Introduction

Adolescents living with HIV (ALHIV) have worse outcomes in terms of treatment, viral load suppression and mortality than do HIV positive children and adults. In sub-Saharan Africa, where 80% of the global total of 1.74 million ALHIV reside [1], they are the only group for whom mortality rate is increasing [2]. The evidence indicates that across chronic illnesses adolescents find it more difficult to sustainably comply with their treatment regimens than do people of other ages [3]. Adherence to HIV treatment is further complicated by the many adverse social consequences of having an HIV positive status [4, 5].

There is also an emerging recognition of the substantial unmet mental health needs of ALHIV, who have higher rates of depression and other common mental health problems than do their HIV negative peers [6, 7]. Although still an emerging area of enquiry, this is considered to be due to both the burden of HIV management and the higher likelihood that an adolescent living with HIV has experienced serious loss in various forms. In Sub-Saharan Africa where the burden of adolescent HIV is concentrated, a fifth of children in southern Africa are orphans, predominantly due to HIV [8]. There are frequently associated losses following parental death including household mobility, separation from siblings, loss of belongings, and disrupted school attendance, compounded by extreme poverty and pervasive stigma and discrimination [9], all of which are factors that contribute to the development of psychological problems [10]. Increasingly there is a connection being made between mental health and wellbeing with adherence and viral load suppression [4, 11–13]. Although the understanding of the relationships between mental health and HIV outcomes is still evolving, there is an increased recognition of the potential effect of attending to mental health as an important outcome in itself, but also tackling the psychological problems that play a role in poor adherence in ALHIV as a means to progress towards achieving the ambitious global target of 95% of those on Anti-retroviral therapy (ART) to be virally supressed [14–16].

In Zimbabwe and throughout the region, clinical services for mental health care are extremely limited, due to a lack of human resources and of service delivery programs, with fewer than 1 psychiatrist per 1,000,000 population and a similarly small number of psychologists [17]. Child and adolescent psychiatrists are all but non-existent. Scarce available care is concentrated in urban settings. In rural settings mental health care is largely delivered by a very small cohort of mental health nurses [17]. Given the lack of existing mental health resources and the urgency and scale of the unmet need, we need to look for alternative mechanisms through which the problem can be addressed [14, 18].

Peer support, which has been shown to have a promising impact on viral suppression and is being delivered at scale [18], may be one potential pathway. A recent trial of the Zvandiri peer support model, which uses differentiated service delivery, showed an increase of viral load suppression among ALHIV of 42% compared to standard care [19]. Despite enthusiasm and donor funding for peer support, its impact on beneficiaries and on the peer supporters themselves has received relatively little empirical attention [20–22]. Also, to date peer support among ALHIV has focused primarily on prevention and general psychosocial support and has not delved into addressing more complex issues associated with common mental health disorders.

In this paper we present the qualitative findings from the Zvandiri–Friendship Bench study, a mixed methods study including a cluster randomised controlled trial, examining the effectiveness of peer-delivery of mental health care on viral suppression and mental health among ALHIV over a period of 12 months, utilizing a problem-solving therapy intervention (Friendship Bench) [23]. Friendship Bench is a community based psychological support organization where lay cadres implement Problem Solving Therapy (PST). The model has been shown to be effective among adults [11, 24–26], but this is the first time that it has been adapted to be delivered by young people for ALHIV, with the delivery done by Zvandiri’s Community Adolescent Treatment Supporters (CATS). We explore the perspectives and needs of young peer supporters as described by themselves when they take on the complexities of expanding their role to addressing the difficult life experiences that challenge the mental health of their peers. Based on our analysis of their accounts, we develop a framework outlining the overarching support and training principles (TRUST) that should be provided to guide the expansion of the peer supporter’s role in delivering critically needed mental health care to ALHIV.

Methods

The study was conducted in rural districts in Zimbabwe in 2018–2019. Sixty clinics within 10 districts were randomised 1:1 to either the intervention or control arm. ALHIV attending the control arm clinics received standard CATS support. Those attending the intervention arm clinics received support from CATS with additional training from Friendship Bench. The intervention consisted of standard CATS support plus a series of individual sessions focused on identifying the problems a young person was facing that were making their life difficult and exploring the support needed and strategies they could employ to improve their coping and resilience [23].

The CATS were recruited using standard Zvandiri selection criteria, including: aged 18–23, HIV positive, virally suppressed, able to read and write, psychologically stable, and able to serve as a role model. All CATS had received the standard initial 5-day CATS training focused on understanding HIV and its treatment, including psychosocial aspects of living with HIV, basic counselling techniques and support strategies enabling them to work within Ministry of Health and Child Care facilities providing adherence support and outreach to children and young people living with HIV in their communities. In addition, CATS delivering the intervention received a 5-day training from Friendship Bench. There were 2 PST trained CATS in each of the 30 intervention facilities. Trial participants, ALHIV aged 10–19 were recruited from the ART registers and screened for common mental disorder using the SSQ-14 [23].

In order to better understand the process of the CATS’ implementing Friendship Bench’s PST model to address depression and anxiety in their peers, we collected qualitative data to capture concurrent and retrospective accounts of the CATS’ experiences of delivering mental health support to clients (Table 1). Case reviews (CR) between 20 individual CATS and their mentors were conducted each month, when feasible, over the 12-month trial duration. Two focus group discussions (FGD) were held with 20 CATS at the end of the trial. Conducted by Zvandiri researchers at the Zvandiri offices in Harare, the FGDs lasted approximately 90 minutes and involved a range of activities to facilitate reflective discussions about their experiences.

Table 1

Qualitative data collection description.

Method	Outline of method	Purpose of data collection	Timing	Sample	Total data collection points
Case Reviews	Individual supervisory discussions (between CATS and mentors) about client cases	CATS’ experiences of provision of support and support needs in real-time	Each month over course of trial (Jan-Dec 2019)	2 CATS in 10 intervention districts (n = 20)	N = 200 (feasibility constrained completion each month)
Focus Group Discussions	Group discussion between CATS	Retrospective reflections of CATS’ on their experiences	End of trial (January 2020)	20 CATS (10/ group)	N = 2

The case reviews and FGDs were conducted in the local languages and audio recorded. They were transcribed and translated into English. The CR transcripts generally ranged from 500–1000 words. A thematic analytical approach was adopted [27]. After extensive reading of the datasets, the FGDs and approximately 20 CRs were open coded by CW, AM, SC and SB. A coding framework was developed which was then applied to the remaining data. The datasets were first analysed separately and then comparatively attending to any differences between them. Analytical memos and weekly analytical team meetings were also used in the development of themes and identification of patterns related to CATS experiences across the datasets [28]. To maximise the value of this thematic analysis, we organized the key implications from our analysis into a framework of guiding operational principles to ensure that CATS are adequately supported to conduct mental health support on a sustained basis.

Ethics approval was given by the Medical Research Council of Zimbabwe #A/2324. The CATS provided written informed consent.

Results

In the CATS’ accounts of supporting their peers who were dealing with depression and anxiety, participants described a number of challenges in their experiences. We identified three overarching themes. These were: the process, described as the journey, of learning to talk about mental health problems; support structures and strategies for the CATS to deliver sustained care; and the critical role of support and supervision. The journey, learning to talk about mental health problems further broke down into four sub-themes: strengths of peer supporters, challenges in ‘moving into mental health support, the complexity and relational embeddedness of the problems faced by ALHIV, and making it ‘less bad’: revised definitions of success.

We present the findings from both the FGDs and CRs together, as the main themes identified were consistent across the two datasets. In our presentation of data extracts we note the different sources and districts they come from.

Discussion

Meeting the mental health needs of ALHIV is a critical aspect of providing care to this vulnerable population. Peer supporters can be an effective cadre to helping improve the health of their peers [16, 18]. However, as demonstrated in this study and elsewhere [17] the very things that make a peer supporter effective, including an understanding of the challenges of being a child or adolescent living with HIV based on lived experience, at the same time put them at emotional risk when they engage in the provision of care and support. They, too, face the problems and vulnerabilities related to living with HIV: including stigma and discrimination, orphanhood, poverty, medical problems and so on. Additionally, the complexity and relationally embedded nature of many of the problems encountered largely rest in the social environment as opposed to being internal to the ALHIV. This renders them not necessarily ‘fixable’. The CATS can instead seek to ameliorate the harms of these structural problems.

As the CATS described their experiences of engaging with the complex problems faced by their peers, we were able to identify what support needs they had to be able to do the work effectively and without harm to themselves. We highlight the key areas that need operational attention if we are to responsibly shift first-line care to this cadre of young people. Attending to the lessons identified within this qualitative study, the authors developed a framework of principles to address the needs of young peer-supporters, TRUST (training, referral pathways, understanding the remit of their role, supervision and mentorship, talking) to guide program development and service delivery.

Talking

In Zimbabwe and throughout the region, depression and other mental health conditions are commonly stigmatised to varying extents [11] and young people are discouraged from talking about them [33]. Whether through using a formalized screening tool or general screening questions about mental health difficulties, peer supporters need specific wording for how to approach these conversations and what to ask about. These conversations break the silence, provide validation and an empathic ear and lay the groundwork for exploring options, coping strategies and strengthening support systems.

For each of the factors identified, Table 2, TRUST, outlines a set of guiding principles with core considerations to promote comprehensive preparation and ongoing support for peer supporters as they engage with the complex challenges faced by ALHIV.

Table 2

TRUST: Guiding principles for expanding the role of peer supporters into mental health support, core considerations.

Recommendations	Core considerations for peer supporters
1. Training	Peer supporters need training to expand their knowledge base, build their skills and understanding that includes:
	• Information on common mental conditions: depression, anxiety, post-traumatic stress, substance abuse
	• Factors that contribute to psychological problems: disconnections, unresolved conflict, unaddressed loss
	• Complex, relationally and socially embeddedness of the problems contributing to the distress in ALHIV
	• Necessity of a systemic and preventive approach
	• Reconciling themselves to the fact that while they will be able to fix some things, there are others they will not
	• Successful impact may include amelioration of problems, where a harm reduction lens is adopted (increasing supports in order to live alongside some of the unchangeable problems).
	• While they can support and encourage a client, they do not have control over the choices made by the client or family.
	• Screening tool or clear guidelines on what to ask about and how
	• Guidance on how to explore options, decision making and intervention strategies
2. Referral pathways	• Clear referral pathways
	• Direction from supervisors on when to reach out for help and to whom, e.g. caregivers/ family members, supervisors, HCWs, other service providers
	• Professional assessment and intervention when distress is elevated to a degree that interferes with overall functioning, schooling, relationships
	• Services and resources such as those that address child protection issues, medical care, food security, schooling
	• Augment the effectiveness of this approach, sensitization of referral system about child and adolescent mental health needs
3. Understanding the remit of their role	Peer supporters well positioned to:
	• Promote wellbeing and prevention of serious problems by reducing social and emotional isolation through ongoing engagement using basic counselling skills, (providing connection, empathy, validation, listening ear), as well as strengthening individual coping mechanisms and a social network
	• Reduce stressors and address factors that contribute to psychological problems: disconnections, unresolved conflict, unaddressed loss
	• Identify substantial needs that require referrals, e.g. child protection issues, serious psychological problems, tangible resources
4. Supervision and mentorship	Supervision must appreciate complicating factors, respond to and support peer supporters in the following ways:
	• Potentially being triggered by engaging in conversations about complex problems of which they share experience
	• Limited experience of having previously talked about mental health problems
	• Increased risks from the cumulative effect of engaging more deeply with the nature of the complex problems and the emotional pain of others
	• Development of coping strategies, scaffolding and confidence to serve as role models related to mental health issues
	• Early support with sensitising caregivers to the peer supporters’ role
	• Managing their expectations of realistic and feasible outcomes
	• Recognition of the value of engaging in self-care.
5. Talking helps	Peer supporters must be helped to:
	• Understand the power of talking when there is an empathic, listening ear
	• Develop a language to talk about the complexity of the problems they potentially face and
	• Have conversations about their own difficult experiences, both for support and to understand what these conversations look like.

Conclusion

Extending peer support to explicitly include a focus on mental health has enormous potential for improving the wellbeing of ALHIV and ultimately, improved virologic suppression. We illustrate that the training and support that is needed not only requires peer supporters to learn new information, but also to learn to use themselves in a new way. In bringing young peer supporters into this arena, we have a responsibility to set them up for success and to prevent potential emotional and psychological harms. To maximise the opportunities and mitigate the risks, we have drawn on our learning to identify a framework (TRUST) for guiding the implementation of peer supporter delivered mental healthcare for ALHIV. Adolescents need someone they trust that they can talk to and peer supporters need to trust they will be able to help and will themselves be okay in providing that support.