental disorders are common, necessitating the integration of mental healthcare into routine HIV care. Consequently, it is necessary to holistically evaluate the mental health of adolescents and young adults living with HIV (AYALHIV, 10-24 years old) by measuring negative and positive psychological constructs (eg, anxiety and self-acceptance, respectively). There has been a proliferation of positive psychological outcome measures, but the evidence of their psychometric robustness is fragmented. This review, therefore, seeks to (1) identify positive psychological outcomes used in AYALHIV in sub-Saharan Africa and map the constructs onto corresponding measures and (2) critically appraise the psychometrics of the identified outcomes METHODS AND ANALYSIS: This mixed review will be done in two parts. First, a scoping review will identify positive psychological outcomes and map them onto corresponding outcome measures. Subsequently, we will systematically evaluate the psychometric properties of the outcomes identified from the scoping review. Independent and blinded reviewers will search articles in PubMed, Scopus, Web of Science, Africa-Wide Information, CINAHL, PsychINFO and Google Scholar from inception through 30 September 2022. Thereafter, separate independent reviewers will screen the retrieved articles. We will apply a narrative synthesis to map the key constructs emerging from the scoping review. For the systematic review, the risk of bias across studies will be evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. The quality of the psychometric properties will be rated using the COSMIN checklist and qualitatively synthesised using the modified Grading of Recommendations Assessment, Development and Evaluation checklist. ETHICS AND DISSEMINATION: No ethical approvals are needed. The mixed-review outputs will collectively inform the development, implementation and evaluation of bespoke interventions for AYALHIV. Review outcomes will be disseminated in a peer-reviewed journal, on social media and through policy briefs. PROSPERO REGISTRATION: CRD42022325172.

From surviving to thriving: integrating mental health care into HIV, community, and family services for adolescents living with HIV.

Adolescents are a crucial generation, with the potential to bring future social and economic success for themselves and their countries. More than 90% of adolescents living with HIV reside in sub-Saharan Africa, where their mental health is set against a background of poverty, familial stress, service gaps, and an HIV epidemic that is now intertwined with the COVID-19 pandemic. In this Series paper, we review systematic reviews, randomised trials, and cohort studies of adolescents living with and affected by HIV. We provide a detailed overview of mental health provision and collate evidence for future approaches. We find that the mental health burden for adolescents living with HIV is high, contributing to low quality of life and challenges with adherence to antiretroviral therapy. Mental health provision is scarce, infrastructure and skilled providers are missing, and leadership is needed. Evidence of effective interventions is emerging, including specific provisions for mental health (eg, cognitive behavioural therapy, problem-solving, mindfulness, and parenting programmes) and broader provisions to prevent drivers of poor mental health (eg, social protection and violence prevention). We provide evidence of longitudinal associations between unconditional government grants and improved mental health. Combinations of economic and social interventions (known as cash plus care) could increase mental health benefits. Scalable delivery models include task sharing, primary care integration, strengthening families, and a pyramid of provision that differentiates between levels of need, from prevention to the care of severe disorders. A turning point has now been reached, from which complacency cannot persist. We conclude that there is substantial need, available frameworks, and a growing evidence base for action while infrastructure and skill acquisition is built.

Exploring the beliefs, experiences and impacts of HIV-related self-stigma amongst adolescents and young adults living with HIV in Harare, Zimbabwe: A qualitative study.

BACKGROUND: HIV-related self-stigma is a significant barrier to HIV management. However, very little research has explored this phenomenon, particularly in sub-Saharan Africa. This study explored the beliefs, experiences, and impacts of HIV self-stigma amongst adolescents and young adults (AYALHIV) in Harare, Zimbabwe to inform future interventions. It aimed to capture the lived experience of self-stigmatization among AYALHIV and its impact on their social context using Corrigan et al (2009) self-stigma framework of 'awareness', 'agreement', and 'application'. METHODS: Virtual semi-structured key informant interviews were conducted between June and July 2020 with adolescents and young adults (Female = 8; Male = 8) living with HIV (18-24 years) in Harare, Zimbabwe. We conducted the interviews with a purposive sample of AYALHIV enrolled in Africaid's 'Zvandiri' program which provides HIV support services. Interviews were mainly conducted in English and with three in Shona, the main indigenous language. Audio-recorded qualitative data were transcribed, translated into English (where necessary) and deductively coded using Corrigan et al.'s self-stigma framework. The outbreak of SARS-CoV-2 coincided with the commencement of data collection activities, which impacted on both the sample size and a shift from in-person to virtual interviewing methods. RESULTS: Sixteen respondents (50% male) took part in the interviews. The mean age of respondents was 22 years. All respondents reported HIV-related self-stigma either occasionally or frequently. Three main themes of self-stigmatizing experiences emerged: disclosure, relationships, and isolation. These themes were then analyzed within the self-stigma development framework by Corrigan et al. (2009) known as 'the three As': awareness, agreement, and application of self-stigmatizing thoughts. Respondents' experiences of self-stigma reportedly led to poor well-being and decreased mental and physical health. Gendered experiences and coping mechanisms of self-stigma were reported. Data suggested that context is key in the way that HIV is understood and how it then impacts the way people living with HIV (PLHIV) live with, and experience, HIV. CONCLUSIONS: HIV-related negative self-perceptions were described by all respondents in this study, associated with self-stigmatizing beliefs that adversely affected respondents' quality of life. Study findings supported Corrigan et al.'s framework on how to identify self-stigma and was a useful lens through which to understand HIV-related self-stigma among young people in Harare. Study findings highlight the need for interventions targeting PLHIV and AYALHIV to be context relevant if they are to build individual resilience, while working concurrently with socio-political and systemic approaches that challenge attitudes to HIV at the wider societal levels. Finally, the gendered experiences of self-stigma point to the intersecting layers of self-stigma that are likely to be felt by particularly marginalized populations living with HIV and should be further explored.

How Do Psychosocial Interventions for Adolescents and Young People Living With HIV Improve Adherence and Viral Load? A Realist Review.

PURPOSE: Psychosocial interventions have the potential to support adolescents and young people living with HIV (AYPLHIV) to achieve better HIV outcomes. However, more evidence is needed to understand which interventions are most effective, and the mechanisms driving how they work in practice. METHODS: We used realist methodologies to generate statements based on evidence from intervention studies and linked evidence included in a systematic review of psychosocial interventions for AYPLHIV. Key data were extracted from available sources to generate cases, including context-mechanism-outcome pathways. Higher level themes were refined iteratively to create a mid-range theory of how these interventions may work. RESULTS: From 26 resulting cases, 8 statements were crafted, grouped into 3 overarching categories, to describe how these interventions worked. Interventions were overall found to set off mechanisms to improve adherence when (1) responding to individual-level factors to support AYPLHIV (via incorporating agency and empowerment, personalized and/or contextualized approaches, and self-care skills); (2) tailoring delivery strategies to address specific needs (via diverse strategies, longer duration, and digital delivery); and (3) providing supportive resources (via peer and broader support, and structural support and integration into existing services). DISCUSSION: A collection of diverse mechanisms may individually or collectively drive improved outcomes for AYPLHIV engaged in psychosocial interventions. Recommendations for integrating our findings into practice are discussed.

Peer-led counselling with problem discussion therapy for adolescents living with HIV in Zimbabwe: A cluster-randomised trial.

BACKGROUND: Adolescents living with HIV have poor virological suppression and high prevalence of common mental disorders (CMDs). In Zimbabwe, the Zvandiri adolescent peer support programme is effective at improving virological suppression. We assessed the effect of training Zvandiri peer counsellors known as Community Adolescent Treatment Supporters (CATS) in problem-solving therapy (PST) on virological suppression and mental health outcomes. METHODS AND FINDINGS: Sixty clinics were randomised 1:1 to either normal Zvandiri peer counselling or a peer counsellor trained in PST. In January to March 2019, 842 adolescents aged 10 to 19 years and living with HIV who screened positive for CMDs were enrolled (375 (44.5%) male and 418 (49.6%) orphaned of at least one parent). The primary outcome was virological nonsuppression (viral load ≥1,000 copies/mL). Secondary outcomes were symptoms of CMDs measured with the Shona Symptom Questionnaire (SSQ ≥8) and depression measured with the Patient Health Questionnaire (PHQ-9 ≥10) and health utility score using the EQ-5D. The adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were estimated using logistic regression adjusting for clinic-level clustering. Case reviews and focus group discussions were used to determine feasibility of intervention delivery. At baseline, 35.1% of participants had virological nonsuppression and 70.3% had SSQ≥8. After 48 weeks, follow-up was 89.5% for viral load data and 90.9% for other outcomes. Virological nonsuppression decreased in both arms, but there was no evidence of an intervention effect (prevalence of nonsuppression 14.7% in the Zvandiri-PST arm versus 11.9% in the Zvandiri arm; AOR = 1.29; 95% CI 0.68, 2.48; p = 0.44). There was strong evidence of an apparent effect on common mental health outcomes (SSQ ≥8: 2.4% versus 10.3% [AOR = 0.19; 95% CI 0.08, 0.46; p < 0.001]; PHQ-9 ≥10: 2.9% versus 8.8% [AOR = 0.32; 95% CI 0.14, 0.78; p = 0.01]). Prevalence of EQ-5D index score <1 was 27.6% versus 38.9% (AOR = 0.56; 95% CI 0.31, 1.03; p = 0.06). Qualitative analyses found that CATS-observed participants had limited autonomy or ability to solve problems. In response, the CATS adapted the intervention to focus on empathic problem discussion to fit adolescents' age, capacity, and circumstances, which was beneficial. Limitations include that cost data were not available and that the mental health tools were validated in adult populations, not adolescents. CONCLUSIONS: PST training for CATS did not add to the benefit of peer support in reducing virological nonsuppression but led to improved symptoms of CMD and depression compared to standard Zvandiri care among adolescents living with HIV in Zimbabwe. Active involvement of caregivers and strengthened referral structures could increase feasibility and effectiveness. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201810756862405.

Psychosocial interventions for improving engagement in care and health and behavioural outcomes for adolescents and young people living with HIV: a systematic review and meta-analysis.

INTRODUCTION: Adolescents and young people comprise a growing proportion of new HIV infections globally, yet current approaches do not effectively engage this group, and adolescent HIV-related outcomes are the poorest among all age groups. Providing psychosocial interventions incorporating psychological, social, and/or behavioural approaches offer a potential pathway to improve engagement in care and health and behavioural outcomes among adolescents and young people living with HIV (AYPLHIV). METHODS: A systematic search of all peer-reviewed papers published between January 2000 and July 2020 was conducted through four electronic databases (Cochrane Library, PsycINFO, PubMed and Scopus). We included randomized controlled trials evaluating psychosocial interventions aimed at improving engagement in care and health and behavioural outcomes of AYPLHIV aged 10 to 24 years. RESULTS AND DISCUSSION: Thirty relevant studies were identified. Studies took place in the United States (n = 18, 60%), sub-Saharan Africa (Nigeria, South Africa, Uganda, Zambia, Zimbabwe) and Southeast Asia (Thailand). Outcomes of interest included adherence to antiretroviral therapy (ART), ART knowledge, viral load data, sexual risk behaviours, sexual risk knowledge, retention in care and linkage to care. Overall, psychosocial interventions for AYPLHIV showed important, small-to-moderate effects on adherence to ART (SMD = 0.3907, 95% CI: 0.1059 to 0.6754, 21 studies, n = 2647) and viral load (SMD = -0.2607, 95% CI -04518 to -0.0696, 12 studies, n = 1566). The psychosocial interventions reviewed did not demonstrate significant impacts on retention in care (n = 8), sexual risk behaviours and knowledge (n = 13), viral suppression (n = 4), undetectable viral load (n = 5) or linkage to care (n = 1) among AYPLHIV. No studies measured transition to adult services. Effective interventions employed various approaches, including digital and lay health worker delivery, which hold promise for scaling interventions in the context of COVID-19. CONCLUSIONS: This review highlights the potential of psychosocial interventions in improving health outcomes in AYPLHIV. However, more research needs to be conducted on interventions that can effectively reduce sexual risk behaviours of AYPLHIV, as well as those that can strengthen engagement in care. Further investment is needed to ensure that these interventions are cost-effective, sustainable and resilient in the face of resource constraints and global challenges such as the COVID-19 pandemic.

Risk factors for HIV virological non-suppression among adolescents with common mental disorder symptoms in Zimbabwe: a cross-sectional study.

INTRODUCTION: Adolescents are at increased risk of HIV virological non-suppression compared to adults and younger children. Common mental disorders such as anxiety and depression are a barrier to adherence and virological suppression. The aim of this study was to identify factors associated with virological non-suppression among adolescents living with HIV (ALWH) in Zimbabwe who had symptoms of common mental disorders. METHODS: We utilized baseline data from a cluster-randomized controlled trial of a problem-solving therapy intervention to improve mental health and HIV viral suppression of ALWH. Sixty clinics within 10 districts were randomized 1:1 to either the intervention or control arm, with the aim to recruit 14 adolescents aged 10 to 19 per clinic. Adolescents were eligible if they scored ≥7 on the Shona Symptom Questionnaire measuring symptoms of common mental disorders. Multivariable mixed-effects logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95% CI) for factors associated with non-suppression, defined as viral load ≥1000 copies/mL. RESULTS: Between 2 January and 21 March 2019 the trial enrolled 842 participants aged 10 to 19 years (55.5% female, 58.8% aged <16). Most participants (N = 613) were taking an NNRTI-based ART regimen (13 PI-based, 216 unknown) and median duration on ART was six years (IQR three to nine years, 240 unknown). Of the 833 with viral load data 292 (35.1%) were non-suppressed. Virological non-suppression was independently associated with male sex (adjusted OR (aOR) = 1.43, 95% CI 1.04 to 1.97), and with not knowing one's own HIV status (aOR = 1.77, 95% CI 1.08 to 2.88), or knowing one's status but not disclosing it to anyone (aOR = 1.99, 95% CI 1.36 to 2.93), compared to adolescents who knew their status and had disclosed it to someone. CONCLUSIONS: ALWH with symptoms of common mental disorders have high prevalence of virological non-suppression in Zimbabwe, especially if they do not know their status or have not disclosed it. In general adolescents should be informed of their HIV status, with encouragement on the beneficial health and social effects of viral suppression, to incentivise adherence. Efforts to strengthen the operationalization of disclosure guidelines for adolescents should now be prioritized.

The transient effect of a peer support intervention to improve adherence among adolescents and young adults failing antiretroviral therapy in Harare, Zimbabwe: a randomized control trial.

BACKGROUND: Adolescents and young adults living with HIV in sub Saharan Africa are at high risk of poor adherence to antiretroviral therapy (ART) and virologic failure (VF). METHODS: We conducted a randomized control trial among adolescents and young adults on ART with VF to assess the effectiveness of a community-based peer support intervention aimed at improving VF. Viral load (VL) levels were obtained at 12, 24 and 36 weeks. A subset of the participants had baseline HIV drug resistance (HIVDR) genotyped using Sanger sequencing. RESULTS: The participants' median (interquartile range (IQR)) age was 18.1 (IQR: 15.1-20.0) years and half (50.5%, n = 107) were male. At week 24, the proportion of subjects with a detectable viremia was significantly lower in the intervention arm than in the standard of care (SOC) arm (76.0% (n = 79) vs. 89.0% (n = 96), p = 0.013). At Week 36, there remained a difference in the proportion of subjects with a detectable VL between the intervention arm (68.3%, n = 71) and SOC arm (79.6%, n = 86), which was trending towards statistical significance (p = 0.059). There was no difference in the probability of having a detectable VL over time between the intervention and SOC groups (adjusted odds ratio: 1.14, p = 0.439). Baseline HIVDR was observed in 44.0% of the participants in the intervention and 56.0% in the SOC group (p = 0.146). CONCLUSION: A transient effect of the peer support intervention in improving VF was observed among adolescents and young people failing ART. TRIAL REGISTRATION: This study is registered with www.clinicaltrials.gov under the reference number: NCT02833441.

It helps to talk: A guiding framework (TRUST) for peer support in delivering mental health care for adolescents living with HIV.

INTRODUCTION: Adolescents living with HIV have poor treatment outcomes, including lower rates of viral suppression, than other age groups. Emerging evidence suggests a connection between improved mental health and increased adherence. Strengthening the focus on mental health could support increased rates of viral suppression. In sub-Saharan Africa clinical services for mental health care are extremely limited. Additional mechanisms are required to address the unmet mental health needs of this group. We consider the role that community-based peer supporters, a cadre operating at scale with adolescents, could play in the provision of lay-support for mental health. METHODS: We conducted qualitative research to explore the experiences of peer supporters involved in delivering a peer-led mental health intervention in Zimbabwe as part of a randomized control trial (Zvandiri-Friendship Bench trial). We conducted 2 focus group discussions towards the end of the trial with 20 peer supporters (aged 18-24) from across 10 intervention districts and audio recorded 200 of the peer supporters' monthly case reviews. These data were thematically analysed to explore how peer supporters reflect on what was required of them given the problems that clients raised and what they themselves needed in delivering mental health support. RESULTS: A primary strength of the peer support model, reflected across the datasets, is that it enables adolescents to openly discuss their problems with peer supporters, confident that there is reciprocal trust and understanding derived from the similarity in their lived experiences with HIV. There are potential risks for peer supporters, including being overwhelmed by engaging with and feeling responsible for resolving relationally and structurally complex problems, which warrant considerable supervision. To support this cadre critical elements are needed: a clearly defined scope for the manageable provision of mental health support; a strong triage and referral system for complex cases; mechanisms to support the inclusion of caregivers; and sustained investment in training and ongoing supervision. CONCLUSION: Extending peer support to explicitly include a focus on mental health has enormous potential. From this empirical study we have developed a framework of core considerations and principles (the TRUST Framework) to guide the implementation of adequate supportive infrastructure in place to enhance the opportunities and mitigate risks.

Effectiveness of a peer-led adolescent mental health intervention on HIV virological suppression and mental health in Zimbabwe: protocol of a cluster-randomised trial.

BACKGROUND: Adolescents living with HIV (ALHIV) experience a high burden of mental health disorder which is a barrier to antiretroviral therapy adherence. In Zimbabwe, trained, mentored peer supporters living with HIV (Community Adolescent Treatment Supporters - CATS) have been found to improve adherence, viral suppression and psychosocial well-being among ALHIV. The Friendship Bench is the largest integrated mental health programme in Africa. We hypothesise that combining the CATS programme and Friendship Bench will improve mental health and virological suppression among ALHIV compared with the CATS programme alone. METHODS: We will conduct a cluster-randomised controlled trial in 60 clinics randomised 1:1 in five provinces. ALHIV attending the control arm clinics will receive standard CATS support and clinic support following the Ministry of Health guidelines. Those attending the intervention arm clinics will receive Friendship Bench problem-solving therapy, delivered by trained CATS. Participants with the signs of psychological distress will be referred to the clinic for further assessment and management. The primary outcome is HIV virological failure (≥1000 copies/ml) or death at 48 weeks. Secondary outcomes include the proportion of adolescents with common mental disorder symptoms (defined as Shona Symptom Questionnaire (SSQ-14) score ≥8), proportion with depression symptoms (defined as Patient Health Questionnaire (PHQ-9) score ≥11), symptom severity (mean SSQ-14 and PHQ-9 scores) and EQ-5D score for health-related quality of life. CONCLUSIONS: This trial evaluates the effectiveness of peer-delivery of mental health care on mental health and HIV viral load among ALHIV. If effective this intervention has the potential to be scaled-up to improve these outcomes.Trial registration: PACTR201810756862405. 08 October 2018.

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.

INTRODUCTION: Low rates of viral suppression among adolescents living with HIV (ALHIV) indicate that more effective support is urgently required at scale. The provision of peer support has generated considerable enthusiasm because it has the potential to ameliorate the complex social and relational challenges which underpin suboptimal adherence. Little is known about the impact on young peer supporters themselves, which is the focus of this paper. METHODS: We present qualitative findings from the Zvandiri trial investigating the impact of a peer support intervention on the viral load for beneficiaries (ALHIV, aged 13 to 19 years) in Zimbabwe. The Zvandiri peer supporters aged 18 to 24 years, known as community adolescent treatment supporters (CATS), are themselves living with HIV. Individual in-depth interviews were conducted in late 2018 with 17 CATS exploring their experiences of delivering peer support and their own support needs. Interviews were analysed iteratively using thematic analysis. RESULTS: The CATS reported that being peer supporters improved their own adherence behaviour and contributed to an improved sense of self-worth. The social connections between the CATS were a source of comfort and enabled them to develop skills to manage the challenging aspects of their work. Two substantial challenges were identified. First, their work may reveal their HIV status. Second, managing the emotional labour of this caring work; given how commonly the complexity of the beneficiaries' needs mirrored the circumstances of their own difficult lives. Both challenges were ameliorated by the support the CATS provided to each other and ongoing supervision from the adult mentor. There was variation in whether they felt their roles were appropriately valued through the remuneration they received and within the health system. There was a consensus that their experience meant that they would graduate from being a CATS with transferable skills that could enhance their employability. CONCLUSIONS: Their experiences illustrate the advantages and opportunities of being a CATS. To minimize potential harms, it is vital to ensure that they feel valued in their role, which can be demonstrated by the provision of appropriate remuneration, recognition and respect, and that there is continued investment in ongoing support through ongoing training and mentoring.

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

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. FINDINGS: Between Aug 15, 2016, and March 31, 2017, 500 adolescents with HIV were enrolled, of whom four were excluded after group assignment owing to testing HIV negative. Of the remaining 496 adolescents, 212 were recruited at Zvandiri intervention sites and 284 at control sites. At enrolment, the median age was 15 years (IQR 14-17), 52% of adolescents were female, 81% were orphans, and 47% had a viral load of at least 1000 copies per µL. 479 (97%) had primary outcome data at endline, including 28 who died. At 96 weeks, 52 (25%) of 209 adolescents in the Zvandiri intervention group and 97 (36%) of 270 adolescents in the control group had an HIV viral load of at least 1000 copies per µL or had died (adjusted prevalence ratio 0·58, 95% CI 0·36-0·94; p=0·03). Qualitative data suggested that the multiple intervention components acted synergistically to improve the relational context in which adolescents with HIV live, supporting their improved adherence. No adverse events were judged to be related to study procedures. Severe adverse events were 28 deaths (17 in the Zvandiri intervention group, 11 in the control group) and 57 admissions to hospital (20 in the Zvandiri intervention group, 37 in the control group). INTERPRETATION: Peer-supported community-based differentiated service delivery can substantially improve HIV virological suppression in adolescents with HIV and should be scaled up to reduce their high rates of morbidity and mortality. FUNDING: Positive Action for Adolescents Program, ViiV Healthcare.

Effects of a Peer-Led Intervention on HIV Care Continuum Outcomes Among Contacts of Children, Adolescents, and Young Adults Living With HIV in Zimbabwe.

BACKGROUND: Africaid Zvandiri, in partnership with the Ministry of Health and Child Care (MOHCC) in Zimbabwe, implemented a comprehensive, peer-led program, focused on children, adolescents, and young adults living with HIV aged 0-24 years. The peers, known as community adolescent treatment supporters (CATS), are people living with HIV (PLHIV) aged 18-24 years who are trained and mentored to support their peers throughout the HIV care continuum through support groups, home visits, phone call reminders, and messages. We report the HIV care continuum outcomes (HIV testing uptake, antiretroviral therapy [ART] uptake, retention, and viral suppression) in a cohort of household contacts and sexual partners (aged younger than 25 years) of index children, adolescents, and young adults living with HIV identified by CATS from October 2017 to September 2018 in 24 districts of Zimbabwe. METHODS: This was a retrospective cohort study involving analysis of routine program data, extracted from electronic databases consisting of data on contacts of index PLHIV and ART outcomes. We used April 30, 2019, as the censor date for all analyses. RESULTS: A total of 15,223 household contacts and sexual partners with unknown HIV status (linked to 9,353 index PLHIV) were identified and referred for HIV testing. Of these, 12,114 (79.6%) were tested and 1,193 (9.8%) were HIV-positive. Of the latter, 1,153 (96.6%) were initiated on ART with 99% starting on the day of diagnosis. Of those on ART, 1,151 (99.8%) were alive on ART at 6 months and 2 (0.2%) died. A total of 1,044 (91%) children, adolescents, and young people living with HIV underwent viral load testing at 6 months or later, of whom 1,037 (99.3%) were virally suppressed (<1000 copies/ml). CONCLUSION: These findings add to the global evidence demonstrating the effectiveness of peer-led interventions in children, adolescents, and young adults living with HIV and justify the decision of the MOHCC in Zimbabwe to scale-up the model nationally. Future research should aim to understand the reasons for the gaps in HIV testing and viral load testing using qualitative research.