"Someone who is in this thing that I am suffering from": The role of peers and other facilitators for task sharing substance use treatment in South African HIV care

Abstract

South Africa is home to the largest number of people living with HIV/AIDS in the world. Alongside the HIV/AIDS epidemic, problematic alcohol and other drug (AOD) use is prevalent and associated with poor HIV treatment and secondary HIV prevention outcomes. International guidelines and local policy both support the integration of mental health care and AOD treatment into HIV care, yet barriers exist to implementation. This study aimed to explore patient and provider perspectives on the integration of HIV and AOD treatment services in Cape Town, South Africa. This included barriers and facilitators to task sharing AOD treatment in HIV care and preferences for a task shared approach to integrating AOD treatment in HIV care, including who should deliver the behavioural intervention. We conducted thirty semi-structured qualitative interviews with HIV and AOD treatment staff, providers, and people living with HIV/AIDS (PLWH) with moderate, problematic AOD use and difficulties (personal or structural) adhering to HIV treatment. Findings illustrated several key themes: (1) the separation between AOD and HIV services (a "siloed treatment experience"), even in the context of geographic co-location; (2) low AOD treatment literacy among HIV patients and providers, including a low awareness of existing AOD use services, even when co-located; (3) substance use stigma as a barrier to HIV and AOD treatment integration; (4) a strong patient preference for peer interventionists; and (5) the role of community health workers (CHWs) in detecting AOD use among some PLWH who had not followed up in HIV care. These findings will inform a future type 1 hybrid effectiveness-implementation trial, guided by the RE-AIM framework, to evaluate a task shared, evidence-based intervention to address problematic AOD use and improve HIV medication adherence in this setting.

Keywords: Global mental health; HIV/AIDS; Integrated care; Problematic substance use; South Africa; Task sharing.

Conflict of interest statement

Declarations of Interest: None.

Copyright © 2018 Elsevier B.V. All rights reserved.

Figures

Figure 1.

Intersecting themes depicting barriers and faciliators to task sharing an intervention for problematic substance use in HIV care in South Africa. Figure 1 depicts how these themes intersect. HIV and substance use care were isolated, even in the context of co-located services. This “siloed” treatment experience contributes to low substance use treatment literacy and awareness of existing services, particularly among patients in HIV care. The siloed treatment experience and low substance use treatment literacy may perpetuate substance use stigma. In the context of substance use stigma, patients voiced a preference to connect with peers who could share their lived experience. Finally, CHWs were identified as playing an important role in re-engaging patients who may be lost to follow up and are using substances, yet may benefit from stigma reduction interventions.