South Africa (SA) is home to the largest number globally of people living HIV (PLWH; 7.7 million). Further, substance use disorder (SUD) is prevalent among PLWH in SA, and when untreated, contributes to poor engagement in HIV care and HIV transmission. Interventions are needed to help PLWH with SUD re-engage in care. Yet, SUD stigma among health care workers (HCWs) is a barrier to their provision of SUD services and a contributing factor to poor engagement in HIV care among PLWH. Peers may be a promising solution for addressing SUD stigma among HCWs while also improving engagement in HIV care for PLWH with SUD. Although peer recovery coach (PRC) models have rapidly scaled in the US, they have yet to be tested in a low- income setting with a generalized HIV epidemic such as SA, where PRCs could play an important role in improving HIV care outcomes. This proposal aims to evaluate whether PRCs can be integrated into ward- based outreach teams (WBOTs), which are being piloted in SA to reach vulnerable PLWH who have disengaged from HIV care. Building upon our preliminary studies, our overall aim is to explore the feasibility and acceptability of integrating PRCs into WBOTs to improve re-engagement in HIV care and reduce SUD stigma among HCWs. Our conceptual model integrates the Link and Phelan Stigma Framework and Situated Information Motivation Behavioral Skills Model of Care Initiation and Maintenance, and uses the Consolidated Framework for Implementation Research (CFIR) to identify implementation barriers. We propose three aims: (1) First to explore barriers and facilitators to integrating PRCs into WBOTs in SA using in-depth interviews with managers (n=10), HCWs (n=15), and patients (n=15), assessing attitudes towards working with PRCs, intersecting HIV and SUD stigmas at the patient and provider levels, and contextual factors (e.g., community violence and drug use) that may be barriers for PRCs in this setting. (2) Next, we will use this feedback to adapt a PRC model integrated into WBOTs aimed at improving re-engagement in HIV care and reducing SUD stigma. This model will be discussed in 4 workshops with PLWH (n=12) and HCWs (n=12) to increase acceptability. (3) Our final aim will evaluate the feasibility, acceptability, and preliminary effectiveness of the PRC model compared to a matched comparison WBOT team receiving enhanced treatment as usual to improve patient re- engagement in HIV care (n=50 patients) and HCW SUD stigma (n=30 HCWs). Feasibility and acceptability will be assessed via mixed methods. This proposal is responsive to PAR-19-326 as an innovative evaluation of how to integrate peers into a novel HIV care setting, and how PRCs can shift SUD stigma and improve HIV care engagement. Capacity building efforts will support building a research network focused on HIV and SUD stigma in sub-Saharan Africa. Findings will inform an R01 proposal to evaluate effectiveness and implementation of a scalable PRC model to reduce SUD stigma and improve HIV care engagement for PLWH with SUD.
Substance use contributes to poor engagement in HIV care in South Africa, which is home to the largest number of people living with HIV in the world. Stigma towards substance use among healthcare workers is a barrier to provision of evidence-based care as well as patient engagement in HIV care. The integration of peer recovery coaches within community-based HIV teams may offer an effective, feasible, and acceptable way to address substance use stigma among health care workers and improve HIV care engagement in a vulnerable population at high-risk for ongoing HIV transmission.
