Operation Triple Zero: Empowering Adolescents and Young People living with HIV in Ethiopia

In 2020, about 1.75 million [1.16 million-2.3 million] children and adolescents between the ages of 10 and 19 were living with HIV (C/ALHIV) worldwide (UNAIDS 2021).  With lifelong, continuous antiretroviral therapy (ART), C/ALHIV can live normal, healthy lives. However, without treatment, they may suffer from severe illness and the majority will tragically not survive into adulthood.

Since 2007, the Ethiopian Ministry of Health (MOH) and its partners effectively scaled up pediatric HIV care and treatment services across health centers and hospitals in the country, reaching about 32,500 C/ALHIV as of 2020. Although enrollment on ART has progressively improved over the years, HIV viral load suppression (VLS), an indicator of effective treatment, remains lower among C/ALHIV than for adults living with HIV.

To improve VLS among C/ALHIV, CDC Ethiopia worked closely with MOH and partners to promote key interventions such as optimizing pediatric ART regimens and providing customized service delivery for adolescents, consistent with WHO and PEPFAR guidelines.

One customized adolescent-focused service delivery model introduced by Ethiopia is Operation Triple Zero (OTZ), which stands for “Zero viral load, Zero missed appointments, and Zero missed drugs.” OTZ enrolls adolescents ages 10-19 years old in peer support groups at selected health facilities in the capitol city of Addis Ababa.  OTZ provides innovative health service delivery options for C/ALHIV including weekend services, monthly peer support group sessions, integrated sexual and reproductive health services, HIV status disclosure counseling, and high viral load management.  OTZ training and curriculum materials are modernized to reflect the latest in HIV science with messages tailored to adolescent audiences.

The introduction of OTZ is one reason why HIV viral suppression among C/ALHIV ages 10-19 years old in Ethiopia has improved from 81% in 2019 to 91% in 2021, meeting UNAIDS 2020 targets for VLS. OTZ builds upon existing peer support programs by engaging C/ALHIV participants in the planning and implementation of the program.  Participants who have gone through the program and have shown great leadership and communication skills are selected as “Adolescent Champions” and work directly with health providers to design group sessions, participate in counseling sessions for C/ALHIV and their caregivers, and communicate directly with participants who have missed appointments or medication refills.

A recent review of the program showed high levels of program participation, HIV treatment continuity, and VLS among OTZ participants, far superior to program results prior to its introduction.  In addition, OTZ provides life-changing psychosocial benefits to participants.

Ermias, 19, is an Adolescent Champion. He explains how OTZ has changed his life: “Before I enrolled in the OTZ program, I dealt with challenges, including severe discrimination, even by my own relatives. When my relatives heard that my mother and I were living with HIV, we faced eviction and destitution. Because of that, I spent so much time alone with hopelessness. There were times when I even contemplated suicide. Most of my friends in the program have similar stories. Before we joined OTZ, most of us had been living with HIV symptoms and were told we had high viral load, which meant that our HIV was not controlled. Thanks to OTZ, we have reinvented ourselves. The close follow up by the adherence supporters helped to suppress our viral load levels. The psychosocial support sessions and life skill trainings have helped us grow into young boys and girls who can take care of ourselves and become great role models for our friends. So, in broad terms, this program will play its own part to set values in our society. We have high hopes for our futures.”

OTZ has helped transform Ermias from struggling to manage his HIV to becoming a champion for HIV treatment and helping other youth.  CDC is now supporting further scale up of OTZ to reach more eligible C/ALHIV, an important step in achieving an AIDS-free generation in Ethiopia.