Siyakhana Peer: Evaluating a Peer Recovery Coach Model to Reduce Substance Use Stigma in South African HIV Care

South Africa has the most people living with HIV in the world, many of whom use alcohol and other drugs. Alcohol and other drug use is associated with worse HIV care engagement, contributing to increased HIV-related morbidity and mortality.

Healthcare worker stigma towards alcohol and other drug use is associated with poorer treatment of patients who use substances and worse patient engagement in HIV care. There is evidence that healthcare workers in this setting, including community health workers who play a central role in re-engaging patients who are lost to follow-up from HIV care, exhibit stigmatizing behaviors towards HIV patients who use substances.

Peer recovery coaches (PRCs) are trained individuals with lived substance use recovery experience who are integrated into healthcare teams. Healthcare workers who work with PRCs have sustained contact with a person with lived substance use experience, which is associated with lower stigma. In the United States, preliminary research has demonstrated that PRCs can be successfully integrated into healthcare teams, and that PRC contact is associated with increased patient engagement in healthcare. Yet, a PRC model has not yet been tested in South African HIV care.

Therefore, the purpose of this study is to examine the preliminary implementation and effectiveness of integrating a PRC model into existing teams of healthcare workers who are tasked with re-engaging patients in HIV care through community-based primary care teams. In a type 1, hybrid effectiveness-implementation trial, and comparing a healthcare worker team that works with a PRC to one that does not, the investigators will primarily assess the rate of patient re-engagement in care and implementation (i.e., feasibility, acceptability) of the model. Healthcare worker stigma towards patients living with HIV who use substances will also be measured.

• Siyakhana - P (Behavioral), also known as Peer Recovery Coach Integrated Intervention, PRC Integration: A trained peer recovery coach (PRC) will be integrated onto the healthcare worker team randomized to Siyakhana - P. The PRC on this team will work with eligible and consenting patients who are seen by members of this healthcare team.

Primary outcomes

• Healthcare Worker Substance Use Stigma [3-months post-baseline assessment]: Healthcare worker stigma towards substance use measured using the Social Distance Scale (SDS). SDS scores range from 6 to 24, with higher scores indicating more desired social distance (higher stigma).

Secondary outcomes

• Healthcare Worker Feasibility (Intervention Arm Only) [6-months post-integration assessment]: Feasibility subscale of the JHU Applied Mental Health Research (AMHR) D\&I Measure, a 10-item measure for assessing dissemination and implementation outcomes in low- and middle-income settings, completed by healthcare worker participants. Items are rated on a 0-3 scale, and averaged, with lower scores (closer to 0) indicating lower feasibility and higher scores (closer to 3) indicating higher feasibility. Findings will be supplemented with qualitative interviews.
• Healthcare Worker Acceptability (Intervention Arm Only) [6-months post-integration assessment]: Acceptability subscale of the JHU Applied Mental Health Research (AMHR) D\&I Measure, a 14-item measure for assessing dissemination and implementation outcomes in low- and middle-income settings, completed by healthcare worker participants. Items are rated on a 0-3 scale, and averaged, with lower scores (closer to 0) indicating lower acceptability and higher scores (closer to 3) indicating higher acceptability. Findings will be supplemented with qualitative interviews.

Other outcomes

• Patient Re-Engagement in HIV Care [3-months post-baseline assessment]: Patient HIV care re-engagement (dichotomous yes/no), assessed via clinic records.
• Patient Feasibility (Intervention Arm Only) [3-months post-baseline assessment]: Feasibility subscale of the JHU Applied Mental Health Research (AMHR) D\&I Measure, a 14-item measure for assessing dissemination and implementation outcomes in low- and middle-income settings, completed by patient participants. Items are rated on a 0-3 scale, and averaged, with lower scores (closer to 0) indicating lower feasibility and higher scores (closer to 3) indicating higher feasibility. Findings will be supplemented with qualitative interviews.
• Patient Acceptability (Intervention Arm Only) [3-months post-baseline assessment]: Acceptability subscale of the JHU Applied Mental Health Research (AMHR) D\&I Measure, a 12-item measure for assessing dissemination and implementation outcomes in low- and middle-income settings, completed by patient participants. Items are rated on a 0-3 scale, and averaged, with lower scores (closer to 0) indicating lower acceptability and higher scores (closer to 3) indicating higher acceptability. Findings will be supplemented with qualitative interviews.

Sex: All, ages: 18 Years to any, accepts healthy volunteers

1. HEALTHCARE WORKER:

   1. Inclusion Criteria:

      * At least 18 years old
      * Employed as a healthcare worker (e.g., community health worker, nurse, supervisor, etc.,) for one of the partner healthcare worker teams that provides HIV re-engagement services
   2. Exclusion Criteria:

      * Unable or unwilling to complete informed consent and study procedures in English, isiXhosa, or Afrikaans
2. PATIENT:

   1. Inclusion Criteria:

      * At least 18 years old
      * Living with HIV
      * Problematic alcohol or other drug use defined by either: a) AUDIT-C score ≥ 2; or b) self-report illicit drug use within past 3 months
      * Seen by a healthcare worker from one of the healthcare teams partnered with this study because of recent disengagement in HIV care
   2. Exclusion Criteria:

      * Unable or unwilling to complete informed consent and study procedures in English, isiXhosa, or Afrikaans

Participant flow

Outcome results

• Healthcare Worker Substance Use Stigma (Primary), Mean, score on a scale: Enhanced Treatment as Usual (Healthcare Workers) 11.63 +/- 2.87; Siyakhana - P (Healthcare Workers) 9.95 +/- 2.93; Enhanced Treatment as Usual (Patients) ; Siyakhana - P (Patients) (p 0.023)
• Healthcare Worker Feasibility (Intervention Arm Only) (Secondary), Mean, score on a scale: Enhanced Treatment as Usual (Healthcare Workers) ; Siyakhana - P (Healthcare Workers) 2.35 +/- 0.63; Enhanced Treatment as Usual (Patients) ; Siyakhana - P (Patients)
• Healthcare Worker Acceptability (Intervention Arm Only) (Secondary), Mean, score on a scale: Enhanced Treatment as Usual (Healthcare Workers) ; Siyakhana - P (Healthcare Workers) 2.46 +/- 0.58; Enhanced Treatment as Usual (Patients) ; Siyakhana - P (Patients)
• Patient Re-Engagement in HIV Care (Other pre specified)
• Patient Feasibility (Intervention Arm Only) (Other pre specified), Mean, score on a scale: Enhanced Treatment as Usual (Healthcare Workers) ; Siyakhana - P (Healthcare Workers) ; Enhanced Treatment as Usual (Patients) ; Siyakhana - P (Patients) 2.77 +/- 0.24
• Patient Acceptability (Intervention Arm Only) (Other pre specified), Mean, score on a scale: Enhanced Treatment as Usual (Healthcare Workers) ; Siyakhana - P (Healthcare Workers) ; Enhanced Treatment as Usual (Patients) ; Siyakhana - P (Patients) 2.86 +/- 0.28

Adverse events

Time frame: Adverse events are monitored an average of 15 months for each participant, from signing of informed consent to the final follow-up.

Serious adverse events by term

Other adverse events by term

• Study Protocol and Statistical Analysis Plan (PDF, 2024-08-23)

• Jessica F Magidson, PhD, Principal investigator, University of Maryland, College Park
• Bronwyn Myers, PhD, Principal investigator, Medical Research Council, South Africa

NIH grants: R21DA053212