Examining the Effect of Peers on Internalized Substance Use Stigma in the Context of HIV and Substance Use Care Engagement in South Africa

Abstract

South Africa has the most people living with HIV (PWH) in the world and a high burden of substance use disorder (SUD), which is associated with worse HIV care engagement and health outcomes. Internalized substance use stigma is a known barrier to engaging in HIV care and SUD treatment among PWH who use substances. In high-income countries, peer recovery coaches (PRCs), defined as trained lay health workers with lived substance use recovery experience, have been used to help patients who use substances stay better engaged in care, largely due to the assumption that PRCs’ shared lived experience helps reduce patient internalized substance use stigma. Yet, it is unclear if any studies have examined this assumption. Therefore, the first aim of this study was to conduct a scoping review to summarize the state of the research on formal peer workers, like PRCs, reducing substance use stigma globally. Following a systematic search through June 2023, we identified n=16 articles. Of these, only n=2 had a primary aim related to peer workers shifting substance use stigma, and none quantitatively examined internalized substance use stigma. In the second aim, as part of a pilot study, we examined if meeting with a PRC (intervention; n = 23) decreased internalized substance use stigma in comparison to enhanced treatment as usual (ETAU control; n = 24) among PWH who use substances in a resource-limited South African community. We also examined changes in internalized HIV stigma (exploratory). Stigmas were measured with the internalized subscales of the Stigma Mechanism Scales at baseline and three-month follow-up assessments, and data was analyzed using repeated measures ANOVAs. Findings revealed that internalized substance use stigma significantly decreased in both conditions and had no impact on internalized HIV stigma, suggesting that the PRC did not significantly affect either stigma. This dissertation represents a first step in examining whether PRC contact reduces internalized stigma in a low-income setting. To optimally scale PRC roles, future research is needed to evaluate if and when PRCs may reduce stigma and improve health-related outcomes, and how to optimally implement this role in low-resource settings.