Attitudes toward scale-up of an Intensive Combination Approach to Rollback the Epidemic in Nigerian adolescents (iCARE) intervention for youth in Nigeria: results of a mixed methods early-implementation study

Background: Youth living with HIV (YLH) are disproportionately impacted by HIV with poor outcomes along the entire HIV care continuum. In a 2020–2022 pilot study, iCARE Nigeria, successfully tested a combination intervention incorporating mobile health technology and peer navigation to: 1) improve testing and linkage to HIV care for young men, especially young men who have sex with men (YMSM) and 2) improve medication adherence and treatment outcomes for YLH. The intervention was scaled up to 5 sites in 3 Nigerian cities. Implementation research was used to understand site perspectives on feasibility, readiness and potential facilitators and barriers soon after scale-up commencement. Methods: An explanatory mixed-methods implementation study was conducted, including quantitative surveys on adoption and reach among peer navigators (PNs) and other study staff (55 testing, 172 treatment), and interviews and focus group discussions with PNs and other study staff in both intervention groups (n = 31). Data were analyzed using descriptive statistics (quantitative) and directed content analysis using the Consolidated Framework for Implementation Research and RE-AIM (qualitative). Results: Early into scale-up, PNs and other study staff in the testing and treatment interventions reported high readiness, adoption, feasibility, and appropriateness. Facilitating factors and strategies across both interventions, included supportive institutional culture, ongoing supportive supervision, provision of a manual and training, relevant PN working experiences, communication methods designed to ensure anonymity of targeted youth (testing) or confidentiality (treatment), and access to cellular data and internet. Facilitators specific to each intervention were also identified including PN knowledge of the MSM community, using multiple social media platforms for outreach (testing) and problem-solving by PN and staff to respond to client needs (treatment). Barriers in both interventions included client financial and transportation challenges, and societal stigma. Intervention-specific barriers included legal limitations for MSM and few YMSM friendly clinics (testing), limited client financial resources and cell-phone access (treatment). Conclusions: Implementers of the initial scale-up of both components of the iCARE Nigeria intervention reported high readiness and adoption, supported by implementation strategies and facilitating factors including intervention design. These results are important for informing future work to scale-out iCARE and similar interventions to new settings. Trial registration: ClinicalTrials.gov number, NCT 04950153, retrospectively registered July 6, 2021, https:// clinicaltrials.gov/.