Facilitators and Barriers to Implementing Peer-Led Neurocognitive Screening for Older Adults Living With HIV at a Community Hospital in Thailand: A Multiple-Methods Study.

introductionNeurocognitive impairment (NCI) is increasingly prevalent among older adults living with HIV (OALHIV). HIV clinics in low- and middle-income countries often do not routinely screen for NCI. Task-shifting screening to peer educators might be an alternative approach. We explored facilitators and barriers to implementing a peer-led NCI screening tool in an HIV clinic in Thailand.

methodsThe study took place at a community hospital HIV clinic in suburban Chiang Mai. Peer educators were trained to screen OALHIV ≥50 years for NCI using the International HIV-Dementia Scale for global cognition, the Trail-Making Test for psychomotor speed and the General Practitioner Assessment of Cognition. We interviewed OALHIV who participated in the peer-led NCI screening during and after a 12-week implementation phase, peer educators and healthcare professionals to identify individual and intervention characteristics categorized according to the Consolidated Framework for Implementation Research. Transcribed and imported digital materials were used for thematic analysis in Dedoose (version 9.2.12).

resultsFrom March to June 2023, 162 eligible OALHIV were recruited. Among the 144 (89%) screened, the median age was 58 (IQR 54-62) years, and 93 (65%) were female. On at least one measure, 40 (28%) matched the study-defined referral criteria for NCI, of whom 20 (50%) were diagnosed with mild NCI, representing 14% of all those screened. We conducted 39 interviews with OALHIV (n = 26) and clinic-based staff (n = 12; five peer educators, eight healthcare professionals). The perceived benefits of neurocognitive screening, the empowerment of peer educators, the reliance on established links between peers and clinic clients, and OALHIV acceptance of screening were facilitators of the intervention. The main reported barriers were a lack of perceived necessity among OALHIV, clinic staff concerns about screening quality and comprehensiveness, and a lack of supportive national policies to integrate screening into routine HIV care for OALHIV.

conclusionsWe demonstrated that a peer-led NCI screening intervention was feasible and acceptable in our setting. Raising awareness of the benefits of NCI screening among OALHIV and improved training and coordination in the healthcare setting would facilitate more effective implementation.