Search

South Africa has one of the highest rates of HIV/tuberculosis (TB) co-infection, and poor engagement in HIV/TB care contributes to morbidity and mortality. In South Africa, community health workers (CHWs) are tasked with re-engaging patients who have dropped out of HIV/TB care. CHWs have described substantial challenges with substance use (SU) and depression among their patients, while patients have described CHW stigma towards SU and depression as barriers to re-engagement in care. Yet, CHWs receive little-to-no training on SU or depression. Therefore, we piloted Siyakhana, a brief CHW training to reduce stigma related to SU and depression while improving skills for re-engaging these patients in HIV and/or TB care. This study evaluated the preliminary effectiveness (stigma towards SU and depression; clinical competence assessed via roleplay) and implementation (quantitative ratings of feasibility, acceptability, appropriateness, adoption; semi-structured written qualitative feedback) of Siyakhana among CHWs and supervisors (N = 17) at pre- and post-training assessments. SU stigma significantly decreased (F(1,16) = 18.94, p < 0.001, ηp2 = 0.54). Depression stigma was lower than SU stigma at both timepoints and did not significantly decrease after training. CHW clinical competency towards patients with SU/depression significantly improved (t(11) = -3.35, p = 0.007, d = 1.00). The training was rated as feasible, acceptable, appropriate, and likely to be adopted by CHWs and their supervisors. Nonjudgmental communication was commonly described as the most useful training component. Based on this pilot, the training is being refined and evaluated in a larger randomized stepped-wedge clinical trial., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Regenauer et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Stress is a challenge among non-specialist health workers worldwide, particularly in low-resource settings. Understanding and targeting stress is critical for supporting non-specialists and their patients, as stress negatively affects patient care. Further, stigma toward mental health and substance use conditions also impacts patient care. However, there is little information on the intersection of these factors. This sub-analysis aims to explore how substance use and mental health stigma intersect with provider stress and resource constraints to influence the care of people with HIV/TB. We conducted semi-structured interviews ( N =30) with patients ( n =15) and providers ( n =15, non-specialist health workers) within a low-resource community in Cape Town, South Africa. Data were analyzed using thematic analysis. Three key themes were identified: (1) resource constraints negatively affect patient care and contribute to non-specialist stress; (2) in the context of stress, non-specialists are hesitant to work with patients with mental health or substance use concerns, who they view as more demanding and (3) stress contributes to provider stigma, which negatively impacts patient care. Findings highlight the need for multilevel interventions targeting both provider stress and stigma toward people with mental health and substance use concerns, especially within the context of non-specialist-delivered mental health services in low-resource settings., Competing Interests: The authors declare no conflicts of interest., (© The Author(s) 2024.)

Background: South Africa has deployed community health workers (CHWs) to support individuals to enter and stay in HIV/TB care. Although CHWs routinely encounter patients with mental health (particularly depression) and substance use (SU) conditions that impact their engagement in HIV/TB care, CHWs are rarely trained in how to work with these patients. This contributes to mental health and SU stigma among CHWs, a known barrier to patient engagement in care. Mental health and SU training interventions could reduce CHW stigma and potentially improve patient engagement in care, but evidence of the feasibility, acceptability, and preliminary effectiveness of these interventions is scarce. Therefore, we designed a hybrid type 2 effectiveness-implementation pilot trial to evaluate the implementation and preliminary effectiveness of a CHW training intervention for reducing depression and SU stigma in the Western Cape, South Africa., Methods: This stepped wedge pilot trial will engage CHWs from six primary care clinics offering HIV/TB care. Clinics will be block randomized into three-step cohorts that receive the intervention at varying time points. The Siyakhana intervention involves 3 days of training in depression and SU focused on psychoeducation, evidence-based skills for working with patients, and self-care strategies for promoting CHW wellness. The implementation strategy involves social contact with people with lived experience of depression/SU during training (via patient videos and a peer trainer) and clinical supervision to support CHWs to practice new skills. Both implementation outcomes (acceptability, feasibility, fidelity) and preliminary effectiveness of the intervention on CHW stigma will be assessed using mixed methods at 3- and 6-month follow-up assessments., Discussion: This trial will advance knowledge of the feasibility, acceptability, and preliminary effectiveness of a CHW training for reducing depression and SU stigma towards patients with HIV and/or TB. Study findings will inform a larger implementation trial to evaluate the longer-term implementation and effectiveness of this intervention for reducing CHW stigma towards patients with depression and SU and improving patient engagement in HIV/TB care., Trial Registration: ClinicalTrials.gov NCT05282173. Registered on 7 March 2022., (© 2023. The Author(s).)

Background: Despite a high prevalence of problematic substance use among people living with HIV in South Africa, there remains limited access to substance use services within the HIV care system. To address this gap, our team previously developed and adapted a six-session, peer-delivered problem-solving and behavioral activation-based intervention ( Khanya ) to improve HIV medication adherence and reduce substance use in Cape Town. This study evaluated patient and provider perspectives on the intervention to inform implementation and future adaptation., Methods: Following intervention completion, we conducted semi-structured individual interviews with patients ( n = 23) and providers ( n = 9) to understand perspectives on the feasibility, acceptability, and appropriateness of Khanya and its implementation by a peer. Patients also quantitatively ranked the usefulness of individual intervention components (problem solving for medication adherence 'Life-Steps', behavioral activation, mindfulness training, and relapse prevention) at post-treatment and six months follow-up, which we triangulated with qualitative feedback to examine convergence and divergence across methods., Results: Patients and providers reported high overall acceptability, feasibility, and appropriateness of Khanya , although there were several feasibility challenges. Mindfulness and Life-Steps were identified as particularly acceptable, feasible, and appropriate components by patients across methods, whereas relapse prevention strategies were less salient. Behavioral activation results were less consistent across methods., Conclusions: Findings underscore the importance of examining patients' perspectives on specific intervention components within intervention packages. While mindfulness training and peer delivery models were positively perceived by consumers, they are rarely used within task-shared behavioral interventions in low- and middle-income countries., (© The Author(s) 2022.)