1. 2015
ST THERESA RUVENEKO C&HBBC
Box 15 Charandura
ruvheneko@iwayafrica.com
LADDER TO SAFETY REPORT

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Abbreviations
AIDS Acquired Immuno Deficiency Syndrome
ASRHR Adolescent Sexual Reproductive Health and Rights
AREX Agricultural Extension
ART Anti-Retroviral Therapy
C&HBC Community and Home Based Care
DA District Administrator
DDF District Development Fund
DHE District Health Executive
FGDs Focused Group Discussions
HIV Human Immuno Virus
OI Opportunistic Infection
PHE Provincial Health Executive
PMTCT Prevention of Mother to Child Transmission of HIV/AIDS
PSS Psycho-Social Support
SRHR Sexual Reproductive Health and Rights
STI Sexually Transmitted Infection
VET Veterinary Services
VCT Voluntary Testing and Counselling
VFU Victim Friendly Unit
VHW Village Health Worker
ZVITAMBO Zimbabwe Vitamin A for Mothers and Babies Organization
ZRP Zimbabwe Republic Police

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PROJECT REPORT
Project: Ladder to Safety
Area of coverage: St Theresa’s catchment area (Chirumhanzu District)
Implementing partner: St Theresa’s Ruvheneko
Partner: SWISS Embassy
Implementation period: 1 Jan 2015- 30 Nov 2015
REPORT DESCRIPTION
This is a project report prepared for Swiss Embassy providing an update of the Ladder to Safety project
implementation from period 1 January 2015 to 30 November 2015. It provides both a qualitative and
quantitative description and analysis of project activities on how they contributed in meeting project
outputs and outcomes.
The report also includes key findings and recommendations for the way forward in as much as the lives
and the future of HIV positive children/adolescents is concerned.

4. CHAPTER 1
Project background
“Ladder to Safety” project is an HIV/AIDS
targeted intervention that aimed at filling the
gap between ART at infant and adolescence
stage of life. For some time as an implementer
on the ground St Theresa’s C&HBC gathered
that there is a gap for children started ART at
the stage of infancy and their development into
the adolescence stage where they become
sexually active and begin having intimate
relationships.
Prior to Ladder to Safety in our catchment area,
as a service provider we had no intervention
that followed up on the children to explain,
train and educate them on what they are taking
as ART. The children/ adolescents were thus
provided with a treatment which they did not
have a comprehensive understanding of and
hence there was always the grave danger that
they may obtain wrong information about ART
from peers and their significant others.
Further buttressing on this problem, parents
and guardians at times would withhold correct
information from the children and at
adolescence when they discover that it is
actually HIV/AIDS treatment then child-parental
relations are highly severed.
As the children grow older, they begin to
explore, ask friends, experiment and examine
their environment- that is where problems
start. Some children in our catchment area have
refused to keep taking ART at adolescence.
Some default for some time until a clear
explanation has been given. In some instances
however, it may be too late as the defaulting
child may resist Second Line treatment and thus
ultimately die.
The meaning of the term “Ladder to Safety”
The term “Ladder to Safety” is a derivate of two
words, “Ladder” and “Safety” whereby St
Theresa’s Ruvheneko is arguing that every step/
initiative that we as a community take in
helping children/adolescents on Anti Retroviral
Therapy (ARVs) towards knowledge,
acceptance, disclosure and adherence to
HIV/AIDS medication is a Step of the Ladder
that were are helping the children climb until
they reach a place/ state of safety whereby they
become fully empowered young adults.
This also means parent/guardian empowerment
so that they climb the ladder together with the
children/adolescents on ART.
With the Ladder to Safety project we are
helping them go through the steps of the ladder
to create an environment that is safe and
conducive not only for the HIV positive but for
the negative as well. The ultimate goal is to
have a healthy empowered community where
there are “zero” new HIV infections. A state of

5. 5 | P a g e
being where those who are HIV negative remain
as such and those who are HIV positive live
long, healthy and fulfilling lives surrounded by a
community which is tolerant, respectful,
indiscriminate and supportive.
Project strategy
The project had an integrated approach to
health delivery which sought to integrate
service delivery at both Institutional and
Community level.
It sought to create a seamless relationship
between institutional care (hospital level),
school and community health (community
support systems). In pursuit of this, the project
integrated service provision from different
support systems which include but are not
limited to medical staff, teachers, community
leaders, churches, traditional leaders, Village
Health Workers and Secondary Caregivers as
well as parents/ guardians of children on ART
and the general community.
Vision
To see an HIV free generation in the near future
Goal
To build the capacity of children on ART and
their caregivers towards coping with HIV/AIDS
and its lifelong treatment
AIM
To build the capacity of children and
adolescents on ART and their parents/guardians
towards accepting, appreciating and disclosing
their HIV status thus adhering to ART therapy.
Project components
The project had two main components as
follows:
I. Knowledge generation
The project was a generally new form of
intervention thus there was a lot of knowledge
to be gathered through the various project
activities and target areas.
The knowledge generation component evolved
around the following key questions:
a. Are the government and community
aware that there are HIV positive
children/ adolescents in their
communities?
From interactions during sensitization
workshops in the beginning of the action
research, it was quite evident that people in
the community thought that the only
“As the church we will continue to teach
about abstinence even though we know that
children are engaging in sexual activities at a
tender age”, Church leader.

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people with HIV/AIDS were adults in
Chirumhanzu South.
During meetings, people would somehow
be surprised, alarmed or even doubtful
when we told them that our ART registers
had 517 HIV positive children/adolescents
on ART aged between 0-22 years.
To the community, HIV/AIDS among
children/adolescents was not an issue; the
community is reluctant to acknowledge
their presence. HIV positive
children/adolescents therefore largely
remain invisible in communities except for a
few isolated cases where the community
would know about the HIV status of a
child/adolescent.
Each family would try as much as possible
to keep the HIV status of their child as
secret as possible. Some parents would
even collect ARVs for their children at odd
hours i.e. after the clinic has closed when no
one is around. This would often lead to HIV
positive children marrying without
disclosing.
Findings from the initial phase of the
project thus revealed that while
Chirumhanzu boasts of a high rate of
disclosure amongst HIV positive adults (over
90% of HIV positive adults would disclose
and talk about their HIV status during
sensitization workshops), there is still a lot
of HIV/AIDS related stigma towards and
among children/adolescents.
In this regard it was one of the target areas
of the project to work towards creating an
environment that is conducive towards
children/adolescents on ART.
This was done mainly through creation of
child support groups that included the HIV
positive and negative alike to reduce stigma
and discrimination.
b) Do HIV positive children/adolescents
know each other?
It emerged from the research that HIV
positive adolescents do not know each
other. When the Ruvheneko Department
was recruiting HIV positive peer educators,
we discovered that over 75% of the 50
children we shortlisted did not know each
other.
Those who knew each other only had basic
information but did not know each other’s
HIV statuses. This would make it difficult for
HIV positive adolescents to form
“It is far much better to marry an HIV positive
person, because if i marry an HIV negative
person i become their slave but the problem
is where do i find and HIV positive partner?”,
HIV positive female adolescent.

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friendships, linkages, networks and
relationships with each other because they
are largely invisible.
During PSS workshops and FDGs with HIV
positive adolescents, they suggested that it
was better off to marry amongst them so
that they avoid being stigmatized and
labelled as “killers” by the community.
However, the challenge was that they did
not know each other.
This called for most interactive activities
such as PSS workshops, group work (FDGs),
edutainment and sporting activities which
would attract HIV positive adolescents to
gather together and socialize.
The knowledge generation component saw the
drawing of hypothesis and operational theories
so as to understand describe and explain the
nature of issues around HIV/AIDS, ART and
disclosure. These theories and hypothesis are
described in the appendix section.
II. Training for Disclosure (TfD)
The project revolved around categories of
disclosure targeting:
 Parent/Guardian to Child (Simple to
complex approach- parent discloses
his/her status first to the child to make
the child understand what it is like to be
HIV positive).
 Partner to Partner (adolescents)
 Adolescents in support groups and
FDGs
 Parent to Parent, Adolescent to
Community
 Parent to School
 Child/adolescent to school and school
to hospital.
This component focused on gathering
knowledge to educate our communities on
HOW, WHEN, WHERE, WHAT and WHY to
disclose. It involved information sharing by
those who have disclosed telling those who
have not how they have managed to do it. It
was a learning and information sharing
experience.
Among the array of factors why parents/
guardians fail to disclose to their
children/adolescents the following emerged
most prominent:
 “Fear” of the unknown-
parents/guardians form all sorts of
perceptions, imaginations and myths
about HIV.
This fear is compounded by the fear
that the child/adolescent will be
stigmatized and discriminated in the
community especially at school.
There is also the fear that the family will
become the laughing stock of the

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community if the child/adolescent’s
status is publicised. In the end no one
would want to marry the HIV positive
child/adolescent.
Some parents/guardians are also afraid
of being physically assaulted by the
children if they are older. We
encountered cases where HIV positive
boys would beat up their parents
(especially the fathers) each time the
issue of HIV treatment came up,
blaming them for deliberately giving
them the HIV virus.
It would appear that the community of
Chirumhanzu is of the view men are the
main spreaders of HIV/AIDS. In the
sensitization meetings and workshops
we held- even with professionals-
people had a strong conviction that the
male partner is the one who brings
HIV/AIDS into the family.
 Lack of information on HIV/AIDS. Most
guardians of children on ART are the
elderly; they do not have
comprehensive information on
HIV/AIDS and therefore cannot fully
explain to their child about their HIV
status.
 Not knowing the right time and age to
disclose. Parents/guardians professed
that sometimes they would delay
disclosure thinking that the child is too
young only to realise suddenly that the
child has grown into a young adult.
In some cases disclosure would be
delayed until the child becomes
sexually active thus risking new HIV
infections.
From workshop discussions, FGDs and
interviews, the general idea drawn from
the research is that disclosure should be
done in small bits and pieces following
the child’s stages of psycho-social
development.
Main results achieved
1. 63 children/adolescents who had
defaulted brought back on ART. Of
these 31 were boys and 32 were girls.
We gathered that the rate of defaulting
is higher amongst boys than girls.
Those who are below 16 years mainly
cited that they defaulted because they
did not know and understand the
tablets they were taking. With proper
explanation, the children were
reinitiated back on treatment.
However, those who were over 16
years defaulted when they began
having intimate relationships. On the
whole they are more complex to deal
with and up to date we still have 7
adolescent boys who are so aggressive

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that we haven’t managed to engage
them in a proper counselling session.
All the 63 had defaulted 1st
line
treatment. 44 were reinitiated on 1st
line while 19 were put on 2nd
line. The
children/ adolescents who were
reinitiated back on 1st
line treatment
were defaulting in terms of time but
they were taking their treatment
everyday (they were not consistently
taking their treatment on the
prescribed time) this was corrected and
they are now taking treatment
consistently.
However, the other 19 who were put on
2nd
line had defaulted for weeks and
others months. 3rd
line ART treatment is
not available in our district currently.
2. Parents/Guardians managing to disclose
to children/adolescents- we
encountered 103 cases of parents
failing to disclose to their children/
adolescents about their HIV status.
These ranged from complete non-
disclosure to partial disclosure. Of these
we have dealt fully with 53 cases so far.
3. Correcting religion driven defaulting
through effective engagement of
church leaders and prophets and
church visits.
4. HIV retesting so that HIV positive
children/adolescents over the age of 16
are sure of their HIV positive status.
5. Partner to partner- only 3 cases of
partner to partner disclosure were dealt
with in the entire project. This points
out that a very limited number of
adolescents are willing to come for VCT.
There is need for further strengthening
this aspect.
6. Adolescents being able to disclose in
support groups and FGDs. From the
FGDs we found that HIV positive
adolescents had differing gender needs.
The girls were shy and they said that
they are afraid to disclose in public
because some of the comments they
would make might be traced back to
their families and parents. They are
afraid of being labelled as prostitutes.
However, reports are indicating that
girls are opening up in the
“Ruwadzano” support groups where
they will be female participants only.
“HIV/AIDS is not sickness, sickness is when
either the physiological or psychological
person is not functioning properly. So when
you are taking ART and you are feeling well
physiologically and psychologically then you
are definitely not sick”, School teacher and
Lead parent.

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Boys on the other hand expressed that
they are comfortable in accessing
condoms at various health centres
while girls are finding it very difficult to
approach health staff seeking condoms.
7. Disclosure at public gatherings- we
managed to pool together 28
adolescents who are willing to talk
about their status in the communities.
They also received a boost as they are
interacting and networking with other
HIV positive adolescents at Zvandiri
House (AfricAID).
8. Reconciliation cases- we dealt with at
total of 19 reconciliation cases. All these
cases involved parents who had kept
their children’s HIV positive status a
secret until the children found out by
themselves.
9. Additional financial contributions by
VSO. VSO injected an additional £59
000.00 (1 April 2015- 30 April 2016) and
these funds supported peer educator
training, their allowances and bicycles.
The fund also helped us in further
conducting training workshops for
OI/ART nurses and other service
providers.
We also received a donation of a
Chemistry analyzer machine from VSO.
This donation complemented the gaps
that could not be filled by the SDC
funds. The donation gave us room to
follow up on the target groups we held
sensitization workshops with and this
allowed us to review progress. The peer
educator initiatives together with the
Youth Friendly Corners give the project
an extra component of peer to peer
counselling which increased drug
adherence.
The chemistry analyzer enabled those
defaulting children/ adolescents who
had been identified by the SDC fund to
be having liver function tests and other
blood tests before they are reinitiated
on ART.
The component of exchange visits was
important in that it allowed both
project staff and adolescents to share
ideas and learn on how other
organizations are dealing with similar
problems within their catchment areas.
Such an exchange visit was done at
Zvandiri house which has got a program
being run by AfricAID which is similar to
Ladder to Safety.
10. Establishment of Youth Friendly
Corners so that children/adolescents
have a place where they can meet,
“We cannot preach about condoms in
church”, Church leader
“When we say ‘condom’, everyone thinks of
the male condom, in our culture, female
condoms do not exist”, Community headman.

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share experiences and form positive
relationships.
11. Establishment of sporting grounds
and equipment to support edutainment
services in Youth Friendly Corners.

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CHAPTER 2
Outcomes Achieved
1. Trained, educated and empowered
children/adolescents on ART who can
understand and accept their HIV status
thus building, reparation and
maintenance of family relationships
through positive disclosure
We managed to identify 372
children/adolescents on ART in the sensitization
meetings by 30 June 2015. There were 87 more
in our ART registers but these did not attend
the workshops, in our baseline statistics we had
512 children/ adolescents on ART in our VCT
registers.
Adherence however appears to be an issue as
85% of the children interviewed showed that
they are not taking their treatment well i.e.
time, type of drug, consistency etc. Initial
sensitization meetings done with
children/adolescents on ART show that 35% of
them at the beginning of the project had basic
understanding of HIV/AIDS. A review workshop
done in April showed that 65% of them had
basic understanding of HIV/AIDS. This is a 30%
increase in the number of adolescents who
were imparted with knowledge.
A PSS workshop done in November showed that
80% of the children over 12 years had a basic
understanding HIV/AIDS.
This positive result has been attributed to the
further strengthening and operating of the
Youth Friendly Corner, Focused Group
Discussions, PSS, counselling sessions and
empowered guardian and parent. We also
initiated peer to peer health education
outreaches.
However, there still are a number of
misconceptions in cases where
parents/guardians lie to children about their
status. Sometimes parents tell their children
that they are taking Vitamin tablets or heart
condition medication.
 There has been an increase in
involvement of children/adolescents
coming to the Youth Friendly Corner
(an average of 15 youths visited per
month in 2014 but by June 2015 the
number had risen to 40 and in
November an average of 54 youths
were visiting).The highest numbers
came during weekends and holidays.
 Increase in VCT adolescent counselling
sessions (a monthly average of 3 rose
to 8). This is due to peer to peer
“If I disclose to every man who proposes love
to me, I will end up disclosing my HIV status
to the whole nation”, HIV positive female
adolescent

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counselling approach we are employing
and an extensive referral system we
created with the “Ruwadzano” and “Pa
Dare” Lead parents.
Activities
1. Ward level sensitization- Ward
sensitization was subdivided into 13
meetings so as to increase coverage.
We managed to reach a total of 452
people (317 female and 135 male), with
each one of them representing one
household. The project targets to
increase male involvement through
increased education in public
community meetings e.g. field days,
church services and meetings.
2. A sensitization workshop with
stakeholders- 53 % of the attending
stakeholders were male. The male
proportion increases further if one
considers that male community leaders
and male church leaders were 65% and
66% respectively. These two categories
represent groups which are wielding
power within the community. The
community leaders have got socio-
cultural and political power while the
church leaders have got religious
influence hence their participation in
the Ladder to Safety project is
important.
3. Workshops with Parents/ Guardians of
Children/ Adolescents on ART- At the
beginning of the project, 7 workshops
were held with Parents/ Guardians of
children/ adolescents on ART. A total of
477 parents attended the sensitization
workshops.
However, the issue of gender disparity
is still emerged to be a festering sole as
attendance figures were largely
exaggerated towards women. Of the
total number of people who attended
the workshops 392 were female and 85
were male.
Towards the end of the project, we held
7 more review meetings with
parents/guardians in the locality to give
them an update of the project and as a
part of an activity to gather on their
perceptions and recommendations
towards moving on after the SWISS
funding is done.
4. Workshops with Children on ART- 5
workshops were held with children on
ART at Hama, Siyahokwe, St Theresa,
Holy Cross and Nyautonge clinics
respectively.
“Despite being HIV positive, I also have sexual
needs”, HIV positive adolescent.

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Outcome 2: Children/adolescents on ART
shared experiences, created positive
relationships and freely disclosed their HIV
status in their communities
Parents were encouraged to disclose to their
children/ adolescents about their HIV positive
status.
However, we gathered that adolescents are
finding it difficult to disclose to their partners.
The adolescents are not willing to come for VCT
with their partners hence partner to partner
disclosure needs a lot of supportive action.
The main factors that were found to hinder
disclosure are fear of stigma and discrimination,
lack of knowledge on health issues etc. On this
component the project team adopted a strategy
that focused on intensive counselling, health
education and community sensitization to
achieve the project deliverables.
However, this still proved very difficult as the
project time frame was too short. The task of
convincing adolescents to come for VCT is a
process not an event thus efforts should be
continued even outside the project time frame.
The STEPS Peer educators
With support of VSO we trained 28 HIV positive
adolescents to be placed at St Theresa’s
Hospital and clinics within our catchment area.
These peer educators termed “STEPS” are
providing peer to peer PSS and counselling, PSS
group work and other support activities within
the project framework. The term “STEPS” was
inspired by the project title “Ladder to Safety”.
The term “STEPS” stands for- Support for
Treatment Empowerment Pillar Soldiers and is a
derivate of the Ladder concept. The STEPS (peer
educators) are HIV positive adolescents aged
between 16-22 years who are ready to disclose
their HIV status and help others to disclose as
well.
They are there to Support other children on
Treatment, Empower them when they face
challenges of acceptance, disclosure and
adherence hence they are the Pillar Soldiers for
other HIV positive children. In disclosing their
HIV status the STEPS (peer educators) are
showing other HIV positive
children/adolescents that they are not alone.
The STEPS provide support and care to others
through peer to peer Psycho-social support,
networking and counselling.
S- Support
For
T- Treatment
E- Empowerment
P- Pillar
S- Soldiers

15. 15 | P a g e
The STEPS stand as positive role models who
provide an inspiration to younger children on
treatment by showing them that despite being
HIV positive, they can grow and live normal and
healthy lives through drug adherence and
positive living.
In this pretext, the “STEPS” are steps through
which other children/adolescents on ART utilize
to climb the “Ladder” as they move towards a
place of “Safety” whereby our communities
become an environment that is enabling and
supportive.
ASRHR meetings
We held ASRHR meetings with various groups
which included, Health service providers,
parents and guardians, traditional leaders
(headsmen), sex workers, church leaders,
prophets, ZRP Victim friendly officers and
teachers). From these activities were the
following key highlights:
 Health personnel (nurses, counsellors
and Village Health Workers) are finding
it difficult to provide Sexual
Reproductive Health (SRH) services to
their own children even if the children
have reached the legal age of sexual
consent i.e. 16 years for girls and 18
years for boys.
 Male adolescents have got greater
access to SRHR services and are more
willing to come for the services than
girls. When information from FGD
groups was triangulated it emerged that
socio-cultural factors that suppress
women are a play. If a girl comes to a
facility looking for a condom the
community thinks that she is a
prostitute.
 Young boys and girls are indulging in
sexual activities early. Different FGD
groups purported that children were
engaging in sexual relationships from as
early as 12 years. If children are
indulging that early and the community
is not willing to grant them access to
SRHR, it means that there is the risk of
new HIV infections, pregnancy and
unsafe abortions.
 Children are engaging in prostitution
and reluctant to use protection. In
depth interviews with sex workers
gathered that children of ages ranging
from 15 to 22 years are engaging the
services of sex workers but they are not
willing to use condoms.
Girls of the same age are also engaging
in sex work during the school holidays.
Adolescent girls are engaging in these
activities but they are not empowered
to negotiate for condom use and often
are abused without being given the
promised payment.
 The church is not willing to teach
ASRHR. All church leaders in the FGDs
said that the church is not prepared to
talk about sexuality and encourage the
use of contraceptives especially to
children and adolescents even if they
have reached the legal age of consent.
“Sexuality is a gift from God and is an integral
part of being a human being”, Church leader

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Effects of intervention
 OI infections- in the first phase we
encountered an average of 2 OI
infections per month amongst children
and adolescents compared to last year
which had an average of 4 cases. The
number decreased because the project
helped increase drug adherence which
in turn reduced the number of OIs as
many children are now consistent in
taking their medication.
We encountered a total of 24 STI cases
involving children/ adolescents.
However, of special noting is that in July
we encountered a case of Sexually
Transmitted Infections (STIs) which had
wider implications.
This case involved 5 adolescents who
infected each other with in one
geographical area. All the 5 victims
were attending the same school and
were treated of the same STI condition.
The girl who was said to be the root
source of the STI is 15 years old and
thus under the Children’s Act 5:06 of
the Zimbabwean constitution she
cannot consent to sex.
This therefore was a case of sexual
abuse of a minor thus we engaged the
ZRP VFU and the Department of Social
Welfare Services to work with us in
dealing with this case.
We also set up a team of VHWs, OI ART
nurses and Project staff to find out if
there are other people who contracted
the STI from the 5 clients so that they
get early treatment. To this, we found
out that there were 3 more adolescents
who had contracted the STI but had
been afraid to open up. Fortunately, all
the 8 received treatment.
At departmental level, we are still
working to investigate further if there
are no other such cases in our
communities that have remained
hidden.
We are also of the conviction that the
girl was abused by an adult and gave
her the STI. The child is vulnerable thus
is in need of social protection.
Activities
I. FGDs- 12 support groups were
established where children/adolescents
on ART meet to discuss and share
“Churches have often had significant
difficulties in dealing with HIV/AIDS related
issues constructively. At times their
theological teaching has done more to
impede rather than facilitate effective
prevention efforts”, Program team.

17. 17 | P a g e
experiences on issues which affect their
lives. These support groups involve the
HIV positive and negative alike to
reduce stigma and discrimination.
II. PSS workshops-
 28 HIV positive adolescents
were identified to provide peer
to peer counselling in order to
strengthen adherence, reduce
the feeling of being alone and
to enable them to form positive
relationships. The PSS success
stories platform has saw the
progressive increase in
adolescents who are willing to
share their life experiences with
HIV/AIDS.
 To harness the support of men
in the Ladder to Safety Project
we initiated male support
groups termed “Padare” which
sought to involve men more in
the Ladder to Safety project
and general community health
issues.
So far we created 6 support
groups of this nature and these
are composed of headmen,
male Village Health Workers,
Caregivers and ordinary men in
the community.
Effective engagement of male
traditional leadership increased
male participation in the
project.
III. Counselling sessions The Ladder to
Safety project managed to address 76
special cases which involved children/
adolescents on ART.
Of these 76 cases we managed to
comprehensively resolve 61. The
remaining 15 are very complex and at
times involve the ZRP, extended
families, churches e.t.c hence even up
to now are still being dealt with as a
process not an event.

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CHAPTER 3
FINDINGS AT OUTPUT LEVEL
In the implementation process we managed to
make the following key findings at Output level:
 Number of children/adolescents who
were re-initiated on ART between Jan-
May had defaulted due to a number of
reasons: The major reasons for
defaulting have been identified as
stigma and discrimination, fear of
reaction of partner, early marriages and
religion also proved to play a pivotal
role in influencing defaulting.
 Health Service Providers are failing to
identify the children who are
defaulting.
Health service providers have been
focusing on children who default ART by
skipping taking their tablets- hence the
physically pill count. However, we
discovered that most of the defaulting
is on issues to do with consistently
taking medication at the prescribed
time, drug storage i.e. some
children/adolescents would change
containers or store them in a place
exposed to high temperatures thus
drugs would lose their opacity.
This would partly explain why we have
children/adolescents who are said to be
adhering to their treatment yet their
CD4 count is dropping when we expect
it to be rising.
 Child parent relationships of cases
involving parents/ guardians of
children: The research revealed that
parents/ caregivers are finding it
difficult to disclose to their children
especially those who are already in the
adolescence stage.
Disclosure is painful and emotional; we
have often seen the parent/ guardian
and child crying to an extent that we
would have to terminate and post pone
the counselling session. Disclosure
therefore should be done as early as
possible.
 HIV/AIDS is gender patterned: It was
gathered from interviews and FDGs
with HIV positive children/ adolescents
that girls are more dreadful of what the
future holds for them. They are not sure
if they will ever get married, bear
children and be accepted by the
prospective husband’s relatives.
This sentiment proves to be true as 75%
of parents randomly asked if they
would accept an HIV positive daughter
in law said they would not, this is 35%
more than the case if it was a son in
law.

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It is of interest to note that of the
parents who said that they would not
accept a daughter in law, 85% of them
were female. This shows that
discrimination and marginalization of
women is coming from other women.
To try to redress this situation St
Theresa’s Ruvheneko with the help of
Secondary Caregivers and Village Health
Workers came up with 8 women
support groups termed “Ruwadzano”
who are helping in educating other
women to understand and accept
people living with HIV/AIDS (with
special focus on adolescents).
 Conducive environment is an
important prevention tool for both
adolescents and adults. There is need
therefore to change the school
environment so that it becomes
conducive. However, it is very difficult
to change the people’s beliefs
especially those of a professional
person.
Implementation constrains
 Access to schools- We failed to get the
letter from the Ministry of Education to
grant us access to enter into schools to
sensitize children in schools.

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CHAPTER 4
FINANCE AND HUMAN RESOURCES
MANAGEMENT
We received an amount of $28 000.00 (US)
from the SWISS Embassy to support
implementation of the project from period 1
January to 30 November 2015.
Finance management
Since the project was an action research, most
of the funds were used for sensitization
workshops, Psycho-social support activities,
client follow ups and review meetings towards
the end of the project in preparation of the final
project report.
 To maximize coverage of the project we
decentralized the sensitization
meetings to be at Ward Level. However,
the total cost of the activity was still
minimal because no food was provided
for this activity. Funds were only used
for fuel, communication and food for
project officers.
 Ruvheneko department, with support
of Dominican Sisters bought bicycles for
Secondary caregivers while ZVITAMBO
(in 2014) had provided VHWs with
bicycles as well. This lessened the
burden on VHW community support
especially to areas which have got no
other means of modern transportation
besides the bicycle.
In this regard, the bulk of the funds for
VHW community support were used to
support activities they initiated with
children/adolescents on ART and their
Parents/caregivers.
Most of this support was in terms of
food and communication as well as
travelling assistance to areas which
were too far for ridding. It would be
worthwhile to note that some of the
VHWs are females over 40 years in age
hence find it difficult to ride a bicycle
over great distances.
 We closed the project without being
granted permission to get into schools.
However, we still managed to gather
children at clinic level during weekends
and holidays for PSS workshops and
counselling.
Human resources
St Theresa Ruvheneko Community and Home
Based care staff implementing Ladder to Safety
Project mainly comprised of
1. The Program manager
2. Field officer
3. Monitoring and Evaluation officer
Besides providing services falling under their job
description and expectations, the three are also

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providing crucial input to meet the project
deliverables through providing integral
expertise from the following fields:
 Nursing: helped us in identifying OI
infections as well as other health
related conditions among
children/adolescents in the Ladder to
Safety community outreach.
 Counselling: provided counselling
services and PSS to
children/adolescents and their families.
 Social worker: provide counselling
services, research and PSS to clients.
To supplement this staff, the Ruvheneko
department employed an integrated approach
in our outreach programme and the integration
of Ladder to Safety project into everyday health
education. This reduced the cost of outreach
programs and increased coverage. This enabled
us to also have the services of OI ART nurses
and PSS counsellors at St Theresa’s Hospital and
surrounding clinics.
This was only achievable with unwavering
support we received from our Provincial Health
Executive (PHE), District Health Executive (DHE)
and our feeder clinics- Rural Health Centres
(RHCs).

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CHAPTER 5
IMPORTANT FINDINGS
 People are unaware of legislation
around HIV/AIDS. 0 % of children/
adolescents on ART and their parents
knew about the wilful transmission ACT.
 Children/adolescents on ART are
unaware of SRHR. In our meetings with
HIV positive adolescents at the
beginning of the project we gathered
that they were unaware of such
important services as PMTCT.
We also gathered through our
interactions with them that they were
having unprotected sex, especially the
HIV positive girls said that they could
not negotiate condom use hence they
only used condoms when the male
partner suggested so. This would mean
that there are probably new HIV
infections in the community which are
yet to be discovered.
 HIV/AIDS, ART and Disclosure are
gender patterned.
 There is an age gap on stigma,
discrimination, ART uptake and
adherence between parents and the
children/ adolescents on ART in that the
parents themselves are older than the
HIV/AIDS pandemic. They have practical
experience of HIV/ AIDS from the
period when Zimbabwe as a country
was not accepting HIV/ AIDS up until a
time now in our catchment area where
parents can freely disclose their status
in public and no one stigmatizes them.
However, on the part of the children/
adolescents there is still a lot of stigma
and discrimination on the part of
children who still do not have adequate
knowledge and acceptance of HIV/AIDS.
While Chirumhanzu has got an 85% ART
uptake and a very low adult stigma and
discrimination rate, the culture of
acceptance has not been passed on to
the children. Stigma and discrimination
is still high among school pupils
especially in secondary schools.
 There is the grave danger that we might
be creating a new generation of drug
resistant children who are being given
birth to by HIV positive adolescents
who have defaulted ART.
Medical experts argue that if an
adolescent defaults ART and later give
birth to an HIV positive baby; the baby
will not be responsive to ART. This
would mean the mutation of a new
vicious virus which is not manageable
and may result in further financial costs
at both national and global level in
trying to come up with a new drug to
counter the virus.

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 There was a shocking revelation that
the general health information that we
would expect our professionals to
possess is non-existent. There is need
for further training and refresher
courses especially for the teachers and
nurses.
 We found that in all the activities we
did with the children/adolescents on
ART throughout the project cycle, we
did not even on a single day meet an
HIV positive child/adolescent living with
disability. This has left us with the
challenge of investigating on whether
there are no such children or they are
being stigmatized to such an extent that
they cannot come out in public.
OBSTACLES
1. The Ministry of Education did not give
us approval to enter into schools to
sensitize school pupils and teachers.
The school environment is one of the
most discriminatory. We sadly
witnessed two boarding school pupils
default treatment and dying after
friends had laughed at them.
The challenge is not only on the part of
stigma and discrimination. Instead,
there is a high probability that there are
new HIV infections happening in
schools each day.
There have been numerous reports
about sexual activity among school
pupils and this is evidenced by the
number of school going pregnancies (St
Theresa Maternity Ward records).
These pupils do not have enough
information on ASRHR, they are not
willing to come for VCT and some of
them begin to indulge in sex at the ages
of 12 years or even less.
As articulated earlier in this report, HIV
positive adolescents are indulging in
sexual activities without using condoms,
further more the Ministry of Education
vehemently refused the provision of
condoms in schools hence even when
the pupils want to use the condoms
they do not have the access to them.
This would point that all the sexual
activity being done in schools is
probably being done without
protection.
Without permission to get into schools
for further health education and
research, only God knows how much
HIV transmission is going on in our
secondary schools and how many of our
children should actually be on HIV
treatment.
Something needs to be done and done
very quickly otherwise we might end up

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having an entire generation of HIV
positive children/adolescents.
2. Project time frame- The Ladder to
Safety concept is a process, which takes
time as children/adolescents have got
different problem solving and coping
capacities.
The issues that Ladder to Safety
unravelled are multi-faceted. Adopting
Ladder to Safety as a medium to long
term project would increase the quality
of service given.
3. Lack of adequate IEC materials covering
all languages.
4. Documentation of good practices
especially at clinic level and by VHWs
and Secondary Caregivers.
5. Participation of middle aged parents
was limited. These are parents of
reproductive age hence their
participation was of grave importance
since they are the ones at risk of giving
birth to HIV positive off spring.
6. Male adolescents’ participation in the
project was also limited. In all our
activities less than 50% of adolescent
males identified in the baseline
participated. This would mean that
these male adolescents are still yet be
empowered on issues to do ASRHR.
7. Inadequate human resources, limited
involvement of HIV negative
adolescents and parents/guardians of
HIV negative adolescents.
8. The behaviour change component of
the project was made an event not a
process.
9. The project followed a bottom-up
approach (from the community and
project office) and this was difficult to
fit into the bureaucratic institutions and
ministries which are used to the
“straight jacket” approach.
BEST PRACTICES
1. Integrating Ladder to Safety into PMTCT
and general health education
2. Creation of community support
networks namely the “PaDare” and
“Ruwadzano” concept (Lead Parents).
3. Networking with structures already in
existence e.g. “Chirumhanzu Church
Leaders Association”
4. Peer to peer PSS activities
5. An all-encompassing referral and follow
up system
6. Establishment of Child Protection
Committees (CPS) at Ward level.
7. Offering of Legal AID protection
through networking with the
Department of Social Welfare and
Msasa Project.

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8. Simple to complex approach (begin with
telling your own story before you talk
about the other person.
Recommendations
 Expanding the Ladder to Safety into a
PMTCT research project that identifies
HIV positive pregnant women; follows
up on them, monitors them until giving
birth and early childhood development
to ensure that the off spring will not
contract HIVAIDS before, during and
after birth.
 A comprehensive program to
extensively cover on ASRHR with special
focus on HIV positive adolescents and
vulnerable minorities such as children
with disability to curb new HIV
infections with special target on school
going pupils.
 Expanding the project to also focus on
socio-economic empowerment of HIV
positive adolescents especially girls so
that they do not become objects of
ridicule, use and abuse.
 Equipping Youth Friendly Corners
 Training more STEPS service providers

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Annex 1 Statistics
SENSITIZATION MEETINGS WORKSHOPS WITH CHILDREN/ ADOLESCENTS ON ART
Stakeholder Attendance Venue Attendance by age group
0-5 yrs 6-10 yrs 11-15 yrs 16-22 yrs TOTAL
M F M F M F M F M F
St Theresa Staff M F Total Siyahokwe 3 10 10 11 20 10 8 11 41 42
Community leaders 24 13 37 Hama 0 5 3 11 2 16 4 3 9 35
Church leaders 25 13 38 St Theresa 7 13 26 14 15 23 8 6 44 56
OI/ART nurses 8 14 22 Holycross 9 7 9 21 7 19 3 7 28 54
School headmasters 63 44 107 St Theresa 2 16 15 28 29 45 44 7 7 96 95
VHWs & Caregivers 24 45 69
TOTAL 144 129 273 218 282
CLINIC MEETINGS WITH PARENTS COUNSELING SESSIONS
0-5 yrs 6-10 yrs 11-15 yrs 16-22 yrs TOTAL
M F Total M F M F M F M F M F
Denhere 7 33 40 Defaulting cases 0 0 0 0 10 12 17 19 27 31
Holycross 5 65 70 Adherence sessions ALL CHILDREN MET WERE TAUGHT ON THE IMPORTANCE OF ADHERENCE
Hama 9 35 44 Non-disclosure
cases(Parent to Child)
0 0 93 57 23 17 8 6 124 80
St Theresa 35 122 157 Reconciliation cases 0 0 0 0 3 5 11 7 14 12
Guramatunhu 9 49 58 STI counselling 2 1 13 8 15 9
Mhende 11 29 40
Nyautonge 23 59 82
TOTAL 85 392 477 180 132
Notes: For the community leaders workshop we had, 4 Councillors, 6 Sub-chiefs, 20 other line ministries e.g. AGRITEX, VET, EMA, DDF e.t.c, 1 District Nursing Officer, 1 District Health
Promotions Officer, 1 District Coordinator, 2 St Theresa Staff, 1 Priest, 1 District TB Coordinator, 1 Ministry of Health. Kraal Heads were not present at the Community leaders meeting they
were all met during the community sensitization. Out of a total of 397 kraal heads we managed to meet 302.

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Annex 2 STEPS of the LADDER
STEP 1: Knowledge- the child/ adolescent is provided knowledge about HIV status is taught on the importance of ART and adherence.
STEP 2: Acceptance- child/adolescent is helped to accept their HIV status, this helps reduce denial which leads to defaulting.
STEP 3: Disclosure- child/ adolescent is able to freely disclose their status without fear to partner and peers, this helps reduce new infections.
STEP 4: Adherence- the child is now equipped to adhere to treatment. Has arrived at a place of safety and is able to live a sexual and reproductive life which is
not harmful to him/ her and others. Zero New HIV infections and Zero HIV related deaths.

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Annex 3 THE ENVIRONMET WHICH NEEDS TO BE DEALT WITH
We realized from experiences in implementation that there is no relationship/ concurrence between the home-school and hospital environment. The HIV
positive child/ adolescent are floating in between and there is no communication between the parent-teacher and health staff on the condition of the child.
The community as a central figure also involves other community structures and institutions such as the church, peers, and traditional courts etc. which are
influential in the life of the HIV positive child.

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Annex 4 Sensitization and review workshops
Ministry of Health and Child Care Ministry of Education Local governance Community
PHE DEO DA VHWs
DHE Headmasters and health masters Chirumhanzu RDC Parents and caregivers
St Theresa hospital Chiefs Children on ART
Muvonde hospital Traditional leaders Church leaders
Mvuma hospital Headmen Prophets
Nyautonge clinic Ward sensitizations
Hama clinic
Denhere clinic
Guramatunhu clinic
Chengwena clinic
Siyahokwe clinic
Holycross clinic

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Annex 5 HIV Re-tests
CENTRE Male Female
Chaka clinic 12 2
Muwani shopping centre 28 34
Makanya primary school 54 37
Makanya shopping centre 8 19
Shashe primary school 14 20
St Theresa’s hospital 91 72
Guramatunhu 52 20
Chengwena clinic 25 18
Mhende clinic 35 27
Holycross clinic 31 32
Siyahokwe clinic 18 23
Nyautonge clinic 15 9
Hama clinic 17 11
TOTAL 400 324
 We encouraged all HIV positive adolescents to be tested regularly to continuously confirm their HIV status. This was mainly to curb the confusion that is
being steered by prophets who claim to have to powers to cure HIV. However, it is interesting to note that despite all the multiple retests all the HIV
positive children still tested positive; including those who had been told by their prophets that they had been cured of HIV. Some of the retests were
coming from as far as Shurugwi and Gokomere (outside catchment area).
 We also noted that HIV positive people do not know that it is their right to be retested periodically if they wish.