Implementation and Adaptation of a Combined Economic Empowerment and Peer Support Program Among Youth Living With HIV in Rural Rwanda

Abstract

Background: Youth living with HIV in rural Rwanda experience poor clinical outcomes. In 2017, we implemented Adolescent Support Groups (ASGs), which provided economic incentives and peer support to youth aged 15-25. Methods: We assessed the ASG program using programmatic and electronic medical records. We described group composition and achievement on three indicators used to determine economic incentive levels: (1) quarterly pharmacy visit attendance, (2) biannual savings target achievement, and (3) annual viral suppression. Results: In total, 324 members enrolled in 34 ASGs. Group size and member ages varied more than anticipated. Groups performed well on pharmacy visit attendance (median quarterly group attendance range 91-100%) and on achieving savings targets (median biannual achievement range 80–83%). The viral suppression indicator could not be implemented as planned. Conclusion: To reflect contextual realities, adaptations in enrollment, indicator evaluation, and awarding of incentives occurred during implementation. Future research should assess whether these adaptations affected results.

Interventions to Improve Treatment Outcomes among Adolescents on Antiretroviral Therapy with Unsuppressed Viral Loads: A Systematic Review

“…An experiment conducted in Cape Town between 2017–2019 identified the incentive amount, incentive format, recipients, delivery mode, and program participants as key components [ 44 ]. A combined economic empowerment and peer support intervention in rural Rwanda achieved successes in high pharmacy attendance, attaining target savings, and in viral suppression [ 45 ].…”

Receipt of a combined economic and peer support intervention and clinical outcomes among HIV-positive youth in rural Rwanda: A retrospective cohort

“…In our previous assessment on the implementation of the ASG program, we noted that a number of adaptations and infidelities to the program occurred over time [25]. Because recruitment into the ASG program was left to the nurses' discretion, we observed a much wider range of ages and a much wider range of groups sizes than expected.…”

“…However, key deviations included sporadic doubling of incentives and providing 15,000 RWF for each individual virally suppressed patient or patient designated "stable" in the national Differentiated Service Delivery Model rather than according to the stepwise groupbased incentive scheme. Additional details on the adaptation of the intervention, group characteristics, group composition, group achievement on indicators, and group earnings have been reported elsewhere [25].…”

“…Finally, in our previous work where we used programmatic data to assess group-level performance on key indicators, nurses reported much higher group achievement than what was observed in the EMR. For example, based on programmatic data, over half of the ASG groups reported 100% viral suppressions rates in the first year of the program [25]. There are three likely explanations for this.…”