Engage and adapt: peer-led implementation of HIV navigation in Australia
Timothy Krulic
A B * , Graham Brown A , Sara Graham B and Adam Bourne A
A
B
Abstract
Alongside partnership, adaptation is one of the enduring themes of the Australian response to HIV, but the ability of peer insight and engagement to shape responses to change is often undervalued. In this article, we present a case study of a peer navigation for people living with HIV, run in partnership with clinical stakeholders, to examine its effectiveness and adaptability within a changing epidemiological landscape.
We draw on interviews and focus groups conducted in 2019 and 2020 with 30 peer workers, management and clinical stakeholders of a peer navigation program for people living with HIV operating in Victoria, Australia. Our interpretation uses a complex systems framework to evaluate peer programs, including their influence on health and service systems.
We found that the peer navigation program’s ability to adapt and remain effective in a changing epidemic and clinical service landscape was based partly on its engagement with its communities and partly on its efforts to align with the service and policy systems. There was evidence that the program influenced the policy sector based on the quality of its community engagement to reduce the vulnerabilities the sudden implementation of COVID-19-related restrictions created for people living with HIV.
Our findings demonstrate the wider value peer navigation programs deliver in the response to HIV and illustrate the partnership and investment strategies required to improve the implementation and impact of similar programs.
Keywords: Australia, evaluation, implementation, peer navigation, people living with HIV, qualitative, quality of life, thematic analysis.
Introduction
The Australian HIV partnership, characterised by the early mobilisation and involvement of the communities most affected by HIV, is often lauded for its successes. Relative to other high-income countries, Australia has sustained community behaviour change and low prevalence over the course of the epidemic.1 To remain effective, the response has needed to continually adapt to change, but services and advocacy led by people living with HIV, or peers, are rarely funded well enough to evaluate and promote their adaptations to new communities and challenges.2 This article examines the effectiveness and adaptability of a Victorian peer navigation program for people living with HIV within a changing epidemiological and clinical landscape, drawing on the experiences of 30 staff and stakeholders, which included peer workers, management and clinical partners.
Currently, adaptations to new priorities for HIV management and a diversifying epidemic are required to provide equitable care and support in Australia. The proportions of new diagnoses in gay and bisexual men from Asia and the Americas, as well as in heterosexual men and women, increased steadily in the decade prior to the COVID-19 pandemic.3–5 These populations also experience significant gaps in the HIV care cascade.6 In Australia, much of the HIV caseload is managed by hospital-based and sexual health physicians and a network of accredited general practitioners (GPs) with a special interest in HIV care.7 Although this service environment has historically engaged Australian-born gay men, general practices that are geographically dispersed and accessible to the wider community play an increasingly important role in the detection of STIs, including HIV.8 The quality of life that people living with HIV experience is also a major focus of national strategy.9 Research suggests that migrants and people living with HIV from low-prevalence countries require specialised support and referral to manage the impact of stigma and discrimination on their health, wellbeing and relationships.10,11
In recent years, restrictions designed to curb the spread of COVID-19 tested the adaptability of the HIV response and disrupted access to care, support and community. Within Australia, COVID-19-related restrictions were most severe in the state of Victoria and continued in various forms from March 2020 to November 2021. These included limits on social gatherings, an 8 pm curfew, travel restrictions to within 5 km of home, and the closure of non-essential services. To reduce the harms associated with a loss of income stemming from COVID-19-related restrictions, the federal government increased payments for people eligible for unemployment and other welfare programs and subsidised the wages of people who were unable to work or required to work less. Although there is evidence that the adaptations made to clinical services meant that viral loads and access to antiretroviral treatment were largely unaffected, people living with HIV reported negative impacts on their personal relationships, income, employment, and other factors related to their health and wellbeing.12,13 Understanding how peer navigation programs adapted to these challenges can inform future strategies for improving HIV care resilience in crisis situations.
This article reports findings from our implementation study of an HIV peer navigation program operating in Victoria. The program was established by a peer-led organisation for people living with HIV and its clinical partners in 2018. Other stages of this research examined the experiences of service users.14,15 We found that the sexual, gendered and transnational experiences of HIV that navigators shared with clients enhanced the quality and outcomes of peer navigation. Navigators also facilitated situational and relational HIV literacy, which supported stronger engagement with the service and community environments that can enable better quality of life. The strategies and mechanisms of HIV peer navigation programs often imply such a multi-sector approach.16 However, a recent scoping review found that, internationally, there is a paucity of research on how clinicians and community-controlled organisations can best work together.16 There is also little research on the strengths and challenges of program implementation led by community organisations, despite the prominence of community and non-profit partners delivering these programs in many parts of the world, including Australia.17–19
This article presents a case study to examine the effectiveness and adaptability of HIV peer navigation programs run by community organisations in partnership with providers of clinical care. We consider systems influence as part of the effects peer programs aim to produce, and our research draws on systems thinking to evaluate peer programs. As Brown et al.2 note, peer programs influence and engage stakeholders in a unique way: as part of and in collaboration with community, service and policy systems. Observing how a peer program engages, influences and adapts to align with its social system can guide policy and program improvement.20 We therefore produce rich description of these processes, with a particular focus on how the peer navigation program responded to the disruption of service provision and policy settings brought about by the COVID-19 pandemic. From our interpretation, we draw findings and recommendations that should be used to improve the impact, quality and resilience of similar programs, service and policy systems.
Materials and methods
Research setting and program description
Our case study peer navigation program was implemented by Living Positive Victoria, a community-controlled organisation that has represented people living with HIV in the state since 1988. Peer navigator positions were funded to respond to requests for tailored, in-person support from clinical partners. Navigators supported clients with any health issue or quality of life concern related to HIV. Individual sessions lasted an hour or so, but client access to the program was not limited. At the time of data collection, peer navigation sessions were conducted in English or offered with translation from an interpreter.
Living Positive Victoria recruited three peer navigators with skills and experiences demonstrated through engagement with diverse communities of people living with HIV, including women and heterosexual men, gay and bisexual men, and people from migrant backgrounds. Navigators were employed part-time and paid in line with national skills-based awards for social and community work. Navigators received training and supervision from Living Positive Victoria.
The program established formal referral relationships with five major treatment centres in Melbourne. Partner clinics include two general practices with high HIV caseloads, two hospital-based infectious disease clinics and the state’s largest, publicly funded and free sexual health clinic.
Participants and approach
Our approach drew on community participatory research principles. Representatives from participating organisations assisted in the design of appropriate research methods, participant recruitment, the evaluation of findings and authorship of journal articles.
This article draws on interviews and focus groups with 30 staff and representatives of Living Positive Victoria, as well as five partner clinics, including peer navigators, healthcare professionals and program managers. Participants included each of the three peer navigators, four members of leadership and management, and four peer workers delivering other initiatives at Living Positive Victoria. Among the clinician stakeholders were five infectious disease specialists, eight nurses and clinical support staff, and two nurse practitioners who worked across the two public hospitals and the sexual health clinic. Four GPs, two from each clinic, participated in the study. The infectious disease specialists and GPs included members of clinic management and casuals who worked fractional hours across several partner clinics.
We selected study participants who had close working knowledge of the peer navigation program. The research team worked with Living Positive Victoria to identify peer workers with extensive experience in supporting different communities of people living with HIV. To ensure the representativeness of the sample, we also selected participants from diverse disciplinary perspectives (treatment specialists, GPs, nurses, clinical support staff and peer workers) working across each of the program’s five partner clinics, which reflected a diversity of healthcare settings. This enhanced the reliability that participants were aware of the care and support needs of a range of different communities of people living with HIV in Victoria as well as contextual and organisational factors relevant to the program’s success. Key program staff and partners were identified through meetings with program management and invited to participate directly by the research team. A wider invitation to all staff who had knowledge or involvement with the program was sent by management in email communications. Participants provided written- and oral-informed consent. Ethical approval was obtained from La Trobe University (HEC19033) and Alfred Health (HREC53336) review boards.
Data collection and analysis
In this article, we draw on data collected in interviews and focus group discussions (FGDs) held from June 2019 to May 2020. These provided detailed accounts of the peer navigation program’s operation and how it learned, adapted and aligned with the HIV service environment in response to its engagement with its social system.
The first author held four FGDs with staff groups of three peer navigators, four other peer workers, and eight nurses and clinical support staff working across two separate clinics. Interviews were held in person or over the phone with five infectious disease specialists, one nurse, one nurse practitioner, four GPs, and four members of leadership and management at Living Positive Victoria.
Interviews and focus groups were semi-structured. Participants responded to a set of questions about their involvement with the program and how they believed it effected changes in the HIV care and service environment as well as the health and wellbeing of service users. Participants were then asked to describe any recommendations or lessons learned from implementing the program.
A follow-up discussion was held with two peer navigators and the program manager in May 2020. Participants were asked to describe the response of the program to any changes they had observed in the needs of their clients and the operation of the service environment during COVID-19-related restrictions.
The first author transcribed and performed a reflexive thematic analysis of the data in a manner similar to that described by Braun and Clarke.21,22 Interviews were recorded, transcribed, and read and reread to gain familiarity with the data. The first author independently developed descriptive codes to group data extracts using NVivo 1 software (R elease 1.6 Lumivero; https://www.lumivero.com). These codes and data extracts were then reviewed and discussed through meetings and supervision with other members of the team to develop and revise initial themes. Themes were produced to describe patterns of meaning we identified across the sample and broader research literature, using Brown et al.’s2 complex systems framework to evaluate peer programs as an interpretive lens. Our themes therefore strongly reflect narratives of engagement, influence, adaptation and alignment to guide policy and program development and improvement.
Results
We found that the peer navigation program’s ability to adapt and remain effective in a changing epidemic and clinical service landscape was shaped by its deep engagement with its communities but also its efforts to align with the service and policy system. Follow-up interviews also showed how the peer navigation program’s ability to engage and adapt produced alignment within the policy response to the COVID-19 pandemic to better support its community.
Strong engagement with people living with HIV community supported the recruitment and development of a diverse peer workforce
Many of the factors that enabled Living Positive Victoria to attract and develop a diverse peer workforce stemmed from its longstanding engagement with people living with HIV as a peer-led organisation. Indeed, recruitment of peer navigators was, in part, built on Living Positive Victoria’s established engagement and development of people living with HIV as a provider of peer-based services. In her interview, the manager of the peer navigation program elaborated on the importance of selecting navigators who could use their awareness of the needs and experiences of the local community of people living with HIV to support others.
Obviously [navigators] needed to be living with HIV, but they also needed to be quite at ease with it [and] have a level of empathy and understanding of other people living with HIV. (Program manager)
This awareness, she said, would enable navigators to discuss ‘topics that some people were going to be really uncomfortable with, and to do it in a way that was respectful and empathetic’ (Program manager). The organisation advertised widely when seeking recruits but attracted people living with HIV of diverse sexuality, age, gender and cultural background already engaged in its peer support and community development initiatives for women, heterosexual men, and youth and young people. During the application process, these candidates drew on their experiences as volunteers and users of these services to demonstrate role-specific knowledge, skills and awareness of the local community of people living with HIV. The program manager contrasted these applicants with others who had demonstrated no connection to the HIV sector or community.
Senior management stressed the need to upskill, compensate and support peer workers operating in a demanding environment. ‘We believe in remuneration and acknowledgement and really, really strong support around our peer navigators,’ said one member of leadership who was living with HIV. In her interview, the manager of the peer navigation program agreed that these values were part of its ‘organisational cultures.’ In her view, Living Positive Victoria had ‘very strong, sort of, beliefs [about] looking after peer staff and making sure [that] staff were well equipped to do the job.’ Training spanned organisational policy, counselling skills, HIV medical management, trauma-informed practice and cultural sensitivity. Supervision with the program manager covered program administration, workloads, clients and stakeholders. Group supervision facilitated learning and collaboration to support clients. Navigators also had access to clinical supervision with a qualified counsellor, enabling them to develop skills and discuss personal issues related to work. In group discussions, one peer navigator reflected on the value of a range of avenues for feedback and support.
I think it’s awesome. Like we should be, we need to be debriefing and discussing stuff. Shit comes up and you’re like, have I done the right thing? We need those open lines of communication. (Peer navigator)
Peer navigators also reported feeling empowered by a workplace culture that accommodated and appreciated their diverse life experience. In a focus group discussion, one navigator who had never worked in an office described their experience of becoming part of the workplace.
I’ve got history with this office through being around, but the integration as a peer navigator has been incredible. Like it’s so welcoming … There’s been a lot of support from the guys that have been here longer … helping [me] with phones or just language…I know I can be pretty crass. (Peer navigator)
This navigator’s challenges included the use of office-appropriate language and computer and phone systems, but as they explained, guidance from managers and peers ‘was all done really kindly and really professionally, so I never felt embarrassed by it.’ Captured too in the quote above is the mentoring available from peers who had been in the workplace longer. One experienced peer worker spoke about managing triggers and boundaries as key skills that are often difficult to apply in peer work. ‘We all think that we can manage the burdens of our jobs,’ he said. Having struggled with these issues in the past, he makes himself available for informal debriefs and conversations with navigators. Navigators reported that the visibility of peers, including leadership and management at Living Positive Victoria, fostered a sense of safety and acceptance. In a previous workplace, one navigator who was a gay man felt that he had to hide his sexuality. ‘Here I never had to like deal with any of that, because it’s like, ‘just be yourself,’’ he said.
Adapting to a complex and changing service landscape through clinical and community partnership
Feedback from all participant groups suggested that the peer navigation program needed to adapt to a complex and changing HIV clinical service environment. Partner clinics differed significantly in terms of service models and clientele. One hospital-based clinic in an outer metropolitan area operated within limited hours, 2 days a week. The nurses there highly valued peer navigators being onsite during clinic hours. In a focus group, one participant said that she often introduced clients to the service after medical appointments.
Being able to say, ‘actually I’ve just got someone in the room next door, would you like to [meet them]?’ I think that opportunity … has been really good for many, many people. (Infectious disease clinic nurse)
Nurses explained that clients from low-prevalence, culturally diverse groups were less likely than other clients to contact community organisations that traditionally engaged Australian-born gay men or travel to the inner city where they were located. Although participants from the other hospital-based and sexual health clinics described similar barriers for their clients, long hours prevented navigators from remaining onsite. In response to feedback from these clinics, the program provided flexibility for appointments to be held onsite, in community settings, on outreach, over the phone or online.
The changing HIV epidemic posed challenges for engaging new clients through general practice. GPs working at high HIV caseload partner clinics reported a steady decline in the number of new diagnoses in the years immediately before and after the peer navigation program was established. Although their practices remained major treatment centres for Australian-born gay men and other people living with HIV, GPs indicated that most of their clients were already well connected to services and support. ‘My patients are by and large people who have had HIV for 20 years,’ explained one GP. ‘The issues around HIV are all things that they addressed a long while ago.’ Living Positive Victoria management agreed that people living with HIV who are newly diagnosed were more likely to need the help of a navigator, but they explained that many people living longer term with HIV who may be socially isolated or from culturally diverse and low-prevalence groups can still benefit greatly from peer support.
Participants acknowledged that a growing number of new HIV diagnoses were now reported in general practices with low or no caseloads. GPs and community representatives said that it was difficult to reach people living with HIV diagnosed in these settings. While the peer navigation program had leveraged pre-existing relationships with a small number of major treatment centres, developing a larger referral network with a wider range of GP clinics would stretch the capacity of a small community organisation. As a member of management elaborated, Living Positive Victoria aimed to reach the people living with HIV in most need, but required more funding:
To do something that is representative, that is inclusive and that engages people as they should be, requires a reinvestment of human resources, the finance[s], to be more things to more people. (Living Positive Victoria management)
At the time of the interviews, Living Positive Victoria’s management was exploring the possibility of building on the relationships it had established with hospital infections disease clinics operating in other outer suburban areas to reach people who transferred their care to these treatment centres.
Responding to the COVID-19 crisis: how peer engagement contributed to better community and policy system alignment
The peer navigation program’s ability to engage and adapt was exhibited in its response to COVID-19, which influenced stronger service and systems alignment to reduce the vulnerabilities new policy settings had created for its communities.
The program relied on its engagement with the community of people living with HIV to identify the people most in need during COVID-19-related restrictions. While navigators fielded requests for help directly from community members, the program manager reported that referrals from its clinical partners had stopped once COVID-19-related restrictions came into force. ‘New referrals pretty much ground to a halt,’ she said. Peer navigators began to make telephone calls to check on the wellbeing of previous clients but also people who had attended other community events run by Living Positive Victoria. One peer navigator explained that talking to a wider range of service users sometimes helped to identify new community members who needed help. ‘I rang a woman, and she asked me to call her friend who’s also positive,’ she said. ‘[I]t turns out he really needs support.’
The program learnt that people who normally did not need to access welfare and social services were feeling the social and economic impacts of extended COVID-19-related restrictions. The program manager expanded on these client experiences.
[For] people who haven’t had to access things like CentrelinkA or other social services [before] … it’s actually quite challenging. Particularly if English isn’t your first language. You know, they don’t necessarily know [where] to get a food voucher or that you can access a no interest loan scheme. (Program manager)
Navigators became more active in helping clients access services and financial aid. This included directing people to partner clinics, where they could obtain low-cost prescriptions and care.
The peer navigation program also found that many of its clients were falling between gaps in the Australian welfare system. Many were non-residents who were excluded from federal government programs intended to protect people from the economic fallout of COVID-19-related restrictions; others experienced delays. A peer navigator said that, in addition to its effects on mental health, financial stress risked unplanned treatment interruptions. She explained that ‘people who’ve lost their jobs and starting to run out of meds [are] concerned that they can’t afford the co-payments.’ Living Positive Victoria reported to the state health department what it was learning in real time about the impacts of COVID-19-related restrictions on HIV treatment access. The department responded by providing additional finance that enabled Living Positive Victoria to set up an emergency fund. Peer navigators then helped administer targeted financial relief up to A$200 to clients experiencing treatment interruptions due to loss of income.
The program also adapted its response to reducing social isolation. Instead of navigators focusing on increasing client engagement with the community environment, they conducted regular welfare checks to alleviate some of the loneliness people experienced. Single women and mothers were identified as clients who were most likely to be out of work or juggling care responsibilities. One navigator explained that she liked to check in with these women from time to time. ‘It’s a long game,’ she said. ‘One week they’re … renovating and gardening and writing … really active and engaged. And then the next fortnight they’re not okay and they’re really down.’ Program staff anticipated that clients would benefit from being kept up to date with emerging evidence about the risks of COVID-19 for people living with HIV and related health conditions.
Discussion
This article draws on the perspectives of clinician and community stakeholders in a peer navigation program for people living with HIV in Victoria, Australia. Participants had close working knowledge of the program, the needs of its clients and factors relevant to its success. Their accounts provide a detailed description of the obstacles to the adaptation of care and support environments as HIV epidemics and the priorities for management evolve, as well as the ways in which peer practices and engagement can inform and strengthen the response to change. Our findings offer several insights to improve the implementation and impact of peer navigation programs as well as access to care and support for people living with HIV more generally.
This study investigated program implementation led by a peer organisation with longstanding engagement of people living with HIV. Our previous research showed that a peer navigation team that reflected the diverse sexuality, gender and transnational experiences of its clients enhanced peer support and helped to meet individual needs.14,15,23 In the present study, peer workers and management characterised a reciprocal relationship with the communities they served, from which the organisation drew key skills, diverse personnel and even insights about how to respond quickly to changes in the needs of clients. There was also evidence that the involvement of people living with HIV at all levels in the organisation supported the development, competency and safety of the diverse peers working in the program. These findings underline the unique strengths of HIV peer navigation programs led and implemented by communities of people living with HIV, which are rarely captured in research despite the prominence of the community sector in the global HIV response.16 They also draw attention to greater involvement of people living with HIV (GIPA) and meaningful involvement of people living with HIV (MIPA) principles and standards for peer support, which all organisations seeking to implement HIV peer navigation programs can follow.18,19,24
GIPA and MIPA principles recognise community membership and the lived experiences of people who are HIV-positive as expertise that can enhance and improve public health responses.24 The principles are based on the reasoning that it is more effective to support and develop people to promote health in their community than to teach others the skills, knowledge and awareness acquired through daily lived experience. Although peer- and community-based initiatives are seen as critical to contemporary efforts to end the epidemic, inadequate investment, management and training remain barriers to the meaningful involvement of people living with HIV in local responses across the world.25 The peer workers and management in our study stressed the importance of adequate renumeration and employment conditions that included comprehensive training, development and a variety of supervision structures as factors that enabled the success of the program. These support structures are now promoted through national standards and practice-based guidelines for peer support and navigation programs.17–19 This contrasts with the reality of many peer programs operating in the global HIV response, which rely heavily on volunteers who work in demanding contexts with minimal support and development.16,26
A key challenge for this peer navigation program was the need to understand and respond to the nature of clinical encounters experienced by people living with HIV from low-prevalence, culturally diverse communities within a variety of service environments. It was met, in part, through consultation with clinics to tailor the program according to how clinicians understood the needs of their clients. Although the Australian HIV response has been praised for this kind of partnership, the local care and support sector has endured periods of policy neglect and disinvestment.1 Our study suggests that a deepening of clinical and community collaboration in the contemporary treatment environment was facilitated by a relatively modest but targeted investment in a systems-focused peer navigation program.
We noted differences between how some clinician partners and the peer organisation understood the peer support needs of people living with HIV over the long term. Although some clinician stakeholders viewed peer navigation as largely relevant to people newly diagnosed with HIV, community representatives noted that people living with HIV, especially those from culturally diverse or low-prevalence groups, are often socially isolated and experienced ongoing need for peer support. These community perspectives more closely reflect findings from other stages of this research involving clients of the peer navigation program.14,15 For example, heterosexual clients of the program experienced prolonged experiences of social isolation and engaged with peer navigation not only at the time of diagnosis but at other points of stress and transition in their lives, such as the end of a relationship, grief or migration.14 Although participants from some clinics sought to incorporate the knowledge of peer workers into their practice,23 the results presented in this paper show that there remained scope to share learnings across this partnership to further enhance referral and promotion of the peer navigation program. Care providers should work closely with local community partners to build awareness of going and recurrent peer support needs among culturally diverse and low-prevalence groups, including life events that may be indicators for referral.18
Ultimately, participants cast the peer navigation program itself as an adaptation to a changing HIV epidemic and service environment. Findings from other stages of this research suggest that this collaboration strengthened pathways from high HIV caseload partner clinics to community environments and other services for people living with HIV from culturally diverse and low-prevalence groups.14,15,23 Although high-caseload GP and hospital clinics were responsible for the majority (51%) of HIV notifications in Victoria between 2016 and 2019, reaching the 44% of people diagnosed in low- or no-caseload GP clinics remained difficult for stakeholders without adequate funding.27 Another recent initiative in Victoria enabled GPs to deliver sexual health care and referral in these settings with support from a sexual health specialist service using a hub-and-spoke model.8 Ongoing and adequate investment in systems-focused programs, such as these, and peer navigation is needed to ensure equitable access to care and support for people living with HIV.
The peer navigation program’s rapid response to the COVID-19 pandemic was praiseworthy. The perspectives of people living with HIV, many of whom were vulnerable to social and financial stress during COVID-19-related restrictions, demonstrate the need for community support during such periods of upheaval.13–15 Our study suggests that peer navigators were attuned to the issues affecting the community members most in need. In this case, the peer navigation program was able to advise government of the disruption to treatment access that sudden policy changes had created and advocate for a financial aid program targeted at those most at risk. We argue that consideration of the effectiveness of a peer program should include these policy, service and systems influences. If it does not, the health system is not informed of the full value of investment in even modest peer initiatives.
Limitations
We involved a range of stakeholders to maximise data reliability and understand the influence of service and policy systems on program implementation, but we did not include the perspectives of the people living with HIV who were clients of the program in this analysis. Although our discussion draws on findings from other stages of this research involving clients of the program, we were unable to verify all results with client narratives. Several of our findings are closely related to factors contextual to the Victorian HIV care and support environment, and therefore, they may not be transferable to other health systems, particularly if those systems do not involve a variety of providers in the spectrum of HIV and sexual health care.
Conclusion
Our study demonstrated some of the unique strengths of a peer navigation program for people living with HIV implemented by a peer-led organisation with strong engagement and connection to the communities it served. We argue that close collaboration and the exchange of insights between peer workers and clinical stakeholders can enable programs to reach target groups but that adequate investment is required. There was also evidence that a responsive policy system in Victoria enabled peer navigation to adjust to sudden changes in the care and support needs of people living with HIV in the state during the COVID-19 pandemic. These findings emphasise the importance of genuine partnership as well as stable and responsive investment in peer organisations to enable ongoing adaptation to evolving HIV epidemics. To further build the evidence base for the implementation of peer navigation programs for people living with HIV, we recommend that researchers undertake similar localised investigations in diverse settings, populations and healthcare systems exploring long- and short-term outcomes.
Data availability
The data that support this study cannot be publicly shared due to ethical and privacy reasons and may be shared upon reasonable request to the corresponding author if appropriate.
Declaration of funding
This research was supported by an investigator-led research grant from ViiV Healthcare and a doctoral scholarship from La Trobe University.
Acknowledgements
The authors would like to thank the peer workers, management and clinician stakeholders who participated in this stage of the project across Living Positive Victoria, the Melbourne Sexual Health Centre, Alfred Hospital Infectious Disease Clinic, Monash Hospital Infectious Disease Clinic, Northside Clinic and Prahran Market Clinic.
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