Peer counselors' role in supporting patients' adherence to ART in Ethiopia and Uganda

Abstract

Our aim was to explore peer counselors' work and their role in supporting patients' adherence to antiretroviral treatment (ART) in resource-limited settings in Ethiopia and Uganda. Qualitative semi-structured interviews were conducted with 79 patients, 17 peer counselors, and 22 providers in ART facilities in urban and rural areas of Ethiopia and Uganda. Two main categories with related subcategories emerged from the analysis. The first main category, peer counselors as facilitators of adherence, describes how peer counselors played an important role by acting as role models, raising awareness, and being visible in the community. They were also recognized for being close to the patients while acting as a bridge to the health system. They provided patients with an opportunity to individually talk to someone who was also living with HIV, who had a positive and life-affirming attitude about their situation, and were willing to share personal stories of hope when educating and counseling their patients. The second main category, benefits and challenges of peer counseling, deals with how peer counselors found reward in helping others while at the same time acknowledging their limitations and need of support and remuneration. Their role and function were not clearly defined within the health system and they received negligible financial and organizational support. While peer counseling is acknowledged as an essential vehicle for treatment success in ART support in sub-Saharan Africa, a formal recognition and regulation of their role should be defined. The issue of strategies for disclosure to support adherence, while avoiding or reducing stigma, also requires specific attention. We argue that the development and implementation of support to peer counselors are crucial in existing and future ART programs, but more research is needed to further explore factors that are important to sustain and strengthen the work of peer counselors.

Keywords:

• adherence
• antiretroviral therapy
• disclosure
• HIV/AIDS
• peer counselors
• support
• sub-Saharan Africa
• qualitative research

Acknowledgements

John Chalker, Celestino Obua, Tenaw Andualem, and Rolf Wahlström designed and planned the study. Tenaw Andualem and Celestino Obua selected facilities for the study in their respective countries, helped to train data collectors, carried out the study, and assisted in the analysis of the data. Annelie K. Gusdal, Rolf Wahlström, and Grethe Fochsen performed the major part of analysis and the main writing of the article. All authors have commented on article drafts and read and approved the final text.

The authors would like to acknowledge the other members of the INRUD Initiative on Adherence to Antiretrovirals, which include staff at the national AIDS control programs, local INRUD groups, and local Management Sciences for Health offices in Ethiopia, Kenya, Rwanda, Tanzania, and Uganda, as well as staff in partner organizations: Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA; Division of Global Health, Karolinska Institutet, Stockholm, Sweden; Center for Pharmaceutical Management, Management Sciences for Health, Arlington, USA; and Department of Essential Medicines and Pharmaceutical Policies, World Health Organization, Geneva, Switzerland.

We wish to express our gratitude to all patients and health-care personnel in Ethiopia and Uganda who contributed to this study by sharing their experiences, ideas, and thoughts with us. We also thank the Ministries of Health in both countries, the National AIDS Control Program in Uganda and DACA in Ethiopia for supporting and facilitating our work.

This study was made possible through support provided to Management Sciences for Health by the Swedish International Development Cooperation Agency, under the terms of contribution 72300310, the World Health Organization under an Agreement for Performance of Work OD-AP-07-00516, and by the Rational Pharmaceutical Management Plus Program, which is funded by the US Agency for International Development, under the terms of Cooperative Agreement number HRN-A-00-00-00016-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the Swedish International Development Cooperation Agency, the World Health Organization or the US Agency for International Development.