Patient and provider perceptions of a peer-delivered intervention ('Khanya') to improve anti-retroviral adherence and substance use in South Africa: a mixed methods analysis

BACKGROUND: Despite a high prevalence of problematic substance use among people living with HIV in South Africa, there remains limited access to substance use services within the HIV care system. To address this gap, our team previously developed and adapted a six-session, peer-delivered problem-solving and behavioral activation-based intervention (Khanya) to improve HIV medication adherence and reduce substance use in Cape Town. This study evaluated patient and provider perspectives on the intervention to inform implementation and future adaptation. METHODS: Following intervention completion, we conducted semi-structured individual interviews with patients (n = 23) and providers (n = 9) to understand perspectives on the feasibility, acceptability, and appropriateness of Khanya and its implementation by a peer. Patients also quantitatively ranked the usefulness of individual intervention components (problem solving for medication adherence 'Life-Steps', behavioral activation, mindfulness training, and relapse prevention) at post-treatment and six months follow-up, which we triangulated with qualitative feedback to examine convergence and divergence across methods. RESULTS: Patients and providers reported high overall acceptability, feasibility, and appropriateness of Khanya, although there were several feasibility challenges. Mindfulness and Life-Steps were identified as particularly acceptable, feasible, and appropriate components by patients across methods, whereas relapse prevention strategies were less salient. Behavioral activation results were less consistent across methods. CONCLUSIONS: Findings underscore the importance of examining patients' perspectives on specific intervention components within intervention packages. While mindfulness training and peer delivery models were positively perceived by consumers, they are rarely used within task-shared behavioral interventions in low- and middle-income countries

How to incorporate lived experience into evidence-based interventions: assessing fidelity for peer-delivered substance use interventions in local and global resource-limited settings

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