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By: KD Consulting Staff. What is A Recovery Coach July 7, KD Consulting Interventions Corporation. We recruited peer educators from two harm reduction facilities in Nairobi, Kenya, using random and purposive sampling techniques. Semi-structured interviews explored circumstances surrounding HIV and HCV service access, prevention education and resource recommendations.

A thematic analysis was conducted using the Modified Social Ecological Model MSEM as an underlying framework, with illustrative quotes highlighting emergent themes. Twenty peer educators participated, including six women, with 2-months to 6-years of harm reduction service. Barriers to HIV and HCV care were organized by a individual-level themes including the competing needs of addiction and misinterpreted symptoms; b social network-level themes including social isolation and drug dealer interactions; c community-level themes including transportation, mental and rural healthcare services, and limited HCV resources; and d policy-level themes including nonintegrated health services, clinical administration, and law enforcement.

Stigma, an overarching barrier, was highlighted throughout the MSEM. Facilitators to HIV and HCV care were comprised of a individual-level themes including concurrent care, personal reflections, and religious beliefs; b social network-level themes including community recommendations, navigation services, family commitment, and employer support; c community-level themes including quality services, peer support, and outreach; and d policy-level themes including integrated health services and medicalized approaches within law enforcement.

Participant resource recommendations include i additional medical, social and ancillary support services, ii national strategies to address stigma and violence and iii HCV prevention education. Recommendations emphasized policy and community-level interventions including educational campaigns and program suggestions to supplement existing HIV and HCV services. Currently, OST offers directly observed methadone treatment, which requires patients to visit clinic locations daily, creating barriers around transportation, household responsibilities and financial hardship [ 18 , 19 ].

PEs serve as trusted community liaisons, often bridging the gap between PWID and healthcare providers, who largely serve the general public. Until recently, most studies have highlighted the experiences and perspectives of PWID, healthcare service providers and key stakeholders, but rarely consider the unique vantage-point of PEs, who offer both personal and professional perspectives on dynamics surrounding addiction, HIV and HCV care, and recommendations for improving service uptake [ 13 , 19 ].

Specifically, the MSEM explains the complex relationships between the stage of an epidemic, including HIV and HCV epidemics, and the surrounding risks that fall within political, community, social network and individual domains [ 22 , 23 ]. MSEM levels are not independently operationalized, but often contain dynamic, mutually reinforcing relationships that influence one another and may change over time [ 22 , 23 ].

Until recently, several studies have highlighted the roles and perspectives of clinicians, policy makers and current PWID, but rarely seek input from PEs who offer intimate knowledge of PWID experiences. To avoid contributing to community stigma, location names will not be provided. PEs are trained harm reduction specialists, with a history of substance use disorder and many are former PWID. Until recently, DAA treatment was limited to research studies and pilot programs, with a national HCV treatment rollout anticipated in Study eligibility included: 1 adults 18 years or older; 2 employed as a PE in September ; 3 English or Swahili-speaking; and 4 willing and able to provide informed consent.

Random and purposive sampling techniques were applied, whereby we randomly selected PEs from a roster and oversampled female PEs in order to increase the robustness of participant experiences.

By oversampling PEs who are women, we aim to capture a wide range of experiences including poor treatment by clinical personnel, policing practices, stigma, household responsibilities, and other factors that may not be experienced by men.

A standard script was used to explain the study purpose and procedures, and in total, 20 participants were selected and agreed to participate. A priori research questions included HIV barriers and facilitators to care, with the inclusion of HCV-related aims based on key informant suggestions. The interview guide was developed by several co-authors, including SAPTA leadership, through an iterative process.

Prior to the start of data collection, the interview guide was pilot tested with two PEs to ensure colloquial phrases commonly used between PEs and clients were incorporated and applied appropriately. Semi-structured, in-depth interviews were used to elicit PEs personal and professional experiences surrounding 1 job responsibilities; 2 PWID access and utilization of HIV, HCV and addiction care services; 3 treatment by law enforcement and medical providers; and 4 suggested resources for PWID and PEs who provide harm reduction services.

Data collection occurred from September to December Interviews were audio recorded and ranged from 45 to 90 minutes, with the interviewer taking detailed field notes to summarize the interview content and the physical and mental condition of each participant. Weekly study team discussions were used to a refine the interview guide, b explore emergent topics i. Through study discussions, research team members concluded conceptual saturation had been reached, whereby additional interviews would not elicit new information [ 26 , 27 ].

All transcripts were transcribed verbatim, with all but four transcripts undergoing translation from Swahili to English. We conducted a thematic analysis using similar methods to those described by Braun and Clark [ 26 ].

Codebook development involved three study team members NLB, AMW and LM independently reading and open-coding select transcript excerpts in order to generate an initial list of codes based on a priori topics i. Similar themes were merged together as common or recurring concepts, which were organized into typologies and later into classification schemes. Weekly coding schedules consisted of coding, reviewing field notes, and writing detailed memos, which was followed by study team discussions of major themes and code definitions as an iterative process [ 28 ].

Isolated coding concerns were resolved through team discussions and further refinement of codebook parameters. Higher-level code classifications included a drug use and addiction, b social support systems, c politics and law enforcement, d infectious diseases, and e peer educator employment. Participants provided written informed consent in Swahili or English. Careful consideration was given to SAPTA employment contracts, which outlines grounds for probation or dismissal if a PE disclosed current substance use, particularly the combination of OST and substance use.

Whether PEs admitted to current drug use or felt that the interview content would trigger the use of substances post-interview, they were encouraged to speak with an addiction counsellor. To our knowledge, no PEs were engaging in substance use or felt the need to use substances at the time of their interview, and none were dismissed or placed on probation. Participant average years of service was 3 years range: 2 months-6 years Table 1. He described one client with HCV complications, who voluntarily discharged against medical advice:.

If they are admitted, when they feel a little bit okay, they run away because of the craving. Kizito, M, age 44 years, PE for 2 years. Murwa, M, 37 years, PE for 7 months. PEs highlighted two social network-level themes: social isolation and territorial drug dealers.

Otieno M, 36 years , a PE who injected heroin for 15 years, recalled experiencing social isolation from family and friends following his HIV diagnosis that impacted his mental health. Moha describes acts of physical violence and threats from drug suppliers, who blame PEs for impinging on their revenue:. Sometimes you have to hide, so that you can talk with people [clients] at the den, or when distributing the [needle-syringe] kits, sometimes we hide because the drug lords see us as blocks to their business.

There was a time a peer educator from here, they were beaten. Moha, M, 34 years, PE for 2 years. As a result, clients will avoid PEs, fearing retaliation by drug dealers, which limits their access to harm reduction services. Four community-level themes emerged during PE discussions including: a transportation, b limited care beyond city limits, c limited HCV resources, and d lack of mental health services.

PEs described transportation cost as a common barrier, especially when clients lived or spent time outside of city limits.

We contribute money amongst ourselves [between several PEs] and take him to the hospital. Wangai, M, 42 years, PE for 5 years. However, with limited medical facilities in the villages, family members will often transport clients back to Nairobi when their health conditions are severe. Rita and her sister moved into a Nairobi slum in search of work, where they both developed a heroin addiction. Rita received her HIV diagnosis shortly after her sister passed away, and although her sister was never tested, Rita assumes her death was related to HIV complications.

I took her home [to our village] when I saw things are bad and by that time she was really in a bad condition. My mother took her to the hospital, and the following day when my mother went to visit her, found that she had died.

You know when you are at the base. Rita, F, 38 years, PE for 3 years. Rita was one of two PEs that described returning home to their village for family support and finding limited medical resources. In addition, many clients underestimate the severity of their illness and re-engage in care when they are severely immunocompromised, which limits treatment options and increases the risk of mortality. Several PEs cited an abundance of HIV-related health education and awareness, but limited community awareness on HCV testing, treatment and care options.

In addition, Muniu and one other PE discussed recent public health campaigns around hepatitis B, which created confusion among their clients, who find the similar nomenclature to be challenging when trying to distinguish between the two infectious diseases.

While there has been consistent community-level HIV prevention messaging promoting the use of clean injection equipment and condoms, clients often lack information on HCV prevention services and treatment options. Descriptions of violence, trauma, stress, isolation and experiences of forced migration to major cities in order to support family members, all contributed to poor mental health. Seventeen PEs described experiences of trauma, stress, depression and anxiety after witnessing a peer overdose.

While PEs draw on personal experiences to counsel clients, they recognize their limitations in providing professional mental health services.

Furthermore, PEs conveyed that most mental health services do not treat co-occurring disorders or severe mental health conditions e. PEs described four policy-level themes: integrated and tailored services, clinical administration e.

Harm reduction sites are limited to basic first aid, HIV counseling and testing, peer support groups and social services, with all other medical services provided via assisted referrals. As a result, clients that attend multiple clinics face additional time and financial burdens associated with lost income, transportation costs and household obligations.

Nearly all PEs advocated for integrated medical services provided within harm reduction facilities, which have established positive report with PWID. Administrative barriers included crowded medical facilities, long wait-queues and ambiguity around the financial obligations for medical services.

In several cases, PEs felt obligated to accompany their clients to medical visits in order to provide coping strategies for withdrawal symptoms and to assist in navigating complex administrative processes. Kizito described accompanying his clients to medical appointments and being solicited for payment:.

Once we take the client to the hospital, we take the client to the Social Department where they [apply for a subsidization] waiver. It is a challenge because if they [medical staff] refuse, you keep on telling them that they are street people and they are junkies and we usually have letters with our [SAPTA] letterhead, used for referrals. And then, at long last, they agree to waiver. That is why you have to follow up with them. While HIV medical services are subsidized, clinical administrators will often seek payment for ancillary medical services, including abrasions, infections and bone fractures, that can delay PWID from seeing a provider and increases the possibility of experiencing withdrawal symptoms and undue stress.

Like Kizito, many PEs feel obligated to assist clients in navigating through administrative and clinical barriers, fearing clients will become overwhelmed and neglect their medical care. Several PEs highlighted concerns surrounding confidentiality breaches due to the lack of privacy within the clinical infrastructure. Often small building spaces and the use of curtains as temporary walls impacted privacy, so that patients in the waiting areas could decipher patient-provider conversations.

You will be given your medicine [ART] and then you are given your methadone [OST] through the window and you know there is no curtain.

Or even there are two windows, and you open the other one and you find someone receiving the medicine and then that person will start talking. Kiplimo, M, 35 years, PE for 6 years. The fear surrounding confidentiality breaches causes clients to avoid OST clinics or to enroll in separate facilities.

Notably, clients that attend separate medical facilities face both time and financial constraints, which can increase suboptimal care through missed appointments and treatment regimens.

Nineteen PEs described first- and second-hand accounts of poor treatment, harassment, and violent acts that were carried out by local businesses, police and community members. Mob justice was described as a spontaneous assembly of community vigilantes delivering justice through physical beatings, typically following theft or the destruction of property.

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