Barriers, Facilitators, and Strategies to Improve Participation of a Couple-Based Intervention to Address Women's Antiretroviral Therapy Adherence in KwaZulu-Natal, South Africa.

BACKGROUND: Couple-based interventions (CBIs), despite strong efficacy in improving numerous HIV risk behaviors, are not widely available and have not been tested to improve women's antiretroviral therapy (ART) adherence. We examined barriers and facilitators to participation in a CBI based on cognitive behavioral couple therapy for women's ART adherence in KwaZulu-Natal, South Africa. METHODS: Semi-structured interviews were conducted with women with HIV (n = 15) and men of mixed HIV status (n = 15). Thematic analyses were guided by the Consolidated Framework for Implementation Research. RESULTS: Facilitators mostly related to the couple's relationship, including having an existing healthy relationship, men's desire to support their partners, and a potential opportunity for men's HIV disclosure. Barriers included a lack of understanding of how a CBI approach would be useful for women's ART adherence, sole focus on women if male partners were also living with HIV, and men's lack of prior HIV status disclosure to female partners. CONCLUSION: Findings indicate that relationship context and the male partner's HIV status need to be addressed during recruitment, enrolment, and during the intervention to promote uptake.

Peer Activate: A Feasibility Trial of a Peer-Delivered Intervention to Decrease Disparities in Substance Use, Depression, and Linkage to Substance Use Treatment.

Although effective evidence-based interventions (EBIs) exist, racial/ethnic minority individuals with lower income are less likely to have access to these interventions and may experience greater stigma in the health care system, resulting in disproportionate rates of morbidity and mortality. Peer recovery specialists (PRSs) may be uniquely suited to address barriers faced by those from impoverished areas; however, peers have not traditionally been trained in implementing EBIs. The current open-label trial (N = 8) was performed to evaluate implementation and preliminary effectiveness of an adapted EBI supporting recovery, linkage to treatment, and reduced depression. Results suggest the intervention was feasible, acceptable, and appropriate for linking individuals from a community setting to substance use treatment and could be delivered with fidelity by a peer interventionist. Participants who completed the intervention demonstrated clinically reliable decreases in substance use and depressive symptoms. Findings provide initial support for PRS dissemination of EBIs to increase linkage to care and support recovery in traditionally underserved populations. [Journal of Psychosocial Nursing and Mental Health Services, 61(11), 23-31.].

"I think it's communication and trust and sharing everything": Qualitative evidence for a model of healthy intimate relationships in Black women living with HIV and men in KwaZulu-Natal, South Africa.

In South Africa, couple-based interventions (CBIs) have been used to increase HIV testing, reduce HIV transmission, and shift relationship dynamics. To understand local definitions of healthy relationships, this study sought to collect qualitative data on a model of healthy relationships in a semi-rural area of KwaZulu-Natal, South Africa. We conducted semi-structured qualitative interviews with HIV-positive women (n = 15) and men of mixed HIV status (n = 15) who were in heterosexual, monogamous relationships (not with each other). Thematic analyses guided coding. Three primary healthy relationship behaviour themes emerged, labelled open communication, couple-level problem-solving, and active relationship building, which were related to various relationship facets (trust, support, respect, commitment, and connection). We purposively explored contextual themes, namely the role of HIV, positive community involvement, and power dynamics, to better situate the healthy relationship behaviour themes. HIV was not central to relationship conceptualisations and three different power structures (shared power/flexible gender norms, shared power/traditional gender norms, male-dominated power/traditional gender norms) were described as being healthy. This model of healthy relationships is similar to observed definitions in other African countries and in high-income settings. Findings can inform HIV programming content for couples in KwaZulu-Natal, particularly the active relationship building component.

En Sudáfrica, se han utilizado intervenciones basadas en la pareja para aumentar las pruebas de detección de VIH, disminuir la transmisión del VIH y cambiar la dinámica de las relaciones. Para comprender las definiciones locales de relaciones saludables, en el presente estudio se procuró recoger datos cualitativos sobre un modelo de relaciones saludables en un área semirrural de KwaZulu-Natal, Sudáfrica. Realizamos entrevistas cualitativas semiestructuradas con mujeres VIH positivo (n= 15) y hombres de estados variados en relación con el VIH (n = 15) que estaban en relaciones heterosexuales y monógamas (no entre ellos). Los análisis temáticos guiaron la codificación. Surgieron tres temas principales de conducta en las relaciones saludables: comunicación abierta marcada, resolución de problemas a nivel de la pareja, y construcción activa de la relación, que estuvieron relacionados con varios aspectos de las relaciones (la confianza, el apoyo, el respeto, el compromiso y la conexión). Analizamos específicamente temas contextuales, por ejemplo, el papel del VIH, la participación positiva en la comunidad y la dinámica de poder para ubicar mejor los temas de conducta en las relaciones saludables. El VIH no fue fundamental para las conceptualizaciones de las relaciones y se describieron como saludables tres estructuras de poder diferentes (poder compartido/normas flexibles de género, poder compartido/normas tradicionales de género, poder predominantemente masculino/normas tradicionales de género). Este modelo de relaciones saludables es similar a las definiciones observadas en otros países africanos y en ámbitos de ingresos altos. Los resultados pueden orientar el contenido de los programas sobre el VIH para parejas en KwaZulu-Natal, particularmente el componente de construcción activa de la relación.

"Sometimes you have to take the person and show them how": adapting behavioral activation for peer recovery specialist-delivery to improve methadone treatment retention.

BACKGROUND: Despite efficacy of medication for opioid use disorder, low-income, ethno-racial minoritized populations often experience poor opioid use disorder treatment outcomes. Peer recovery specialists, individuals with lived experience of substance use and recovery, are well-positioned to engage hard-to-reach patients in treatment for opioid use disorder. Traditionally, peer recovery specialists have focused on bridging to care rather than delivering interventions. This study builds on research in other low-resource contexts that has explored peer delivery of evidence-based interventions, such as behavioral activation, to expand access to care. METHODS: We sought feedback on the feasibility and acceptability of a peer recovery specialist-delivered behavioral activation intervention supporting retention in methadone treatment by increasing positive reinforcement. We recruited patients and staff at a community-based methadone treatment center and peer recovery specialist working across Baltimore City, Maryland, USA. Semi-structured interviews and focus groups inquired about the feasibility and acceptability of behavioral activation, recommendations for adaptation, and acceptability of working with a peer alongside methadone treatment. RESULTS: Participants (N = 32) shared that peer recovery specialist-delivered behavioral activation could be feasible and acceptable with adaptations. They described common challenges associated with unstructured time, for which behavioral activation could be particularly relevant. Participants provided examples of how a peer-delivered intervention could fit well in the context of methadone treatment, emphasizing the importance of flexibility and specific peer qualities. CONCLUSIONS: Improving medication for opioid use disorder outcomes is a national priority that must be met with cost-effective, sustainable strategies to support individuals in treatment. Findings will guide adaptation of a peer recovery specialist-delivered behavioral activation intervention to improve methadone treatment retention for underserved, ethno-racial minoritized individuals living with opioid use disorder.

A Pilot Study of Training Peer Recovery Specialists in Behavioral Activation in the United States: Preliminary Outcomes and Predictors of Competence.

BACKGROUND: The peer recovery specialist (PRS) workforce has rapidly expanded to increase access to substance-use disorder services for underserved communities. PRSs are not typically trained in evidence-based interventions (EBIs) outside of motivational interviewing, although evidence demonstrates the feasibility of PRS delivery of certain EBIs, such as a brief behavioral intervention, behavioral activation. However, characteristics that predict PRS competency in delivering EBIs such as behavioral activation remain unknown, and are critical for PRS selection, training, and supervision if the PRS role is expanded. This study aimed to explore the outcomes of a brief PRS training period in behavioral activation and identify predictors of competence. METHOD: Twenty PRSs in the United States completed a two-hour training on PRS-delivered behavioral activation. Participants completed baseline and post-training assessments, including roleplay and assessments of PRS characteristics, attitudes towards EBIs, and theoretically relevant personality constructs. Roleplays were coded for competence (behavioral activation specific and PRS skills more broadly, i.e., PRS competence) and changes were assessed from baseline to post-training. Linear regression models tested factors predicting post-training competence, controlling for baseline competence. RESULTS: There was a significant pre-post increase in behavioral activation competence (t = -7.02, p < 0.001). Years working as a PRS significantly predicted post-training behavioral activation skills (B = 0.16, p = 0.005). No variables predicted post-training PRS competence. CONCLUSIONS: This study provides preliminary evidence that behavioral activation may be appropriate for dissemination to PRSs through brief trainings, particularly for PRSs with more work experience. However, additional research is needed to examine predictors of competence among PRSs.

Psychosocial challenges affecting patient-defined medication for opioid use disorder treatment outcomes in a low-income, underserved population: Application of the social-ecological framework.

INTRODUCTION: Successful engagement with medication treatment for opioid use disorder is an important focus in reducing mortality associated with the opioid crisis. Mortality remains at unacceptably high levels, pointing to a need for improved understanding of factors that affect medication for opioid use disorder outcomes. This study aims to understand how barriers co-occur and interact to interfere with outcomes in methadone treatment for a low-income, underserved patient population with opioid use disorder. METHODS: This study was conducted at a community-based drug treatment center that serves a predominately low-income, racially diverse population. Guided by the social-ecological framework, we analyzed semi-structured interviews and focus groups with patients and providers working in opioid use disorder care and recovery across Baltimore City (N = 32) to assess factors that influence methadone treatment outcomes, and how barriers co-occur and interact to worsen treatment outcomes. The study used patient-centered definitions to describe successful treatment outcomes. RESULTS: Barriers described by both patients and providers fit into several broad levels: individual, interpersonal, institutional, community, and stigma. Participants described co-occurrence of many barriers. Further, the study identified potential interactive effects, such that interrelated barriers were seen as fueling one another and having a deleterious effect on treatment outcomes. Specifically, interrelationships between barriers were described for 1) unstable housing with social influences and mental health factors; 2) transportation with poor physical health and other competing responsibilities; 3) treatment program policies and schedule with competing responsibilities; and 4) stigma with poor physical and mental health. CONCLUSIONS: Understanding barriers to successful medication for opioid use disorder outcomes and considering their co-occurrence may help to identify and promote interventions to mitigate their impact. This work is intended to guide future research to adapt conceptual frameworks for understanding psychosocial and structural barriers affecting opioid use disorder treatment and ultimately intervention efforts to improve treatment outcomes.

"You rise up and then you start pulling people up with you": Patient experiences with a peer-delivered behavioral activation intervention to support methadone treatment.

BACKGROUND: Although medications for opioid use disorder (MOUD) are efficacious treatments for opioid use disorder, retention remains low. Peer recovery specialists (PRSs), individuals with lived substance use and recovery experience, may be particularly well-suited to support patients receiving MOUD. While PRSs are rarely trained in evidence-based behavioral interventions other than motivational interviewing, preliminary evidence suggests that peers can deliver brief behavioral interventions, such as behavioral activation, with efficacy and fidelity. This qualitative study sought to explore patient perspectives on receiving an adapted PRS-delivered behavioral activation intervention (Peer Activate) to support patients receiving methadone treatment. METHODS: The sample (N = 26) included patients recently starting or demonstrating challenges with adherence at a community-based methadone treatment program who received the Peer Activate intervention in a pilot trial. Participants were invited to participate in in-depth, semi-structured interviews at study completion or discontinuation, assessing perceived acceptability and feasibility of Peer Activate, and stigma-related barriers. Interview transcripts were coded using codebook/template thematic analysis. RESULTS: Analysis revealed the importance of two areas to promote intervention acceptability: 1) connection with intervention content and skill building, and 2) valued PRS-specific qualities. Intervention flexibility was found to promote feasibility of the intervention in the context of chaotic and challenging life circumstances. Additionally, participants described stigma towards substance use and methadone treatment as potential barriers to engaging in methadone treatment. CONCLUSION: Results support the acceptability and feasibility to patients of this PRS-delivered behavioral activation intervention in the context of outpatient MOUD treatment among a low-income, majority racially minoritized patient population. Future intervention adaptation and implementation should focus on incorporating content related to relationships and interpersonal skills; balancing behavioral intervention content with system navigation support; maintaining flexibility; and further investigation of the impact of individual PRS attributes, including shared lived experiences, on intervention acceptability and shifts in stigma.

"In their mind, they always felt less than": The role of peers in shifting stigma as a barrier to opioid use disorder treatment retention.

INTRODUCTION: A substantial, national need exists for culturally acceptable, accessible opioid use disorder (OUD) treatment. Medication for opioid use disorder (MOUD) is regarded as effective in treating OUD; however, retention in MOUD programs remains low nationally. One known barrier to MOUD retention is stigma, particularly within ethno-racial minority communities. Peer recovery specialists (PRSs), individuals with shared experience in substance use and recovery, may be particularly well suited to support patients in MOUD treatment, and may have capacity to play a key role in decreasing stigma-related barriers to MOUD retention. METHODS: This study used qualitative methods to solicit feedback on how patients receiving methadone treatment (MT) experience stigma (i.e., toward substance use [SU] and MT). Study staff also gathered information regarding how a PRS role may reduce stigma and improve retention in care, including barriers and facilitators to the PRS role shifting stigma. Study staff conducted semi-structured qualitative interviews and focus groups (N = 32) with staff and patients receiving MT at an opioid treatment program as well as PRSs in Baltimore. RESULTS: Participants identified experiences of internalized, as well as enacted and anticipated, MT and SU stigma, and described these as barriers to treatment. Participants also identified opportunities for PRSs to shift stigma-related barriers for patients receiving MT through unique aspects of the PRS role, such as their shared lived experience. CONCLUSIONS: Reducing stigma surrounding SUD and MT is critical for improving MOUD outcomes, and future research may consider how the PRS role can support this effort.

Supporting Treatment for Anti-Retroviral Therapy (START) Together: Protocol for a pilot, randomized, couple-based intervention to promote women's ART adherence and men's engagement in HIV care in KwaZulu-Natal, South Africa.

Background: South Africa currently has the greatest number of people with HIV globally. The country has not yet met its 95-95-95 goals, with different gaps in the HIV care cascade for women and men. This paper reports on a protocol to pilot test a couple-based intervention designed to improve women's antiretroviral therapy (ART) adherence and men's engagement in care in heterosexual couples living in the Vulindlela area of KwaZulu-Natal, South Africa. Study goals are two-fold: (1) assess the acceptability, feasibility, and fidelity of the experimental intervention, START Together, and (2) collect efficacy data on START Together for women's ART adherence, men's engagement in HIV care, and the couple's relationship functioning. Methods: Women (N = 20) who were not engaged with ART adherence (defined via self-reported ART difficulties, record of missed clinic visits, or viral non-suppression) are the target patients; male partners are not required to know or disclose their HIV status to be part of the study. Couples are randomized 1:1 to the experimental treatment (START Together) or treatment as usual (referrals to the local clinic to support ART adherence or any other HIV-related care). START Together is a 5-session intervention based in cognitive-behavioral couple therapy, which is a skill-based intervention focusing on communication and problem-solving skills, and Life Steps, a problem-solving intervention identifying barriers and solutions to medication adherence. Couples are assessed at baseline, post-treatment (8 weeks post-randomization), and follow-up (12 weeks post-randomization). Conclusion: This study will provide preliminary implementation and efficacy data on whether this novel approach has potential to improve women and men's HIV and healthcare-related needs.