It helps to talk: A guiding framework (TRUST) for peer support in delivering mental health care for adolescents living with HIV

Abstract

Introduction Adolescents living with HIV have poor treatment outcomes, including lower rates of viral suppression, than other age groups. Emerging evidence suggests a connection between improved mental health and increased adherence. Strengthening the focus on mental health could support increased rates of viral suppression. In sub-Saharan Africa clinical services for mental health care are extremely limited. Additional mechanisms are required to address the unmet mental health needs of this group. We consider the role that community-based peer supporters, a cadre operating at scale with adolescents, could play in the provision of lay-support for mental health. Methods We conducted qualitative research to explore the experiences of peer supporters involved in delivering a peer-led mental health intervention in Zimbabwe as part of a randomized control trial (Zvandiri-Friendship Bench trial). We conducted 2 focus group discussions towards the end of the trial with 20 peer supporters (aged 18–24) from across 10 intervention districts and audio recorded 200 of the peer supporters’ monthly case reviews. These data were thematically analysed to explore how peer supporters reflect on what was required of them given the problems that clients raised and what they themselves needed in delivering mental health support. Results A primary strength of the peer support model, reflected across the datasets, is that it enables adolescents to openly discuss their problems with peer supporters, confident that there is reciprocal trust and understanding derived from the similarity in their lived experiences with HIV. There are potential risks for peer supporters, including being overwhelmed by engaging with and feeling responsible for resolving relationally and structurally complex problems, which warrant considerable supervision. To support this cadre critical elements are needed: a clearly defined scope for the manageable provision of mental health support; a strong triage and referral system for complex cases; mechanisms to support the inclusion of caregivers; and sustained investment in training and ongoing supervision. Conclusion Extending peer support to explicitly include a focus on mental health has enormous potential. From this empirical study we have developed a framework of core considerations and principles (the TRUST Framework) to guide the implementation of adequate supportive infrastructure in place to enhance the opportunities and mitigate risks.

Peer-led counselling with problem discussion therapy for adolescents living with HIV in Zimbabwe: A cluster-randomised trial

“…Our finding that PST, as originally envisaged, was not appropriate or feasible for an adolescent population is in line with the literature. Adolescents have very limited agency to resolve their own problems and rely on others to help them [ 23 ]. An important element of PST is for the counsellor to help the client choose a problem that is both meaningful and within their power to change [ 9 ].…”

“…This study supports previous evidence that young people gain fulfilment from being CATS [ 27 ], but it can also be challenging and emotionally draining, particularly when CATS are faced with problems that they do not have the resources or experience to handle. The needs of young peer supporters have been laid out in the TRUST framework [ 23 ], comprising Training, Referral pathways, Understanding the remit of their role, Supervision, and recognition that Talking helps.…”

‘This is what is going to help me’: Developing a co-designed and theoretically informed harm reduction intervention for mobile youth in South Africa and Uganda

“…Although subject to increasing attention, there has been a little empirical investigation into the mechanisms of impact of peer support for improving young people's HIV prevention and treatment outcomes (Grimsrud et al, 2020). The nascent evidence-case indicates the significance of 'connectedness' and the importance of the provision of adequate resourcing for training and supervising peer supporters to sustain the potential considerable gains (Mavhu et al, 2020;Shahmanesh et al, 2020;Wogrin et al, 2021).…”

“It must start with me, so it started with me”: A qualitative study of Project YES! youth peer mentor implementing experiences supporting adolescents and young adults living with HIV in Ndola, Zambia

“…In other peer support programs among youth living with HIV in SSA, such as the CATS Zvandiri Trial [ 30 ], youth implementers raised concerns about deductive disclosure (unintentional disclosure based on one’s job) as they worked in the community [ 31 , 32 ]. Project YES!…”