Stakeholder Perspectives on the Role of Peer Mentors in the Implementation of Long-Acting Antiretroviral Therapy for Use by Adolescents and Young People in Western Kenya: Findings from a Formative Study,KuwaFree! LiveFree!

Abstract

Long-acting antiretroviral treatment (LA ART) is a forthcoming option for adolescents and young people living with HIV (AYPLHIV), but perspectives on using peer mentors to implement LA ART for AYPLHIV are unknown. We conducted seven focus group discussions (n = 58 participants) from November 2021 to April 2022 in Kenya with four stakeholder groups, including AYPLHIV, healthcare providers, advocates, and policymakers. We used inductive coding and thematic analysis. Our stakeholders articulated peer mentors are crucial in the implementation of LA ART for AYPLHIV in leading communication, facilitating referrals, and providing empathy from lived experiences. Additionally, they can serve as early adopters, help navigate service points, and provide messaging on the benefits and drawbacks of LA ART. They emphasized the necessity of training peer mentors for the LA ART scale-up. Peer mentors are essential for linkage and referring of AYPLHIV to LA ART, and peer mentors' involvement should be integrated into a national implementation plan.

“Plain English summary”

In the formative study “KuwaFree! LiveFree!” in western Kenya, stakeholder perspectives on the implementation of long-acting antiretroviral therapy for adolescents and young people were explored. The study focused on the role of peer mentors in this process.

Aim(s) of the research

—To explore stakeholder perspectives on the roles of young people who help in educating their fellow adolescents and youths, often called “peer mentors,” in implementing long-acting HIV treatment, called LA ART, as part of youth-friendly services.

Background to the research

—New long-acting HIV treatment, which is injected every 1 to 2 months, instead of being taken as pills by mouth every day, may alleviate some challenges faced by adolescents and young people living with HIV in keeping their HIV under control. Peer mentors may play a significant role in promoting the uptake of such new treatment among adolescents and young people.

Design and methods used

—We conducted focus group discussions with various stakeholders including the youth living with HIV, healthcare providers, youth advocates, and policymakers in Kenya. The discussions took place in-person or virtually, and we analyzed the recordings for important points.

Patient and public involvement

—Adolescents, peer mentors, healthcare providers, health advocates, and policymakers participated in the discussions.

Dissemination

—We held two stakeholder dissemination meetings at the study health facility, involving adolescents, peer mentors, and healthcare providers. The participants showed great enthusiasm for LA ART and engaged in an interactive question-and-answer session. Health providers concurred with the findings and discussed challenges such as managing stockouts, confidentiality concerns, and treatment failure. They also raised important questions about injection fear, medication costs, safe storage, and potential drug interactions. Other topics included the availability of LA ART for specific demographics, viral load monitoring, and cultural considerations. Dissemination strategies, such as presenting abstracts at conferences, were also discussed. The meeting provided an opportunity for stakeholders to validate focus group discussion results and raise critical questions and concerns related to LA ART.

Keywords

adolescents youth peer mentors long-acting or injectable ART Kenya

Background

Adolescents and young people (AYP), especially girls and young women, face the dual threat of sexually transmitted infections, including HIV, and unplanned pregnancies.^1,2 These threats are especially prevalent among AYPs in the low- and middle-income countries of sub-Saharan Africa. Among AYP living with HIV (AYPLHIV), it is critical to provide integrated sexual and reproductive health (SRH) services alongside antiretroviral treatment (ART) in youth-friendly settings.¹ Challenges AYPLHIV encounter in accessing such integrated services include concerns about confidentiality, stigma and discrimination related to HIV status and early sexual activity, lack of knowledge about available services, perceived unfriendly healthcare environments, and poor linkage between the community and healthcare services.^3,4 Stigma and discrimination are complicated by depression, adding to existing mental health challenges.^1,5 These concerns lead to poorer retention in care, suboptimal sustained viral suppression, and worse overall outcomes among AYPLHIV as compared to adults.^1,6

New HIV treatment modalities, such as long-acting (LA) ART, have potential to overcome some of the barriers and challenges AYPLHIV face in adherence to care and treatment.^7,8 LA ART, specifically injectable cabotegravir/rilpivirine, is approved for people as young as age 15 years, given demonstrated safety in this population. National programs are gearing up for potential implementation of LA ART.⁹ LA ART modeling studies have shown that LA ART will become cost-effective if the cost of introduction falls below twice the current cost of providing oral ART.⁸ AYPLHIV have shown marked interest in LA ART.¹⁰ However, how best to reach subpopulations, such as AYPLHIV, with LA ART remains unclear and peer mentors may have a significant role to play in reaching specific subpopulations.

Studies show that peer mentorship is an effective intervention for improving HIV care outcomes and overall health among AYPLHIV in Africa^1,11–15 Peer mentors, educators, or navigators, which hereforth we term “peer mentors” collectively, are individuals who have lived experiences in a particular situation or condition and can, therefore, provide unique insights and empathy to other persons going through similar experiences.^14,16 Peer mentors for AYPLHIV have been associated with increased knowledge and awareness of integrated services and reduction of concerns about stigma and confidentiality^16,17 and improved linkage to the services as well as uptake and retention in care.¹³ Other studies have also demonstrated reduction in the incidence of gender-based violence and depression among AYPLHIV due to peer involvement for comprehensive care of AYPLHIV.^11,12

Additionally, various models of peer mentors exist in HIV care for various subgroups.^18,19 For instance, among pregnant and postpartum women living with HIV, the “mentor mothers” model of peer mentorship has been adopted in several settings, despite mixed results, to help ensure adherence to ART remains high during these dynamic periods for a mother and infant.^14,20–22 Among AYPLHIV, “adherence clubs” often facilitated through social network mobile apps, such as WhatsApp, have become popular, where the group participants will post messages or pictures of taking oral ART daily.^23–26 Lastly, more generally, “treatment buddies,” where another adult also living with HIV will often accompany the patient coming to clinic, or “support groups” exist for various adults living with HIV.^27–29 In the context of LA ART, where several elements differ, for example, from daily oral pills taken from home to two-monthly injections administered by a healthcare provider, it is less clear how existing models of peer mentors would need to adapt.

Kenya is a priority PEPFAR country, with 1.4 million people estimated to be living with HIV and 22,000 new infections estimated in 2022.²⁸ AYP account for 20% of new infections, and are considered a priority population for Kenya's HIV response, with high need for LA ART. In our preimplementation mixed methods study on the rollout of combined LA ART and contraceptives in western Kenya called KuwaFree! LiveFree! (NCT05044962),^29,30 as a secondary analysis, we explored the perceptions of multiple stakeholders on the anticipated role of peer mentors in introducing LA ART for AYPLHIV into existing comprehensive care programs in Kenya.

Methods

Study Setting and Study Team

This study was conducted in Eldoret, Uasin Gishu County, Kenya, where the estimated HIV prevalence is 3.74%.³¹ Moi University College of Health Sciences, Moi Teaching and Referral Hospital (MTRH), and University of Washington researchers led the study. MTRH is home to the sole youth-friendly clinic, named Rafiki Clinic, in Uasin Gishu County. The Rafiki Clinic was founded in 2016 and provides integrated services, including HIV care, family planning, screening and treatment for sexually transmitted infections, and mental health services. It also provides outreach to street-connected youth, orphans, and vulnerable children and serves as a center for extracurricular and social activities among AYPLHIV. Arguably, this clinic is an exemplar of a comprehensive care program for AYPLHIV, where integration of multiple health services within a single, holistic framework exists to address the unique and complex needs of AYPLHIV.

Academic researchers, study staff, and youth peer mentors comprised the study team. To enhance research design and mentorship, the study team involved three peer mentors during study design, data collection, data analysis, and dissemination of findings, including manuscript writing. Throughout all aspects of the project, including planning, execution, analysis, and dissemination, the team met on a regular basis and generally used a consensus-driven approach for decision making.

Our overall reporting of the study is guided by the Consolidated criteria for Reporting Qualitative research (COREQ),³² and the checklist can be found in the Supplemental materials. This study underwent ethical review with the Institutional Research and Ethics Committee at Moi University in Kenya (0003912) and the Human Subjects Division at the University of Washington in the United States (00012640).

Data Collection

Our qualitative data collection strategy consisted of focus group discussions (FGDs) with four stakeholder groups in western Kenya: (1) AYPLHIV, (2) health care providers, including peer mentors, (3) health advocates, and (4) policymakers. The FGDs were performed between November 2021 and April 2022, and we aimed to conduct two FGDs per stakeholder group. We chose to conduct separate FGDs for each group, as we thought mixing together participants with significant perceived power differentials might unduly influence the group dynamics. The FGDs elicited participants’ perspectives on the introduction of LA ART in Kenya, focusing on implications for AYPLHIV.

Sampling

We recruited participants for the FGDs through a combination of purposive and snowball sampling, with guidance from the peer mentors about recruiting strategies and possible target participants. To recruit AYPLHIV, we used flyers and word-of-mouth to identify an initial round of potential participants. Then, we asked those potential participants to recommend one to two additional potential participants. The AYPLHIV were largely recruited from the Rafiki Clinic by research staff during their scheduled appointments, to provide first-hand experiences with their HIV care needs, including for ART adherence challenges. Providers, ranging from medical officers, nursing staff, and peer mentors, were recruited through the clinic leadership of Rafiki Clinic, other HIV care clinics, and family planning clinics at the study facility. To recruit health advocates, such as persons representing networks of people living with HIV, and policymakers, such as those working at the national and regional levels, we identified key groups and cadres for inclusion through the study team's social networks and contacted them to provide representatives who were willing to participate in the study from their organization or team, and to recommend one to two other groups or team members for us to invite.

FGD Procedures

Prior to participant involvement in the FGDs, we obtained written informed consent which was written in English or Kiswahili, per the participant's preference, and provided participants with a monetary payment of Ksh1100 (∼US$10) for time and travel. We obtained demographic data, including age, gender, education, and experience with HIV treatment for AYPLHIV or their role, area of service, and length of experience for healthcare providers, advocates, and policymakers. We chose the FGD facilitators based on experience conducting FGDs and working with adolescents and people living with HIV from the qualitative research core at the study facility; two facilitators outside of the study team were selected and underwent additional, study-specific trainings. Two (one male, one female, both degree-level training) nonstudy and one study (SB, male, diploma-level training) team members conducted the AYPLHIV and healthcare provider FGDs while two study team members (EW (male), EA (female), both physicians) conducted the advocates and policymaker FGDs. Facilitators conducted the FGDs in the participants’ chosen language, which was either Kiswahili or English, while another Kenyan member of the research team took short discussion notes. We conducted the FGDs in-person or virtually using the Zoom platform, depending on the stakeholder group (i.e., the AYPLHIV and providers FGDs were local to the study facility so those were held in-person, while the advocates and policymaker participants were dispersed throughout Kenya so those were held virtually). We audio-recorded each FGD and then transcribed and/or translated the recording into an English transcript. We typed the short notes directly into English. We used the transcription and translation services within the qualitative research core at the study facility, and the final transcripts were reviewed for accuracy by the respective FGD facilitator. Peer mentors were involved in organizing the FGDs to ensure that the sessions were lively and youth-friendly.

FGD Guides

We developed the initial FGD guides using team knowledge and experience in qualitative research work, and pilot tested it within the study team first. Each FGD for the four target groups was modified for content to be most pertinent to that group (e.g., for AYPLHIV, we asked about their first-hand experiences, while for providers we asked about their observed experiences of providing care to AYPLHIV). Reflecting on the conduct of each FGD and insights gained from the FGD short notes, we iteratively improved on the development of subsequent FGD guides for both that group and other groups. The FGD guide largely focused on deepening understandings of perspectives, feelings toward, and choices of people living with HIV in regards to LA ART and family planning. The guides covered the following four main domains: (1) living with HIV as an adolescent or providing care, advocating, or policy-making for such individuals; (2) perspectives on adolescents using long-acting reversible family planning; (3) perceived advantages or disadvantages of LA ART; and (4) health system readiness for large-scale LA ART rollout. We had not a priori planned to examine the role of peer mentors in LA ART implementation, but related themes arose under the domain of health system readiness. Within each domain, when interrogating specific points, we developed probes based on each level of the socioecological model.³³ For example, for perceived advantages of LA ART, we included probes from the individual to the policy/cultural levels. However, this analysis itself did not employ this model in its analysis or presentation of data. The guides can be found in the Supplementary material.

Data Analysis

We utilized the qualitative analysis software Dedoose (Version 9.0.17, 2021) for coding and initial analysis. We largely used inductive coding, and four team members (DM, SB, WB, and MM), including three peer mentors hired as research assistants, performed the coding under the direct guidance of the research coordinator (SAH), with iterative feedback from the broader research team, including the primary investigators (RCP, EW, EA, and CB) through weekly meetings. Throughout the analysis process, our Kenyan team members verified the emergent themes and subthemes to ensure the results and interpretations resonated with their views, beliefs, or lived experiences.

SAH prepared an initial codebook based on the FGD guides and her read of the first few transcripts. The four research assistants iteratively adjusted the codebook, including parent and child codes or “coding tree,” as transcript coding continued. In the first round of coding, all four coders collectively coded one transcript in a group setting at the same time, with any discrepancies in coding resolved by consensus. In the next round of coding, two coders separately coded a single transcript, and then the group met to resolve any discrepancies. In the third round, the remainder of the transcripts were divided for coding among the four coders, and each coded the remaining assigned transcripts individually, with SAH reviewing and double-coding all transcripts. After coding, the team held a 2-day-long, intensive in-person analysis session in Kenya. We used thematic analysis to identify emerging themes from the codebook.^34,35 The codebook was then reorganized to reflect some overarching themes with subsequent subthemes, both convergent and divergent, and illustrative quotes. We used this codebook to develop analysis memos leading into separate manuscript efforts. Of note, we conducted participant “member check” or vetting of our early findings via dissemination meetings held in-person from July through November 2022 with some FGD participants. All participants were explicitly invited to join these meetings where study staff presented the findings via a prepared presentation, and we elicited participant feedback. One study staff member took notes during these sessions, which we included in the analysis memos stage to help underscore emphasis with certain themes.

Results

Participant Characteristics

We conducted seven focus group discussions with a total of 58 participants, from November 2021 to April 2022, from four key stakeholder groups, including: (1) adolescents and youth, (2) healthcare providers, including peer mentors, (3) health or youth advocates, (4) policymakers (Table 1). For adolescents and youth recruited (n = 14), half were female, below 18 years of age, and had been on ART for 11+ years, majority were in secondary school, and none were married. For the healthcare providers recruited (n = 19), 12 were female, their composition included peer mentors, doctors, nurses, nutritionists, and social workers. The majority had worked in an HIV clinic for more than 5 years and were involved in the provision of ART or family planning. For advocates recruited (n = 16), 10 were female and were drawn from various focuses of advocacy, namely HIV prevention, family planning, youth services, key populations, and mental health. For policymakers recruited (n = 9), six were female and the majority were working within the HIV public sector.

Table 1.

Participant Characteristics for the Focus Group Discussions in the KuwaFree! LiveFree! Study, Kenya, November 2021 to April 2022 (n = Seven Focus Groups, with a Total of 58 Participants).

	Category	N (%)
Variable	Category	Adolescent and youth (n = 14)	Healthcare providers (n = 19)	Health advocates (n = 16)	Policymakers (n = 9)
Gender	Female	7(50)	12(63.2)	10(62.5)	6(67.0)
Gender	Male	7(50)	7(36.8)	6(37.5)	3(33.0)
Age in years		Below 18—7(50)	25 and below—5(26.4)	Below 25—7(43.9)	Below 40—3(33.3)
		18-21—6(42.9)	26-35—9(47.5)	25-30—6(37.7)	40 and above—2(22.2)
		Above 21—1(7.1)	Above 35—5(26.5)	Above 30—3(18.9)	Missing 4(44.5)
Highest level of education	Secondary	11(78.6)	–	–	–
	Some college or higher education	3(21.4)	–	–	–
	Some college or higher education	0
Marital status	Single	14(100)	–	–	–
Occupation		Not employed 11(78.6%)	Clinical Officer—6(31.6)	–	–
		Peer educator 1(7.1)	Nurse—1(5.3)	–	–
		Student 2(14.3)	Nutritionist—1(5.3)	–	–
			Peer mentor—8(42.1)	–	–
			Research assistant—2(10.5)	–	–
			Social worker—1(5.3)	–	–
Services accessed/offered		Type of services accessed at the clinic	Type of services provided at the clinic	Thematic focus of advocacy activities	Area of service
	HIV treatment	14(100)	14(73.7)	3(18.8)	2(22.2)
	HIV prevention	0	13(68.4)	11(68.8)	2(22.2)
	Family planning services	0	10(52.6)	5(31.3)	0
	Adolescent and youth	–	–	12(74.1)	1(11.1)
	Other services	0	12(63.2)^a	5(31.4)^b	2(22.2)
Duration Since ART initiation (years)	≤10	2 (14.2)	–	–	–
	11–20	6(42.6)	–	–	–
	21+	1(7.1)	–	–	–
	Unknown	4(28.6	–	–	–
Length of time worked			Length of time in the position	Duration worked in the organization
		–	<1 year—3(15.9)	<2 years—1(12.5)	–
		–	1–5 years—6(31.7)	2–3 years—3(37.5)	–
		–	>5 years—10(52.9)	>3 years—4(50)	–
Role in organization	Program implementer	–	–	5 (18.8)	3(33.3)
	Service provider	–	–	4(25)

Sector engaged	NGO	–	–	10(62.5)
	CBO	–	–	9(56.3)
	None	–	–	2(12.5)
	Private	–	–	3(18.8)
	Public	–	–	1(6.3)	5(55.5)

Abbreviations: ART, antiretroviral therapy, CBO = community-based organization, NGO = nongovernmental organization.

Adherence counseling, monitoring viral load, helping in financial support, pediatrics research, retention, training on stigma and disclosure and HIV care, treatment of comorbidities, nutrition education, and counseling.

Key populations, mental health promotion.

In this analysis, we identified three dominant themes related to the role of peer mentors in implementing LA ART, especially in the context of integrated services with family planning. These themes centered on the following three questions:

Why are peer mentors so important here?

How exactly can peer mentors help with LA ART implementation? and

What tools do peer mentors need to support LA ART implementation?

Below we detail each theme with its subthemes and supporting quotes, noting both points of convergence and divergence among the four subgroups sampled when present (Table 2).

Table 2.

Themes, Subthemes, and Quotes From Stakeholders About Peer Mentors and LA ART, KuwaFree!-LiveFree!.

Theme	Subtheme title	Subtheme description	Example quotations
1. Why peer mentors?	1a. Facilitating communication	Peer mentors help adolescents communicate openly within the health system by creating a friendly environment where adolescents feel comfortable sharing their needs.	“I think it is a good idea because the peer mentors know their adolescents more than the doctors because they interact more. It is a good idea” (Adolescents FGD 3)
			“For me I can see it is a better option because maybe most of the time the peer mentor is mostly with the youths most of the time. They interact more than the doctor because you find that you are with the peer mentor most of the time. For the doctor, you meet them once in a while.” (Adolescents FGD 3)
			“I can say they are okay because when you look at the peer mentors, those are the people who understand the youths better because they are also there, they are the same ones that spend time with them on activities out there. So they are always with them. So if they give information to the other adolescents, there will be more understanding. They will understand it better. But for a doctor to explain, they will use a mixed language. Also freedom, there will be no much freedom like number 4 has said. So my point is that they relate on the same environment.” (Adolescents FGD 4)
			“For me I am working at Rafiki clinic as a peer mentor… the moment you create rapport with them, they will open up. For some it might be difficult but they can open up ….” (Healthcare provider FGD 1)
			“And then at the same time again they fear about their confidentiality. They think that when they open up to you, you are going to share [with others]. As much as you are providers, all of you, they don’t like that thing of sharing everything with the other health care providers.” (Providers-FGD 1)
	1b. Facilitating referrals	Peer mentors play a key role in integrating adolescents into different services by facilitating referrals for various departments.	“…certain facilities that have been able to adopt integrated service delivery and even when they are doing a referral from one service point to the other, they have a peer sort of help with that.” (Policymaker FGD 6)
	1c. Empathy from lived experiences	Adolescents view peer mentors as empathetic because they share similar lived experiences.	“I can also share my experience with them [adolescents] to see that if they are in the same shoes with me, they see hope in me that they can be like me after some time. I also do support groups to enable each group to hear my experience and see what challenges they face in school or may at home.” (Peer Mentor FGD 1)
			“So how they cope with school, school calendar with the drugs, how they are faring with their challenges and how they overcome them. If there is difficulty, I can share my experience.” (Peer Mentor FGD 1)
			“I am also a peer mentor and a self-proclaimed health ambassador but my experience with adolescents is interesting. It is kind of interesting working with the adolescents because you get to understand some of the things that adolescents go through. You get to find different challenges that young people go through and getting to assist them is something that I have been working on” (Healthcare provider FGD 1)
2. What role do peer mentors have for LA ART rollout?	2a. Serve as early adopters or role models	As role models, peer mentors provide positive peer influence to improve the uptake of LA ART.	“You know adolescents are people who go with the masses. I look at what my other friends are doing and then I follow through to make sure I am also with them. So if this adolescent who is unsuppressed finds that there is a long acting medication, they would truly like to be in because most of them as I said HIV is more of a community infection and so the issues surrounding the community is what is making them maybe not take medication-the pill burden, stigma in school, fear of unknown, right” (Peer Mentor FGD 1)
			“Yes, peer education because you find that I have certain knowledge, my friend here has certain knowledge. Maybe number 1 may say; ‘oh, so this is a good method of family planning, maybe I should try’. That is because of peer education. Peer to peer are free with each other.” (Adolescents FGD 4)
			“I think it is a good idea because the peer mentors know their adolescents more than the doctors because they interact more. It is a good idea.” (Adolescents FGD 3)
			“The support that comes from the family and health facilities is very important. The support that has really worked for us with peers is them meeting with people of their kind makes them feel they are not alone, and it is not a life-threatening disease if you take it positively. With that, they are now able to encourage one another and even take responsibility.” (Healthcare provider FGD 2)
			“They are really doing very well in life having taken career paths that they can show. That one really encourages the adolescents to adhere to their adherence.” (Healthcare provider FGD 2)
	2b. Navigate service points	Peer mentors assist adolescents in navigating clinic services, especially comprehensive care models that include family planning in youth-friendly adolescent clinics.	“Very honestly I think that will be a challenging thing or a very tricky thing. I can imagine for example Uasin Gishu District where MCH has a combination of all women age groups. Most of the time I have seen young people walk out because they are being mixed with mothers who are really stigmatizing them and discriminating them. I think as much as the family planning is being dropped to the CCC, what we had discussed earlier, there should also be a separation of adolescents and the married because if they are brought to the family planning and for example, I am seated in a line with somebody who knows my mother, as much as I am going for family planning it will raise some issues.” (Advocate FGD 5)
			“The peer mentors are the people who understand the youths better because they are also there, they are the same ones that spend time with them on activities out there. So they are always with them. So if they give information to the other adolescents, there will be more understanding.” (Adolescent Youth FGD 4)
			“Then they (peer mentors) advise on those contraceptives.” (Adolescents FGD 3)
	2c. Messaging on LA ART	Peer mentors can help with messaging about LA ART, using platforms like social media and WhatsApp to reach adolescents.	“…we can use flyers so that we disseminate to the adolescents, we can use the adolescents WhatsApp groups, and we have [social] media to educate the population about the injections and the support groups” (Healthcare provider FGD 2)
			“I am feeling that peer mentors need to have enough information about these long-acting medication. Enough information from the long-acting medication. Contraceptives and the interaction between the two so that it will be easier for us to understand. You know with adolescents, they will be able to answer all those questions, that maybe the adolescent may have before they are recruited for the study because if you just tell them I want to put you on long acting and you don’t give them much information, you fear of what can happen, how will it interact with the rest of the people? (Adolescent FGD 3),
			“Even in terms of personnel, the clinics also have been having task shifting. We rely on CCC assistants, we have been relying on retention peers to support the clinic but now you realize the injection will require either a nurse or a clinician to give and that might be overwhelming to the clinic and also the supplies. We need the syringe, we need the needles. Are we ready for that? I don’t think so.” (HCP-FGD 2)
3. What training needs do peer mentors have in regards to LA ART rollout?	3a. Training	Peer mentors need comprehensive training on LA ART to effectively answer adolescents’ questions and facilitate future referrals.	"I am feeling that peer mentors need to have enough information about these long-acting medication…, You know with adolescents, they will be able to answer all those questions, that maybe the adolescent may have before… you just tell them I want to put you on long acting and you don’t give them much information, you fear of what can happen, how will it interact with the rest of the people? Peer mentors need to have this information themselves so that even before an adolescent goes to the doctor, most of the questions they have about fear of the unknown will be answered…” (Adolescent FGD 3)
	3a. Training		“I actually have the same feeling that because it is a new product that we are bringing in, before integrating it first let us start by ensuring that they place it in CCC, the people living with HIV, the young people living with HIV are well equipped with information …” (Advocate FGD 5)
	3b. Mechanism for involvement	A structured system is needed to involve peer mentors in scaling up LA ART, including gathering their input on messaging.	“In terms of messaging, as a youth and an adolescent, I think we should be involved in the creation of the content that should be on those flyers because we as youth we know what we identify with and what our peers can easily identify with. Therefore, when the technical team will be sitting to develop the communication materials, we should be looked in as advocates.” (Advocate FGD 7)

Abbreviations: LA ART, long-acting antiretroviral therapy; FGD = focus group discussion; CCC = comprehensive care clinic (which is the term used for HIV care clinics in this part of Kenya).

Theme 1: Why Are Peer Mentors So Important Here?

In articulating why the various stakeholders felt peer mentors were important to the implementation of LA ART for AYLPHIV, three subthemes emerged: (1) for facilitation of communication, (2) for facilitation of referrals, and (3) due to having empathy from their lived experiences.

Subtheme 1a: Facilitating Communication

In the first subtheme of facilitating communication, the stakeholders stressed that peers play a crucial role in facilitating communication and creating a friendly encounter within the health system for young individuals to express their needs. Youth have their own ways, own language, and their approach to communication that is different than others (eg, through the use of slang), so their approach to communicating with providers is different. Because of AYPLHIV being able to relate more easily with peer mentors, some even suggested that AYPLHIV will more easily disclose their concerns to peer mentors over other types of health providers. Thus, having peer mentors, who themselves use more youth-friendly ways of communicating, would be crucial to help facilitate optimal communication. One participant went as far as to suggest that appearing more “youth-friendly” alone can go a long way in communicating more effectively with AYPLHIV:

Also, the person who will be facilitating the session or rather giving the information should not be like a person who looks like more of a parent, for lack of a better word. Not a person looking like more of a parent to them. It should be someone who is youthful, someone who is quite engaging, someone who is a bit humorous, who is youth friendly in short. (Advocate-FGD 7)

Subtheme 1b: Facilitating Referrals

In the second subtheme of facilitating referrals, peer mentors were deemed valuable in referring and integrating clients into various services, as they seamlessly fit into all departments and provide referrals, education, and social support. Even within integrated service delivery models, exact service points are spread throughout a facility, and peer mentors would be most adept at navigating the referrals and helping the AYPLHIV make connections with those service points.

Subtheme 1c: Empathy From Lived Experiences

In the third subtheme of empathy from lived experiences, peer mentors were considered particularly empathetic due to their own lived experiences and perceived as unlikely to judge AYPLHIV compared to other healthcare providers, especially when accessing family planning and other reproductive health services.

Theme 2: How Exactly Can Peer Mentors Help With LA ART Implementation?

In articulating what roles peer mentors would play in LA ART implementation, three subthemes emerged: (1) serving as early adopters, (2) supporting navigation of service points, and (3) messaging on LA ART. We do note that despite the overall enthusiasm for the use of peer mentors for LA ART among AYPLHIV, healthcare providers highlighted potential limitations to the role of peer mentors here, articulating that, for instance, complex cases or addressing major side effects would require a higher cadre of healthcare providers to manage.

Subtheme 2a: Serve as Early Adopters or Role Models

In the first subtheme of serving as early adopters or role models, the stakeholders echoed that peers can play a crucial role in promoting the uptake of LA ART at health facilities. Healthcare providers also brought to the attention that it helps for AYPLHIV to believe what they see and hear, so that when they see peers in the hospital doing well, healthy, and adhering to ART, it makes them believe they too will be well when they take their ART. They argued this would apply even more so to LA ART, by the way of peer mentors serving as role models. Thus, by AYPLHIV seeing peers there on LA ART, they will be able to resonate with the usage of LA ART.

Subtheme 2b: Navigate Service Points

In the second subtheme of navigating service points, it was echoed that peers can support and assist AYPLHIV with navigating clinic service points, particularly in integrated settings and especially for family planning. There are different service points, even in adolescent's comprehensive care clinics that have a one-stop-shop-all approach, e.g., where HIV and family planning services are offered in the overall same facility. However, often both are not provided by the same provider or at the same service point. Thus, AYPLHIV are referred from one service area to another, and gaps in care arise due to difficulty in moving or fear of stigmatization from one service point to another. Peer mentors would be adept at navigating these service points, and would, thus, be able to reduce gaps in care or missed visits. It was also suggested that peer mentors can provide AYPLHIV emotional or moral support while navigating these service delivery points.

Subtheme 2c: Messaging on LA ART

In the third subtheme of messaging on LA ART, peers were perceived to play a significant role in conveying necessary messages about LA ART. As already noted, peer mentors understand the language and preferences of adolescents and youth, so they can amplify appropriate, authentic messages to engage AYPLHIV. The stakeholders identified specific modalities through which peer mentors can lead messaging on LA ART for AYPLHIV. Peer-to-peer messaging, e.g., through group chats or messaging apps, can foster genuine conversations, build stronger relationships between the group members, and foster improved use of clinical services for AYPLHIV. Given the prominence of social media for youth, it was felt that peer mentors can lead developing, packaging, and disseminating adolescent-friendly education materials about LA ART using social media, given their own personal knowledge and expertise with social media. In addition, peers can identify targeted outreach activities and provide calls to action that inspire their fellow peers to engage in or take the next step. Of note, healthcare providers specifically stressed that peer mentors can sometimes feel overconfident in their knowledge and that additional training for LA ART would need to occur with peer mentors to ensure the prevention of generating misinformation.

Theme 3: What Tools Do Peer Mentors Need to Support LA ART Implementation?

While appreciating that peer mentors would be critical to LA ART implementation, stakeholders also recognized that peer mentors needed tools to support them, including subthemes of: (1) training and (2) vehicles of involvement to involve peer mentors.

Subtheme 3a: Training

In the first subtheme of training, participants noted that in order for peer mentors to help support LA ART implementation, they would themselves need additional training:

I am feeling that peer mentors need to have enough information about these long-acting medication…, You know with adolescents, they will be able to answer all those questions, that maybe the adolescent may have before… you just tell them I want to put you on long acting and you don’t give them much information, you fear of what can happen, how will it interact with the rest of the people? Peer mentors need to have this information themselves so that even before an adolescent goes to the doctor, most of the questions they have about fear of the unknown will be answered… (Adolescent FGD 3)

Specifically, they would need training on elements related to LA ART. The focus for training peer mentors was perceived as being the organization of the services, the basic information on LA ART, its side effects, and how it is integrated into the existing ART services to address adherence challenges occasioned by youths’ social activities, including school- and entertainment-related circumstances. Such training would enable peer mentors to improve their capacity to attend to adolescent issues properly. Interestingly enough, participants suggested that training for LA ART could help peer mentors also build their self-confidence in discussing sexual reproductive health with their peers given the significant overlap in long-acting modalities for ART and family planning. It was also noted that the training needs for other healthcare providers, such as nurses or doctors, and peer mentors are different but should also be complementary. Additionally, training of health care providers to be able to augment or support the information given by the peer mentors was deemed important in facilitating the functions of the peer mentors. The participants emphasized the importance of all healthcare providers being well trained and conversant with the messages peer mentors would be giving to the AYPLHIV. Nonetheless, policymakers did question the logistical and cost implications of peer mentor when the costs of LA ART itself are anticipated to be high.

Subtheme 3b: Mechanism for Involvement

In the second subtheme of mechanism for involvement, it was recognized that national programs, as they consider the rollout of LA ART, should consider putting in place mechanisms for peer mentor involvement in their scale-up. The most prominent space that this consideration arose regarded in gathering peer mentor input in messaging about LA ART. Peer mentors would need specific resources to enable them to support the scale-up of LA ART, such as access to making flyers and posters with information about LA ART or airtime for social media campaigns. Overall, it was acknowledged that peer mentors can play a key part in policy formulation that enables easy LA ART implementation, yet all the vehicles or mechanisms for their involvement were not obvious just yet.

Discussion

In this formative qualitative study involving various stakeholders, from AYPLHIV, peer mentors and other healthcare providers, advocates, and policymakers in Kenya, participants clearly articulated the likely critical role peer mentors may play in LA ART implementation for AYPLHIV. The AYP and the policymakers identified specific roles for peer mentors, particularly, in facilitating the linkage of the AYP with services throughout the facilities and increasing the AYP perception of the clinic as youth-friendly. They also highlighted that peers can play a key part in messaging that can enable LA ART implementation. Healthcare providers emphasized additional training needs for peer mentors while policymakers raised cost concerns of involving peer mentors for what is anticipated to already be a costly HIV treatment option. While LA ART can potentially address some of the challenges the AYPLHIV face in achieving medical adherence and viral suppression, this benefit can only be realized if they become fully aware of, take up, and adhere to the new technologies such as LA ART. Structured involvement of peer mentors is perceived by stakeholders as one approach to optimizing the uptake of LA ART by AYPLHIV.

To date, this is the first article that highlights the role of peer mentors in LA ART implementation for AYPLHIV in settings such as Kenya. Exploring why the peer mentors are needed, stakeholders point to several key considerations. Peer mentors by definition will be persons of nearly the same age and who will have had similar experiences as the AYPLHIV. They are perceived by AYPLHIV as more empathetic and more likely to maintain confidentiality of private health information than traditional health providers who may be older and less able to identify with AYPLHIV. Studies concur with the perception that AYPs are likely to be more receptive to information promoting the uptake of HIV care from peer mentors.^14,16

One characteristic of youth-friendly services is having comprehensive care or multiple services under the same “roof” (e.g., one-stop shop-all).³⁶ However, in reality, it is likely that services such as comprehensive HIV care and family planning services, which constitute responses to the double threat of sexually transmitted diseases and HIV and unplanned pregnancies that AYPLHIV face, are found in different locations within one health facility. Navigating intrafacility referral for services that are not co-located is a challenge for the AYPLHIV, arguably the same for all patients, that peer mentors can help mitigate.³⁶ Peer mentors are not only more likely to create a rapport with AYPLHIV on matters related to sexual behavior and use of contraception, considering the challenges of discussing such issues among persons of significantly different ages than traditional health care providers, but they can also assist AYPLHIV to navigate the movement between multiple points of care so as to maximize their overall visit. Of note, findings regarding points of convergence between LA ART and contraception are forthcoming as a separate analysis from our work. Consequently, proximity in age, having lived experiences, and knowledge of points of care would make peer mentors a valuable asset to a health system attempting to roll out the use of LA ART. We also note other roles that peer mentors can play that our study did not explore, i.e., tracing clients, doing adolescent follow-ups, facilitating risk reduction topics, adherence counseling, and clinic reminders. Overall, therefore, having a peer who understands the care system, has utilized the services before (including LA ART), and is knowledgeable about the side effects and how to navigate the product prescription requirements within the AYP's social environment would be a powerful incentive for other youths to consider the uptake of new products such as LA ART.³⁷ Consequently, the perceived role for peer mentors would be that of relaying health messages relating to LA ART, using their lived experiences to counsel AYPLHIV to understand the use of LA ART and assisting them to navigate the health service points.

Regarding what peer mentors need to function optimally in their perceived roles, stakeholders identified the need for implementers to develop messaging tools that involve peer mentors in LA ART implementation. The primacy of relevant training of the peer mentor on the new product and the appropriate messaging needed to adequately and accurately inform AYPLHIV about LA ART was also noted.³⁸ To allow peer mentors to lead messaging roles, the need for training, akin to interprofessional training, emerged in our findings.³⁹ Interprofessional learning or training constitutes integrated training that is cadre-specific but where specific members of the service provision team (in this case, including peer mentors) are trained together for different roles and where the higher cadres are also aware of the information the lower cadres are giving to the patients. Such training mutually reinforces unified messaging for patients. The importance of youth and peer mentor involvement in designing messages for dissemination using contemporary and youth-friendly media, such as smartphone-based platforms, including WhatsApp, and other social media forums, was another highlight from our findings.⁴⁰ Clearly, the doctrine of “nothing for us without us” appeared heavily embedded in these views.^41–43

Ultimately, existing peer mentor models for HIV care in LMICs may need to be adapted for the nuances of LA ART, including for differences in treatment administration route and frequency. This may require different adherence strategies than those that have existed for oral ART to date, based on early lessons learned from LA ART in high-income countries.^44,45 Unlike traditional oral ART, LA ART involves infrequent but precise dosing schedules, making peer mentors’ role crucial in ensuring patient adherence to injection appointments. Additionally, due to the infrequent dosing but critical timing of injections in LA ART, peer mentors may need to intensify efforts in patient tracing and retention, potentially engaging in home visits or community outreach. LA ART also presents new challenges, requiring peer mentors to provide additional training on managing side effects and counseling patients through concerns about injections. An additional consideration may include using peer mentors in selection processes that prioritize peers to receive LA ART when it is first rolled out in limited phases or if LMICs choose limited use of LA ART—a potentially contentious process. As national programs consider scale-up of LA ART, peer mentors should be included in these discussions, especially for AYPLHIV.

Study Limitations and Strengths

Despite the strengths of our study, it faces some limitations. First, the study clinic we recruited from is very specialized and unique, in that it offers youth-friendly, integrated services in an arguably more optimized manner than others. Therefore, the insights and past experiences of the AYP and health providers may be highly biased, and not easily transferrable to other settings within Kenya or other low- or middle-income country settings. Second, the policymakers we recruited were largely persons working at the programmatic level rather than at the national level, and, therefore, their views are aligned to unique programmatic challenges and may not be more broadly applicable to national guideline making. Third, we acknowledge that our FGD guides did not have a prior plan to examine the role of peer mentors in LA ART; rather this emerged from discussions on the domain of health systems readiness for LA ART. Thus, it is possible we failed to examine in depth various dimensions of peer mentor roles in LA ART implementation.

Nonetheless, our study includes several strengths. First, the study team and participants included peer mentors who were involved with youth services on a day-to-day basis and guided by their own lived experiences. Second, we garnered input from a variety of stakeholders involved in care for AYPLHIV, from healthcare providers to policymakers to health advocates. The commonality of the themes identified across these diverse groups makes our findings compelling.

Conclusion

In conclusion, various stakeholders in Kenya perceived peer mentors to be key for LA ART implementation, including for communication and referral navigation for AYPLHIV. Lastly, involving peer mentors in the development of youth-friendly LA ART messages and training peer mentors, alongside the other health workers, also emerged as important themes. As national programs begin the scale-up of LA ART for various subpopulations, peer mentors should be included in implementation plans, especially for AYPLHIV.

Supplemental Material

sj-docx-1-jia-10.1177_23259582241303579 - Supplemental material for Stakeholder Perspectives on the Role of Peer Mentors in the Implementation of Long-Acting Antiretroviral Therapy for Use by Adolescents and Young People in Western Kenya: Findings from a Formative Study, KuwaFree! LiveFree!

Supplemental material, sj-docx-1-jia-10.1177_23259582241303579 for Stakeholder Perspectives on the Role of Peer Mentors in the Implementation of Long-Acting Antiretroviral Therapy for Use by Adolescents and Young People in Western Kenya: Findings from a Formative Study, KuwaFree! LiveFree! by Salim Bakari, Biegon Whitney, Munyoro Dennis, Shukri Hassan, Caitlin Bernard, Eunice Kaguiri, Mehar Maju, Edith Apondi, Edwin Were and Rena C. Patel in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Supplemental Material

sj-docx-2-jia-10.1177_23259582241303579 - Supplemental material for Stakeholder Perspectives on the Role of Peer Mentors in the Implementation of Long-Acting Antiretroviral Therapy for Use by Adolescents and Young People in Western Kenya: Findings from a Formative Study, KuwaFree! LiveFree!

Supplemental material, sj-docx-2-jia-10.1177_23259582241303579 for Stakeholder Perspectives on the Role of Peer Mentors in the Implementation of Long-Acting Antiretroviral Therapy for Use by Adolescents and Young People in Western Kenya: Findings from a Formative Study, KuwaFree! LiveFree! by Salim Bakari, Biegon Whitney, Munyoro Dennis, Shukri Hassan, Caitlin Bernard, Eunice Kaguiri, Mehar Maju, Edith Apondi, Edwin Were and Rena C. Patel in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Footnotes

Acknowledgments

We acknowledge the remarkable contributions of young people to the fight against HIV and for sexual and reproductive health care. We acknowledge and thank the clinicians, adolescents, youth, and peer mentors who contributed to the success of this study. We also acknowledge the lead PIs and the technical team who served as mentors to their peers all through this journey.

Author Contributions

The peers SB, WB, and DM contributed to data collection, data analysis, and manuscript writing; EW, SAH, CB, RCP, and EA provided leadership and mentorship to the team. SB wrote the first draft with iterative input from EW and RCP. All authors contributed to the preparation of the final manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Sharing

All data, including transcripts and codebooks, can be made available upon responsible request to the corresponding author.

Competing Interests

The authors declare no competing interests.

Ethics Approval and Consent to Participate

This study underwent ethical review with the Institutional Research and Ethics Committee at Moi University in Kenya (0003912). It was also reviewed and approved by Human Subjects Division at the University of Washington IRB in the United States (00012640). We also received approval from MTRH CEO for the study to be done at MTRH. Participants provided informed consent before commencing the FGDs. Confidentiality was assured by the use of pseudonyms.

Informed Consent

Participants provided written informed consent for participation and inclusion of their de-identified data for publication.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The overall study, data collection, and data analysis was supported by the National Institute of Allergy and Infectious Diseases (NIAID, R01AI155052) Division of Microbiology and Infectious Diseases (grant number R01AI155052).

ORCID iD

Salim Bakari

Supplemental Material

Supplemental material for this article is available online.

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