Process evaluation of peer-to-peer delivery of HIV self-testing and sexual health information to support HIV prevention among youth in rural KwaZulu-Natal, South Africa: qualitative analysis

Abstract

ObjectivePeer-to-peer (PTP) HIV self-testing (HIVST) distribution models can increase uptake of HIV testing and potentially create demand for HIV treatment and pre-exposure prophylaxis (PrEP). We describe the acceptability and experiences of young women and men participating in a cluster randomised trial of PTP HIVST distribution and antiretroviral/PrEP promotion in rural KwaZulu-Natal.MethodsBetween March and September 2019, 24 pairs of trained peer navigators were randomised to two approaches to distribute HIVST packs (kits+HIV prevention information): incentivised-peer-networks where peer-age friends distributed packs within their social network for a small incentive, or direct distribution where peer navigators distributed HIVST packs directly. Standard-of-care peer navigators distributed information without HIVST kits. For the process evaluation, we conducted semi-structured interviews with purposively sampled young women (n=30) and men (n=15) aged 18–29 years from all arms. Qualitative data were transcribed, translated, coded manually and thematically analysed using an interpretivist approach.ResultsOverall, PTP approaches were acceptable and valued by young people. Participants were comfortable sharing sexual health issues they would not share with adults. Coupled with HIVST, peer (friends) support facilitated HIV testing and solidarity for HIV status disclosure and treatment. However, some young people showed limited interest in other sexual health information provided. Some young people were wary of receiving health information from friends perceived as non-professionals while others avoided sharing personal issues with peer navigators from their community. Referral slips and youth-friendly clinics were facilitators to PrEP uptake. Family disapproval, limited information, daily pills and perceived risks were major barriers to PrEP uptake.ConclusionBoth professional (peer navigators) and social network (friends) approaches were acceptable methods to receive HIVST and sexual health information. Doubts about the professionalism of friends and overly exclusive focus on HIVST information materials may in part explain why HIVST kits, without peer navigators support, did not create demand for PrEP.

Assessing young Kenyan women's willingness to engage in a peer-delivered HIV self-testing and referral model for PrEP initiation: A qualitative formative research study

“…As several PrEP-naïve AGYW in our study pointed out, having discussions about HIV risk behaviors within the safety of a trusting friendship may better suit AGYW who are hesitant to share details of their personal sex lives with, and/or to accept advice from, AGYW they do not know well or at all. This finding aligns with qualitative findings from a recently completed trial of peer-delivered HIVST kits in rural South Africa, in which some participants randomized to a peer navigator arm reported avoiding sharing personal information with peers due to mistrust (44).…”

“…Yet, in line with other studies of AGYW PrEP-users in SSA (46)(47)(48)(49), many of the PrEPexperienced AGYW in our study described using only select disclosure (divulging their PrEP use to just a few highly trusted individuals), and some expressed hesitancy at the prospect of widening that circle. Limiting peer providers in this model to individuals who are willing to disclose their PrEP use may help mitigate challenges of credibility (distrust of health information received from non-healthcare professionals) (44) by assuring prospective intervention clients that peer providers have first-hand experience using the PrEP. It may also encourage prospective intervention clients to ask questions about PrEP, thus creating an opportunity for peer providers to dispel common misconceptions about PrEP that might otherwise keep AGYW from seeking it.…”

Peer-based Promotion and Nurse-led Distribution of HIV Self-Testing Among Networks of Men in Dar es Salaam, Tanzania: Development and Feasibility Results of the STEP Intervention

“…It also builds on the success of prior recruitment of men from similar social networks as community health leaders in a prior intervention (20). Similar social network-based strategies for HIVST promotion and distribution have been reported with success in other parts of Tanzania and other countries (21)(22)(23)(24). The Ministry of Health in Tanzania, in collaboration with implementing partners such as FHI 360, has also adopted a social and sexual network-based approach during the scale up of HIV self-testing, which was also shown to be acceptable from the formative baseline research phases of the STEP project (15,25).…”

Approaches for improving linkage to HIV care among HIV self-testing individuals in sub-Saharan Africa

“…For peer navigators to be effective in assisting HIVST individuals, they should be known in the communities, and the communities should know their activities. Furthermore, they should always maintain confidentiality for them to be trusted by HIVST individuals who may need their services 26…”