title: Qualitative insights into implementation, processes, and outcomes of a randomized trial on peer support and HIV care engagement in Rakai, Uganda.
abstract: People living with human immunodeficiency virus (HIV) who have not yet initiated antiretroviral therapy (ART) can benefit from being engaged in care and utilizing preventive interventions. Community-based peer support may be an effective approach to promote these important HIV services.
  
  
  
  After conducting a randomized trial of the impact of peer support on pre-ART outcomes, we conducted a qualitative evaluation to better understand trial implementation, processes, and results. Overall, 75 participants, including trial participants (clients), peer supporters, and clinic staff, participated in 41 in-depth interviews and 6 focus group discussions. A situated Information Motivation, and Behavioral skills model of behavior change was used to develop semi-structured interview and focus group guides. Transcripts were coded and thematically synthesized.
  
  
  
  We found that participant narratives were generally consistent with the theoretical model, indicating that peer support improved information, motivation, and behavioral skills, leading to increased engagement in pre-ART care. Clients described how peer supporters reinforced health messages and helped them better understand complicated health information. Peer supporters also helped clients navigate the health system, develop support networks, and identify strategies for remembering medication and clinic appointments. Some peer supporters adopted roles beyond visiting patients, serving as a bridge between the client and his or her family, community, and health system. Qualitative results demonstrated plausible processes by which peer support improved client engagement in care, cotrimoxazole use, and safe water vessel use. Challenges identified included insufficient messaging surrounding ART initiation, lack of care continuity after ART initiation, rare breaches in confidentiality, and structural challenges.
  
  
  
  The evaluation found largely positive perceptions of the peer intervention across stakeholders and provided valuable information to inform uptake and scalability of the intervention. Study findings also suggest several areas for improvement for future implementation of pre-ART peer support programs.
  
  
  
  NCT01366690 . Registered June 2, 2011.
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: April
authors.initials: A
authors.lastname: Monroe
authors.affiliation: Rakai Health Sciences Program, Rakai, Uganda.
authors.forename: Gertrude
authors.initials: G
authors.lastname: Nakigozi
authors.affiliation: Rakai Health Sciences Program, Rakai, Uganda.
authors.forename: William
authors.initials: W
authors.lastname: Ddaaki
authors.affiliation: Rakai Health Sciences Program, Rakai, Uganda.
authors.forename: Jeremiah Mulamba
authors.initials: JM
authors.lastname: Bazaale
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Ronald H
authors.initials: RH
authors.lastname: Gray
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Maria J
authors.initials: MJ
authors.lastname: Wawer
authors.affiliation: Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Laboratory of Immunoregulation, Bethesda, Maryland, USA.|Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Reynolds
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Caitlin E
authors.initials: CE
authors.lastname: Kennedy
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. lchang8@jhmi.edu.|Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. lchang8@jhmi.edu.|Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA. lchang8@jhmi.edu.
authors.forename: Larry W
authors.initials: LW
authors.lastname: Chang
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use; D000962:Antimalarials / Q000627:therapeutic use; D003376:Counseling; D060766:Drinking Water; D005260:Female; D017144:Focus Groups; D015658:HIV Infections / Q000628:therapy*; D006801:Humans; D057148:Insecticide-Treated Bednets; D008297:Male; D008962:Models, Theoretical; D009042:Motivation; D010043:Outcome and Process Assessment, Health Care; D062526:Patient Navigation; D010358:Patient Participation; D010379:Peer Group; D011315:Preventive Medicine; D016032:Randomized Controlled Trials as Topic; D012111:Residence Characteristics; D012944:Social Support; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use; D014454:Uganda
chemical_list: D019380:Anti-HIV Agents; D000962:Antimalarials; D060766:Drinking Water; D015662:Trimethoprim, Sulfamethoxazole Drug Combination
keywords: HIV; Implementation science; Linkage; Mixed methods research; Peer support; Pre-ART; Qualitative research; Randomized controlled trial; Uganda