Thetha Nami: participatory development of a peer-navigator intervention to deliver biosocial HIV prevention for adolescents and youth in rural South Africa

Abstract

Background Despite effective biomedical tools, HIV remains the largest cause of morbidity/mortality in South Africa – especially among adolescents and young people. We used community-based participatory research (CBPR), informed by principles of social justice, to develop a peer-led biosocial intervention for HIV prevention in KwaZulu-Natal (KZN). Methods Between March 2018 and September 2019 we used CBPR to iteratively co-create and contextually adapt a biosocial peer-led intervention to support HIV prevention. Men and women aged 18–30 years were selected by community leaders of 21 intervention implementation areas (izigodi) and underwent 20 weeks of training as peer-navigators. We synthesised quantitative and qualitative data collected during a 2016–2018 study into 17 vignettes illustrating the local drivers of HIV. During three participatory intervention development workshops and community mapping sessions, the peer-navigators critically engaged with vignettes, brainstormed solutions and mapped the components to their own izigodi. The intervention components were plotted to a Theory of Change which, following a six-month pilot and process evaluation, the peer-navigators refined. The intervention will be evaluated in a randomised controlled trial (NCT04532307). Results Following written and oral assessments, 57 of the 108 initially selected participated in two workshops to discuss the vignettes and co-create the Thetha Nami (`talk to me’). The intervention included peer-led health promotion to improve self-efficacy and demand for HIV prevention, referrals to social and educational resources, and aaccessible youth-friendly clinical services to improve uptake of HIV prevention. During the pilot the peer-navigators approached 6871 young people, of whom 6141 (89%) accepted health promotion and 438 were linked to care. During semi-structured interviews peer-navigators described the appeal of providing sexual health information to peers of a similar age and background but wanted to provide more than just “onward referral”. In the third participatory workshop 54 peer-navigators refined the Thetha Nami intervention to add three components: structured assessment tool to tailor health promotion and referrals, safe spaces and community advocacy to create an enabling environment, and peer-mentorship and navigation of resources to improve retention in HIV prevention. Conclusion Local youth were able to use evidence to develop a contextually adapted peer-led intervention to deliver biosocial HIV prevention.

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

“…We conducted a mixed-method process evaluation 34 to assess the acceptability, fidelity and experience of PTP approaches in facilitating linkage to HIV testing and care services among young women and men through the hypothesised theory of change. 31 This process evaluation was embedded in a cRCT comparing two models (social network and peer navigator’s approaches) of PTP delivery of HIVST to facilitate linkage to HIV testing, treatment and prevention (eg, ART and PrEP) among young people aged 18–29 years against a standard of care of peer navigators providing information services without HIVST kits. We report on the acceptability of the intervention using qualitative techniques.…”

Effect of peer-distributed HIV self-test kits on demand for biomedical HIV prevention in rural KwaZulu-Natal, South Africa: a three-armed cluster-randomised trial comparing social networks versus direct delivery

“…The trial design has been described in detail elsewhere. 34 Briefly, between March and December 2019, we conducted a three-arm cRCT comparing two models of peer delivery of HIVST (incentivised peer networks (IPN) and direct distribution by trained area-based peer navigators) with standard of care (SOC, referral by peer navigators to HIV testing, prevention and care services) for increasing the uptake of biomedical HIV prevention (PrEP) or ART among young women (18)(19)(20)(21)(22)(23)(24) and all young people (aged [18][19][20][21][22][23][24][25][26][27][28][29][30].…”

“…Competence was assessed using written and oral assessments to select 57 eligible peer navigators (24 pairs of area-based peer navigators and nine floating peer navigators (ie, on stand-by to support the arm they were randomised to)). 30 Recruitment was community based. An estimated 12 000 young people (aged 18-30 years) residing in the 24 cluster areas were eligible to participate if able and willing to provide written informed consent, and not already taking ART.…”

“…Community-based participatory research (CBPR) was used to provide youth input into the final peer navigator interventions. 30 Peer navigators and youth engagement during CBPR informed the design of the intervention and inclusion of the two different intervention arms, peer navigator distribution and social network distribution of the HIVST. Peer navigators witnessed randomisation and assisted in making study clinics youth-friendly, identifying the sites for the mobile clinics, and designed the information and educational materials.…”

“…7 12 17 30 31 We also hypothesised that mobilising social networks to distribute HIVST using incentivised peer-led methods (respondent-driven sampling) would extend the reach of HIVST and demand for PrEP among young people who were most at-risk compared with direct distribution. 19 32 33 The aim of this cluster-randomised controlled trial (cRCT) was to investigate whether HIVST delivered by peers, either directly or through incentivised social networks, would increase demand for PrEP/ART among adolescent girls and young women aged 18-24 years and all young people (aged [18][19][20][21][22][23][24][25][26][27][28][29][30] in a rural setting with a high burden of HIV in KZN, SA.…”