The Zambia Family (ZAMFAM) Project

The ZAMFAM Project, launched in 2015 with support from the United States Agency for International Development (USAID) via the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), employs a community-based, integrated service delivery model to strengthen household capacity in meeting the needs of OVC living with or affected by HIV, as well as improve child and caregiver wellbeing [26]. Dovetailing existing nationally scaled interventions for OVC and ALHIV in Zambia, ZAMFAM’s intervention components tap into clinical and community volunteer networks to improve case management and outcomes for both OVC and ALHIV, from schooling to retention in HIV care. Recognizing the role of households and communities in shaping OVC and ALHIV livelihoods, ZAMFAM also engages primary caregivers in parenting and economic strengthening activities (e.g., village loans groups), aiming to meet their psychosocial, financial, and nutritional needs in order to foster more optimal, resilient care environments for their dependents. ALHIV have been prioritized for program support in the four provinces where ZAMFAM activities are delivered by two implementing partners: Development Aid from People to People (DAPP), implementing in Central and Southern Provinces, and the Expanded Church Response (ECR) Trust, implementing in Copperbelt and Lusaka Provinces.

Working primarily through government structures that oversee activities for vulnerable populations, cadres of para-social workers and volunteer caregivers conduct regular household visits to develop family-tailored plans and motivate uptake of available community-level activities. These activities include needs-based, age-appropriate interventions addressing multiple dimensions of adversity impacting households’ ability to meet the needs of OVC and ALHIV. By providing households with the resources and skills to meet unrelenting financial and social challenges that can traditionally destabilize health-seeking behaviors and healthcare engagement, ZAMFAM interventions seek to foster resilience among ALHIV and caregivers, so they can continue prioritizing their health needs in the face of overlapping adversities.

To address these multilevel sources of adversity, the ZAMFAM package of interventions cut across five key domains, which are illustrated in Fig 1 and described in detail below:

HIV care and treatment. Program implementers convene health staff and community health workers (CHWs), identifying strategies for scaling HIV testing (i.e., enhanced home-based HIV counseling and testing, index case testing and partner notification services) as well as viral load screening (VLS) and CD4+ count monitoring for those living with HIV. CHWs are additionally paired with ALHIV to monitor and support adherence to care and treatment.

Parenting. Contracting with a local women’s faith-based organization, program implementers train community staff on parenting skills, including child abuse and gender-based violence. Community staff subsequently mobilize caregivers of ALHIV and hold meetings to discuss these issues.

Food security. Farming inputs—including maize seed, legumes, cassava, sweet potatoes, chickens, and goats—are provided to OVC and ALHIV households.

Household economic strengthening. Loans and savings schemes are introduced into Village Action Groups, allowing for members to borrow money for investments (e.g., in businesses, essential household items) or purchase agricultural inputs at lower interest rates.

Psychosocial support. ALHIV are paired with their primary caregiver and an adult from a neighboring household to support the adolescent’s adherence to ART and engagement with HIV services. Counselors and CHWs additionally receive specialized training to enhance their counseling skills.

ZAMFAM’s multilevel interventions supplement an already comprehensive package of health and social support services for OVC, ALHIV, and their households. In 2016, Zambia adopted a ‘Test and Start’ strategy, whereby newly diagnosed HIV-positive persons, irrespective of CD4+ cell count or clinical stage, are offered antiretroviral treatment (ART) [27]. VLS has been rapidly scaled up, with recommendations to provide routine (every 6 months) viral load monitoring [27]. Counseling and health education are almost universally available at health facilities, with a smaller number providing nutritional support to qualified households. Non-governmental organizations (NGOs) have coordinated with government facilities and communities to form support groups for people living with HIV, including for youth. Lastly, some agricultural inputs are made available to qualified farmers, most of whom practice subsistence farming.