Understanding hepatitis C intervention success-Qualitative findings from the HepCATT study.

The United Kingdom has committed to eliminating viral hepatitis as a public health threat. Innovative interventions for marginalized populations are required to realize this goal. In 2016, the HepCATT study team implemented a complex hepatitis C (HCV) intervention in three English drug treatment services, with five controls. We report qualitative study findings from two intervention sites to explore intervention success and transferability potential. The intervention comprised multiple components, including a nurse facilitator, peer support and education initiatives. Qualitative data were generated at baseline (2014) and post-intervention (2016) at two sites through in-depth interviews, focus groups and observations. The 96 participants comprised drug service and intervention providers and clients with an injecting history. Data were triangulated and thematically analysed. Client engagement with a HCV treatment service rose from 16 at baseline to 147 in 2016. There was no comparable increase at the five control sites. Baseline testing and treatment barriers included the following: limited HCV knowledge; fear of diagnosis and treatment; precarious living circumstances and service-specific obstacles. Treatment engagement was aided by intervention timeliness; improved communication structures; personalized care; streamlined testing and treatment pathways; peer support. Multiple interrelated components influenced the increased levels of treatment engagement documented in HepCATT. The nurse facilitator, involved in implementation and innovation, was key to intervention success. Baseline barriers correspond with international literature-indicating transferability potential. Control data indicate that biomedical innovation alone is not sufficient to increase engagement among the most marginalized. Sustainable resourcing of community services is crucial to effect change.

Changing forms of HIV-related stigma along the HIV care and treatment continuum in sub-Saharan Africa: a temporal analysis.

OBJECTIVES: Stigma remains pervasive for people living with HIV (PLHIV) in sub-Saharan Africa, undermining care engagement. Using everyday, biographical and epochal temporalities, we explored the manifestation of stigma at different stages of the HIV care continuum in seven health and demographic surveillance sites in Eastern and Southern Africa. METHODS: Between 2015 and 2016, we conducted qualitative in-depth interviews with 264 PLHIV, 54 health providers and 48 family members of people who had died from HIV. Topic guides explored experiences of HIV testing, care and treatment services. Data were analysed thematically, aided by NVivo 10. RESULTS: In everyday time across these communities, stigma was evident in the presence of gossiping and the relative absence of supportive interpersonal discourse, which fuelled judicious disclosure. This was especially disruptive at testing, counselling and early antiretroviral therapy adherence stages of care. Biographical time framed everyday stigma events, highlighting the dilemma of disclosure in relation to sexual relationship norms, as well as the interfacing of age and healthcare continuum points. Epochal patriarchal relations gave a structural context to everyday and biographical stigma dynamics. Historical shifts to social acceptance of PLHIV within these communities, while positive, were complicated by stigma in everyday life and in respect of biographical goals like having a family. Moreover, low community-level resistance to HIV-related stigma jeopardised stigma reduction strategies. CONCLUSIONS: Despite improvements to HIV care services, stigma remains pervasive across the HIV care continuum in these sites. Context-specific interventions are needed to address stigma and discrimination of PLHIV within the community and in health services, and greater reflection is required to ensure policies aiming to expand HIV treatment do not exacerbate stigma and result in negative HIV outcomes.

How does a decision aid help people decide whether to disclose a mental health problem to employers? Qualitative interview study.

Background Decisions about whether to disclose mental health problems to employers are complex, with potential personal, employment and legal implications. Decision aids are evidence based tools, designed to help individuals make specific choices between treatment options. We previously developed a decision aid-Conceal Or ReveAL (CORAL)-to assist service users with decisions about disclosure to employers. As part of a mixed methods exploratory RCT, which demonstrated that the CORAL decision aid was effective in reducing decisional conflict, we aimed to explore its mechanism of action and to optimise the intervention for a future full scale trial. Methods In depth interviews were conducted with individuals receiving vocational support from a mental health trust and participating in the intervention arm of the pilot trial. Thematic analysis was conducted to identify the main themes relating to participants' perceptions of the CORAL decision aid. Results Thirteen participants were interviewed and five main themes were identified: sense of self and values; sense of control; anticipation of disclosure; experience of disclosure; and mechanism of action of the decision aid. Conclusions Data from our 13 participants suggest that the CORAL decision aid acts on several dimensions of decisional conflict: clarifying the pros and cons of different choices; increasing knowledge; structuring the decision making process; and clarifying needs and values. The current study indicated that it would be most effective when delivered by a professional well versed in employment and mental health matters such as a vocational adviser. The need for employers and policymakers to reduce the negative impact of disclosure is also highlighted.