has the largest HIV/AIDS burden globally. In South Africa, substance use is prevalent and interferes with HIV treatment adherence and viral suppression, and yet it is not routinely treated in HIV care. More research is needed to adapt scalable, evidence-based therapies for substance use for integration into HIV care in South Africa. Behavioral activation (BA), originally developed as an efficacious therapy for depression, has been feasibly used to treat depression in low-and middle-income countries and substance use in high-income settings. Yet, to date, there is limited research on using BA for substance use in low-and middle-income countries. Guided by the ADAPT-ITT framework, this study sought to adapt BA therapy for substance use in HIV care in South Africa. We conducted semistructured individual interviews among patients (n ϭ 19) with moderate/severe substance use and detectable viral load, and HIV care providers and substance use treatment therapists (n ϭ 11) across roles and disciplines at 2 clinic sites in a peri-urban area of Cape Town. We assessed patient and provider/therapist views on the appropriateness of the BA therapy model and sought feedback on isiXhosa-translated BA therapy components. Participants identified the central role of boredom in contributing to substance use and saw the BA therapy model as highly appropriate. Participants identified church and religious practices, sports, and yard/housework as relevant substance-free activities. These findings will inform adaptations to BA therapy for substance use and HIV medication adherence in this setting.
Clinical Impact StatementQuestion: This study aimed to assess the appropriateness and acceptability of the behavioral activation (BA) therapy model applied to substance use in HIV care in South Africa to guide future adaptation of this therapy model. Findings: The BA therapy model was seen as highly appropriate, given the role of boredom in contributing to substance use in this community. Substance-free, accessible activities, including church and religious practices, sports, and yard/housework, were identified. Meaning: The BA therapy model was seen as appropriate and acceptable, and the findings will guide adapting this therapy model in future work. Next Steps: This work can contribute to psychotherapy research to adapt BA therapy for substance use and HIV medication adherence to meet behavioral health needs in underserved communities with shortages of trained therapists.
Background
South Africa has the highest number of people with HIV (PWH) globally and a significant burden of co-occurring substance use disorder (SUD). Health care worker (HCW) stigma towards SUD is a key barrier to HIV care engagement among PWH with SUD. Support from peers—individuals with lived experience of SUD—may be a promising solution for addressing SUD stigma, while also improving engagement in HIV care. We evaluated the perceived acceptability of integrating a peer role into community-based HIV care teams as a strategy to address SUD stigma at multiple levels and improve patient engagement in HIV care.
Methods
Patients and stakeholders (N = 40) were recruited from publicly-funded HIV and SUD organizations in Cape Town, South Africa. We conducted a quantitative assessment of stigma among stakeholders using an adapted Social Distance Scale (SDS) and patient perceptions of working with a peer, as well as semi-structured interviews focused on experiences of SUD stigma, acceptability of a peer model integrated into community-based HIV care, and potential peer roles.
Results
On the SDS, 75% of stakeholders had high stigma towards a patient with SUD, yet 90% had low stigma when in recovery for at least 2 years. All patients endorsed feeling comfortable talking to someone in recovery and wanting them on their HIV care team. Three main themes emerged from the qualitative data: (1) patient-reported experiences of enacted SUD and HIV stigmas were common and impacted HIV care engagement; (2) both patients and stakeholders considered a peer model highly acceptable for integration into HIV care to support engagement and address SUD stigma; and (3) patients and stakeholders identified both individual-level and systems-level roles for peers, how peers could work alongside other providers to improve patient care, and key characteristics that peers would need to be successful in these roles.
Conclusions
Findings from this formative work point to the promise of a peer model for reducing SUD stigma among patients and HCWs within community-based HIV care teams in SA.
Interventions led by peer recovery specialists (PRSs) have rapidly expanded in response to a global shortage of access to substance use treatment. However, there is a lack of guidance on how to incorporate PRSs’ lived experience into the delivery of evidence-based interventions (EBIs). Moreover, few resources exist to assess fidelity that integrate both content fidelity, peer competence, and incorporation of lived experience (i.e., PRS role fidelity). This study aimed to: (a) describe a novel PRS fidelity monitoring approach to assess both content and PRS role fidelity; (b) compare independent rater and PRS-self-reported content fidelity; (c) examine associations between content and PRS role fidelity; and (d) assess whether the PRS role fidelity was associated with substance use at posttreatment. This study was conducted across two PRS-led behavioral intervention trials conducted in global resource-limited settings: Baltimore City, U.S., and Khayelitsha, South Africa. A significant difference was found between PRS- and independent rater content fidelity in both interventions, with PRSs reporting significantly higher content fidelity in both sites. PRS role and content fidelity were not significantly correlated, suggesting greater adherence to the PRS role was not associated with lower adherence to structured EBI content. PRS role fidelity was not significantly associated with substance use at posttreatment. This study provides an important step toward understanding how to assess PRS role fidelity in the context of EBIs for underserved individuals with SUD while also incorporating PRS lived experience.
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