A Peer Intervention Facilitates Trust and Improves Psychosocial Well-Being in Diverse, Low-Income Older Adults

We evaluate a peer outreach intervention to improve the psychosocial well-being of diverse, low-income older adults. Participants (N=74, Age 58-96 years) were recruited from an urban senior center and matched with peers who were >55 years old, received mental health training, and connected participants with health or social activities. We conducted surveys at baseline and 6-month follow-up for 2 years with validated measures of loneliness, social interaction, barriers to socializing, and depression, and thematically analyzed qualitative, semi-structured interviews conducted among a subset of participants (n=15) and peers (n=6). Participants were 58% male, 18% African-American, 19% Latinx, and 8% Asian. Over 2 years, participants experienced sustained reductions in loneliness (p=0.015), depression (p<0.001), and barriers to socializing (p<0.001). Qualitative interviews detailed the role of longitudinal relationships, program flexibility, and the matching process in facilitating trust, motivation, and improved mood. Results can inform larger efficacy studies and implementation of peer-driven community programs.

An Exploration on Trust

“Trust is a form of love,” explained a study participant. As a form of love, trust nourishes connections and accelerates progress. As a result, the purpose of this session is to reflect upon the notion of trust and examine how trust moves science and social justice forward. Trust must be seen as sustained or broken over multiple generations. Moreover, trust between older adults and medical and social support institutions has profound implications for this historical moment. In the COVID-19 pandemic, trust can be viewed as a facilitator of emergency responses in the State of Washington as noted in Dr. Berridge’s paper. On the other hand, distrust and a related sense of abandonment contributes to Black Americans' limited uptake of COVID-19 vaccinations, as noted in Dr. Johnson’s work. On a related note, Dr. Perry’s work shows that lack of trust over time has led those aging with hemophilia to withdraw from care at different points in their own trajectories. Finally, on a positive note, Dr. Kotwal’s work illustrates the role of a peer outreach intervention in facilitating trusting relationships among diverse, low-income older adults which led to sustained reductions, over a 2-year period, in loneliness, barriers to socializing, and depression. This symposium on trust highlights how researchers work, either consciously or unconsciously, within a continuum of trust in their participants' communities. At a broader level, systemic attention to building trust from academia, government, and national advocacy organizations holds the potential to foster meaningful scientific engagement and empowerment of historically marginalized communities.

HIV testing amid COVID-19: community efforts to reach men who have sex with men in three Kenyan counties

In comparison to European and American countries, Kenya has been less impacted by the COVID-19 pandemic in terms of reported cases and mortalities. However, everyday life has been dramatically affected by highly restrictive government-imposed measures such as stay-at-home curfews, prohibitions on mobility across national and county boundaries, and strict policing, especially of the urban poor, which has culminated in violence. This open letter highlights the effects of these measures on how three community-based organizations (CBOs) deliver HIV programs and services to highly stigmatized communities of men who have sex with men living in the counties of Kisumu, Kiambu and Mombasa. In particular, emphasis is placed on how HIV testing programs, which are supported by systematic peer outreach, are being disrupted at a time when global policymakers call for expanded HIV testing and treatment targets among key populations. While COVID 19 measures have greatly undermined local efforts to deliver health services to members and strengthen existing HIV testing programs, each of the three CBOs has taken innovative steps to adapt to the restrictions and to the COVID-19 pandemic itself. Although HIV testing in clinical spaces among those who were once regular and occasional program attendees dropped off noticeably in the early months of the COVID-19 lockdown, the program eventually began to rebound as outreach approaches shifted to virtual platforms and strategies. Importantly and unexpectedly, HIV self-testing kits proved to fill a major gap in clinic-based HIV testing at a time of crisis.

Peer Recruitment Strategies for Female Sex Workers Not Engaged in HIV Prevention and Treatment Services in Côte d’Ivoire: Program Data Analysis

Background In the context of the mostly generalized HIV epidemic in Côte d’Ivoire, key populations bear a higher burden of HIV than that borne by the general reproductive-aged population. Mathematical models have demonstrated the significant potential impact and cost-effectiveness of improving the coverage of HIV prevention and treatment services for key populations in Côte d’Ivoire. However, in 2019, coverage of these services remained limited by multiple intersecting stigmas affecting key populations, necessitating the study of innovative implementation strategies to better meet the needs of those most marginalized. Here, we leverage programmatic data to compare the effectiveness of the enhanced and traditional peer outreach approaches in reaching and providing community HIV testing to female sex workers not readily engaged in HIV prevention and treatment services in Côte d’Ivoire. Objective The aim of this study was to describe the characteristics of female sex workers reached by the LINKAGES project in Côte d’Ivoire with enhanced peer outreach and traditional peer outreach and to compare HIV-related outcomes between the women reached by both strategies. Methods Deidentified routine programmatic data collected as part of LINKAGES Côte d’Ivoire between October 2017 and April 2018 were used in these analyses. Demographic characteristics and HIV indicators including HIV testing history, HIV case-finding, linkage to HIV treatment, and treatment initiation were assessed using descriptive statistics. Differences in these indicators were compared by outreach strategy using Pearson chi-square tests. Results There were 9761 women reached with enhanced peer outreach and routine peer outreach included in these analyses. The overall case-finding rate in the sample was 7.8% (698/8851). Compared with women reached by routine outreach, those reached by enhanced peer outreach were more likely to have previously been tested for HIV (enhanced: 1695/2509, 67.6%; routine: 4302/7252, 60.0%; χ21=43.8; P=.001). The enhanced peer outreach approach was associated with a higher HIV case-finding rate (enhanced: 269/2507 10.7%; routine: 429/6344, 6.8%; χ21=32.3; P=.001), higher proportion of linkage to treatment (enhanced: 258/269, 95.9%; routine: 306/429, 71.3%; χ21=64.4; P=.001), and higher proportion of treatment initiation (enhanced: 212/269, 78.8%; routine: 315/429, 73.3%; χ21=2.6; P=.11). Women reached by both approaches were categorized as high risk for HIV-related behaviors such as condomless sex and number of sex acts in the previous week. Conclusions These analyses suggest that the novel peer-referral strategy, the enhanced peer outreach approach, was effective in reaching female sex workeres in Côte d’Ivoire with demonstrated acquisition risks for HIV and who had not been effectively engaged by routine outreach approaches. Scaling up novel strategies such as enhanced peer outreach in the context of differentiated service models may be needed to optimize HIV prevention and treatment outcomes for key populations in Côte d’Ivoire.

HIV testing amid COVID-19: community efforts to reach men who have sex with men in three Kenyan counties

In comparison to European and American countries, Kenya has been less impacted by the COVID-19 pandemic in terms of reported cases and mortalities. However, everyday life has been dramatically affected by highly restrictive government-imposed measures such as stay-at-home curfews, prohibitions on mobility across national and county boundaries, and strict policing, especially of the urban poor, which has culminated in violence. This open letter highlights the effects of these measures on how three community-based organizations (CBOs) deliver HIV programs and services to highly stigmatized communities of men who have sex with men living in the counties of Kisumu, Kiambu and Mombasa. In particular, emphasis is placed on how HIV testing programs, which are supported by systematic peer outreach, are being disrupted at a time when global policymakers call for expanded HIV testing and treatment targets among key populations. While government measures have greatly undermined local efforts to deliver health services to members and strengthen existing HIV testing programs, each of the three CBOs has taken innovative steps to adapt to the government restrictions and to the COVID-19 pandemic itself. Although HIV testing in clinical spaces among those who were once regular and occasional program attendees dropped off noticeably in the early months of the COVID-19 lockdown, the program eventually began to rebound as outreach approaches shifted to virtual platforms and strategies. Importantly and unexpectedly, HIV self-testing kits proved to fill a major gap in clinic-based HIV testing at a time of crisis.

Peer Recruitment Strategies for Female Sex Workers Not Engaged in HIV Prevention and Treatment Services in Côte d’Ivoire: Program Data Analysis (Preprint)

BACKGROUND In the context of the mostly generalized HIV epidemic in Côte d’Ivoire, key populations bear a higher burden of HIV than that borne by the general reproductive-aged population. Mathematical models have demonstrated the significant potential impact and cost-effectiveness of improving the coverage of HIV prevention and treatment services for key populations in Côte d’Ivoire. However, in 2019, coverage of these services remained limited by multiple intersecting stigmas affecting key populations, necessitating the study of innovative implementation strategies to better meet the needs of those most marginalized. Here, we leverage programmatic data to compare the effectiveness of the enhanced and traditional peer outreach approaches in reaching and providing community HIV testing to female sex workers not readily engaged in HIV prevention and treatment services in Côte d’Ivoire. OBJECTIVE The aim of this study was to describe the characteristics of female sex workers reached by the LINKAGES project in Côte d’Ivoire with enhanced peer outreach and traditional peer outreach and to compare HIV-related outcomes between the women reached by both strategies. METHODS Deidentified routine programmatic data collected as part of LINKAGES Côte d’Ivoire between October 2017 and April 2018 were used in these analyses. Demographic characteristics and HIV indicators including HIV testing history, HIV case-finding, linkage to HIV treatment, and treatment initiation were assessed using descriptive statistics. Differences in these indicators were compared by outreach strategy using Pearson chi-square tests. RESULTS There were 9761 women reached with enhanced peer outreach and routine peer outreach included in these analyses. The overall case-finding rate in the sample was 7.8% (698/8851). Compared with women reached by routine outreach, those reached by enhanced peer outreach were more likely to have previously been tested for HIV (enhanced: 1695/2509, 67.6%; routine: 4302/7252, 60.0%; χ²₁=43.8; <i>P</i>=.001). The enhanced peer outreach approach was associated with a higher HIV case-finding rate (enhanced: 269/2507 10.7%; routine: 429/6344, 6.8%; χ²₁=32.3; <i>P</i>=.001), higher proportion of linkage to treatment (enhanced: 258/269, 95.9%; routine: 306/429, 71.3%; χ²₁=64.4; <i>P</i>=.001), and higher proportion of treatment initiation (enhanced: 212/269, 78.8%; routine: 315/429, 73.3%; χ²₁=2.6; <i>P</i>=.11). Women reached by both approaches were categorized as high risk for HIV-related behaviors such as condomless sex and number of sex acts in the previous week. CONCLUSIONS These analyses suggest that the novel peer-referral strategy, the enhanced peer outreach approach, was effective in reaching female sex workeres in Côte d’Ivoire with demonstrated acquisition risks for HIV and who had not been effectively engaged by routine outreach approaches. Scaling up novel strategies such as enhanced peer outreach in the context of differentiated service models may be needed to optimize HIV prevention and treatment outcomes for key populations in Côte d’Ivoire.

Barriers and facilitators to recruitment and enrollment of HIV-infected individuals with opioid use disorder in a clinical trial

Background The CTN-0067 CHOICES trial tests implementation of extended-release naltrexone (XR-NTX) versus treatment-as-usual (TAU) for opioid use disorders (OUD) in HIV clinics to improve HIV viral suppression. The study team investigated recruitment strategies to elucidate the barriers and facilitators to recruitment and enrollment in the study. Main text Methods: Semi-structured, in-depth, digitally recorded interviews were completed with study recruitment-related staff and medical providers (n = 26) from six participating HIV clinics in the fall of 2018. Interviews probed 1) factors that might prevent prospective participants from engaging in study recruitment and enrollment procedures and 2) strategies used by study staff that encourage eligible patient participation. Interviews were transcribed and thematically analyzed using a content analysis approach. Results: All respondents reported that barriers to recruitment and enrollment included challenging patient social and structural factors (e.g., homelessness or living environments with high substance use, criminal justice involvement), difficulty locating patients with unsuppressed HIV viral load and OUD within the HIV clinic, time-consuming study enrollment processes, and stigma around HIV and OUD which inhibited treatment seeking. Some respondents observed that distrust of research and researchers impeded recruitment activities in the community. A specific medication-related barrier was patient fear of opioid abstinence required prior to XR-NTX induction. Facilitators of recruitment included use of trusted peer outreach/recruitment workers in the community, hospitalizations that offered windows of opportunities for screening and XR-NTX induction, providing participant transportation, and partnerships with harm reduction organizations for referrals. Conclusions Though study personnel encountered barriers to recruitment in the CHOICES study, persons with untreated HIV and OUD can be enrolled in multisite clinical trials by using enhanced recruitment strategies that extend outside of the HIV clinic. Employing peer outreach workers and collaborating with syringe service programs may be especially helpful in facilitating recruitment and merit inclusion in similar study protocols.