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Operation Triple Zero Supports Adolescents in Overcoming HIV

A woman wearing a red shirt sits for an interview inside.
Click here to hear from OTZ heroes — Steve Ooko Opondo, Rubai Kikumba (above), and Ronald Otieno — who share their powerful stories of struggle, stigma, and fear and how they overcame challenges and found restored hope.

HIV is a serious risk among adolescents in Kenya, and Ciheb has been helping address rising infection rates through Operation Triple Zero (OTZ). OTZ uses a contextual “asset-based approach,” whereby adolescents are considered as resources with potential answers to their challenges and are empowered to take responsibility and action for their health.

A Strategy to Address Rising Infection Rates

According to the Kenya AIDS Response Progress Report 2016, individuals between the ages of 15 and 24 years accounted for more than half (51%) of all new HIV infections — with young women being almost twice as likely to acquire HIV as their male counterparts. In 2013, the rate of new infections among this group had been at 29%, representing a rapid rise in new infections in just a few years.

A host of factors have contributed to this rise, including perceptions of HIV risk, unprotected intercourse, and the influence of alcohol or drugs. Adolescents also remain underserved with regards to medical care and confront considerable stigma.

OTZ’s strategy revolves around a commitment to the three zeros: zero missed appointments, zero missed medication, and zero viral load.

  • Zero missed appointments: Adolescents commit to adhere and keep all their scheduled clinic appointments to ensure they receive the full package of care and continue in care.
  • Zero missed drugs: Adolescents committing to keeping all scheduled clinical appointments means they will never miss their drugs. OTZ empowers adolescents to face any challenges they may have and commit to adhere to their medication 100%.
  • Zero viral load: Adolescents commit to be virally suppressed by ensuring optimal adherence to medication, hence good clinical outcomes, improved quality of life, and reduced transmission of HIV among adolescents.

The program also promotes other “zeros,” including zero stigma, zero deaths, zero sex for those abstaining, zero unprotected sex for the sexually active, and zero mother-to-child HIV transmission for pregnant and breastfeeding adolescents and young people, among others. OTZ is part of Ciheb’s Partnership for Advanced Care and Treatment (PACT) Endeleza program, a five-year initiative funded by the U.S. Centers for Disease Control and Prevention under PEPFAR. PACT Endeleza operates OTZ program at 24 care and treatment sites, providing antiretroviral treatment (ART) to 854 adolescents of whom 693 (81%) have been enrolled into the OTZ clubs and 607 (95%) of those eligible for treatment have achieved viral suppression.

PACT Endeleza launched OTZ in December 2016 with five facilities in Nairobi County. During the initial start-up phase, low-risk adolescents readily enrolled into OTZ as they were already committed to the three zeros. "As we progressed we started targeting the high-risk adolescents and viremics so that they can benefit from OTZ," explained Dr. Emmah Momanyi, senior technical advisor for the PACT Endeleza program.

To provide the support for these new clients, the program built on its experience with its initial clients, creating peer groups called “OTZ Clubs.”

The OTZ Clubs

Club members regularly meet to share the challenges they are facing, receive peer support, and come up with their own solutions, including sharing best practices for adhering to treatment. Those who achieve three zeros in the OTZ clubs are called “heroes” and are recognized in front of their peers for their achievement. These heroes speak up and encourage other OTZ members to become heroes, which encourages adolescents and young peoples’ commitment to the three zeros. Facilities that have a high number of adolescents and young people have a dedicated peer educator who coordinates the activities.

The complete OTZ package of care contains three modules: healthcare workers, caregivers, and adolescent modules. OTZ clubs fall under the adolescent module and take into consideration the needs of the adolescent in different groups and circumstances, such as sex, learners in boarding schools, pregnant adolescents, adolescents using and abusing drugs and parental status. An example of this is the OTZ Plus clubs, with “Plus” meaning care for the HIV-positive pregnant adolescent girls. For those who have dropped out of school and/or left their families and are not willing to go back, OTZ Plus provides tailored support. 

“What we've done is we've had financial literacy sessions with them, and some have been trained in income generating activities that they can engage in so that they are able to get something to support themselves and their children,” said Dr. Momanyi.

OTZ champions” are graduates of OTZ who, at the facility-level, are tasked with enrolling new members, providing psychosocial support to newly identified HIV-positive adolescents and young people, providing support to members with high viral loads through pairing, coordinating OTZ clubs, and overseeing various OTZ activities. Twenty OTZ champions have also been enrolled to support club members in their communities with directly observed therapy, ensuring that they are taking their drugs.

Because of the strong support and bonds created in the clubs, some adolescents are reluctant to leave when the time comes for them to transition to adult care. However, some particularly committed graduates of the program qualify to become peer educators. This helps ensure that new adolescents joining OTZ are being supported by someone who has walked the journey they’re embarking on.

Overcoming COVID-19 Challenges

The COVID-19 pandemic necessitated a change in strategy for drug dispensation. OTZ had started multi-month dispensing but was affected by countrywide commodity shortages. “We are in communication with our donor and different stakeholders to track the progress towards availability of commodities and resumption of multi-month dispensing once the stocks are available,” explained Dr. Momanyi.

The adolescents and young people are also engaged continuously on virtual platforms, where their concerns regarding medication are addressed. OTZ is currently offering monthly refills with the option for caregivers to pick up drugs for adolescents, so that they don’t have to come in person. To enhance adherence, there are plans to roll out peer-led community ART groups in five high-volume facilities for OTZ members in June 2021.

Looking to the Future

With the PACT Endeleza program ending in 2021, OTZ operations will transition to be run by the health facilities, Nairobi County through the Nairobi Metropolitan Service (NMS) which currently partners with PACT Endeleza in OTZ rollout, and by the adolescents themselves as part of the OTZ clubs. They are also engaging the Ministry of Education to build the capacity and sensitization of teachers to support learners in schools living with HIV. This, along with the autonomy already present at different levels, ensures that the sustainability of OTZ will not be a challenge, and that adolescents and young people will continue to receive the holistic care necessary for them to lead healthy and fulfilling lives. 

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