Unpacking Stepped Care: What Providers in Kenya Taught Us About Supporting Youth with HIV

Hey there! Let’s chat about something really important – how we can do a better job supporting young people living with HIV. It’s a big challenge, and honestly, adolescents and youth living with HIV (AYLHIV) often face tougher hurdles than adults when it comes to staying in care and keeping the virus under control. We’re talking about lower rates of staying in treatment and achieving viral suppression, which is crucial for their health and preventing transmission.

The global goals (like the UNAIDS 95-95-95 targets) are ambitious, and hitting them for AYLHIV means getting creative and tailoring support to their unique lives, their social circles, and where they are developmentally. One promising idea that’s worked well for adults is something called differentiated service delivery (DSD). Think of it as tailoring healthcare – not everyone needs the same frequency or intensity of visits. If you’re doing great, maybe you don’t need to come in as often. If you need more support, you get it. Simple, right? The cool thing is, the World Health Organization and even Kenya’s Ministry of Health have recently updated guidelines to include AYLHIV in these DSD models. This is a big step!

But here’s the thing: putting these ideas into practice isn’t always straightforward. That’s where this study comes in. We wanted to understand what it’s *really* like on the ground for the healthcare providers who are actually delivering these services. What helps them? What gets in their way? That’s the gold we were digging for in this qualitative evaluation of the Data-Informed Stepped Care (DiSC) study in Kenya.

What’s DiSC All About?

Okay, so the DiSC study was a research project testing a stepped care approach. Imagine a staircase of support. At the bottom (Step 1), you have AYLHIV who are managing well – they might get DSD services like fewer clinic visits or faster pharmacy refills. As you go up the steps (Steps 2, 3, 4), the support gets more intensive, tailored to specific needs like mental health challenges, difficulty sticking to treatment, or not having the virus suppressed. Providers used a special tool, informed by client data, to figure out which step each young person needed.

The study happened in 24 HIV clinics across three counties in western Kenya – areas with higher HIV prevalence. We talked to 43 healthcare providers (mostly clinical officers and nurses) who were part of the intervention sites. We used focus group discussions, basically group chats with a purpose, guided by a framework called CFIR (Consolidated Framework for Implementation Research) to make sure we covered all the angles: the intervention itself, the clinic environment, the outside world (like policies and community), the providers themselves, and the process of putting it all into action.

The Provider Perspective: First Impressions

So, what did the providers think? Overall, they were pretty enthusiastic about DiSC right from the get-go. They saw the value and were quick to jump on board. They found the DiSC tool itself easy to use, which is a huge plus. It wasn’t just another piece of paperwork; they felt it gave them a real advantage. Why? Because it helped them deliver services more efficiently and, crucially, allowed them to spend more quality time with the young people who needed it most.

One provider captured it perfectly, saying they really liked how the tool guided them on whether to step a client up, down, or keep them where they were. They noticed their clients were happier, and that made the providers feel good too. It’s that positive feedback loop that really drives motivation!

Initially, some providers were a bit wary. Adding something new to an already busy workload can feel like “more jobs.” But as they started using the tool, that feeling faded. They realized it actually *lessened* their work in the long run by streamlining things.

What Made it Work? The Facilitators

We heard about several things that really smoothed the path for DiSC implementation:

• Easy Tool, Real Advantage: As I mentioned, the tool was a hit. Providers felt it improved efficiency and helped them prioritize, which is key when you’re juggling many clients. They also appreciated that it could be flexible enough to adapt to changing national guidelines.
• Feeling Prepared: The training they received was generally seen as sufficient. It gave them the knowledge they needed to feel ready to use the tool and talk to clients about it.
• Seeing Results: Providers were motivated by the fact that they could see DiSC working! They noticed young people in the lower-intensity steps were still doing well – sticking to appointments and staying virally suppressed. This perceived effectiveness was a big driver.
• Teamwork Makes the Dream Work: Collaboration among staff and across different health roles was super important. They felt a sense of collective efficacy – a shared belief that they could achieve implementation goals together. Continuous quality improvement meetings helped them troubleshoot and adapt.
• Leadership Support: Having supportive leaders at the clinics was crucial. Leaders helped make space available for things like mental health counseling and even allowed providers to see clients outside of standard hours when needed.
• Tailored Care: Providers felt DiSC helped them provide more individualized care, moving away from a one-size-fits-all approach. This led to better privacy and confidentiality, making it easier for young people to open up about their challenges.
• School-Friendly Appointments: A huge win was aligning appointment intervals with the school calendar, especially for those in boarding schools. This significantly reduced missed appointments and the burden of travel.

Hitting the Roadblocks: The Barriers

Of course, it wasn’t all smooth sailing. There were some bumps along the way:

• Training Gaps: While most felt the training was good, some thought it was too short or didn’t fully explain the “why” behind the tool, leading to initial confusion.
• EMR Headaches: Many clinics are moving towards electronic medical records (EMR), but the DiSC tool was paper-based. This created compatibility issues and sometimes providers forgot to use the paper tool after entering info in the EMR. Integration is definitely needed for the long haul.
• Guideline Mismatch e Data Issues: National guidelines changed during the study, and the viral load cut-offs used by the tool didn’t always match the new guidelines. Plus, country-wide issues with viral load testing meant results weren’t always available or were delayed getting into the EMR, making it hard to assign clients to the correct step based on their current status.
• Mental Health Assessment Challenges: Providers found it tricky to assess mental health, especially in younger adolescents, using the standard tool (PHQ-2). They felt the questions weren’t always age-appropriate or culturally relevant, potentially missing those who needed support.
• Community Perceptions: A big barrier for mental health support was the lack of community awareness or belief that mental health issues are real illnesses. This made it hard to engage and follow up with young people who were recommended for counseling.
• Provider Transfers: Losing staff who had been trained in specific skills, like delivering cognitive behavioral therapy (CBT), disrupted service delivery.
• Phone vs. In-Person: While phone calls offered flexibility, providers (and clients) generally preferred in-person interactions, especially for more intensive counseling, as it allowed for better observation and connection.

Looking Ahead: Recommendations for Scale-Up

Despite the challenges, providers were overwhelmingly in favor of expanding DiSC to other clinics across Kenya. They had some smart ideas for making it even better:

• Tool Modifications: They suggested making the tool more age-specific, maybe having different versions for younger and older adolescents, with questions tailored to their unique experiences. Adding a way to get input from caregivers for younger clients was also seen as crucial for better mental health assessment.
• Seamless Integration: Getting the DiSC tool integrated into the EMR system and the national Green Card (the standard clinic encounter form) was a top recommendation to make it part of routine workflow and overcome the paper-based hurdle. Aligning the viral load cut-offs with current national guidelines is also a must.
• Expand Training: To ensure resource continuity and wider reach, providers recommended training more types of healthcare workers, including peer mentors, community health workers, and lab technicians. Cascading mental health training to more staff was also highlighted.
• Keep Everyone Involved: Continued engagement with all the key players – AYLHIV themselves, their caregivers, clinic leaders, educators, community members, and the Ministry of Health – is seen as vital for successful and sustained implementation.

My Takeaway

What I find really compelling about this study is how it shines a light on the practical realities of putting evidence-based interventions into action. It’s not just about designing a good program; it’s about how it fits into the existing system, how the people using it feel about it, and how it meets the needs of the clients it’s meant to serve.

The providers in Kenya showed incredible adaptability and commitment. They saw the potential of DiSC to truly improve care for AYLHIV, and they actively worked to make it fit their context. Their insights about the tool, the training, the need for better integration with EMRs, and the importance of addressing mental health stigma are invaluable for anyone looking to scale up similar programs.

This evaluation, coming straight from the folks on the front lines, gives us a clear roadmap for optimizing stepped care for AYLHIV. It reminds us that listening to providers is just as important as listening to clients when we’re trying to build health systems that truly work for everyone.

Source: Springer