Cascading training model to promote screening, brief intervention, and referral to treatment across South Africa : rollout in an HIV service organization

Abstract

BACKGROUND : In South Africa, rates of HIV and alcohol use are among the highest globally, with a detrimental synergistic relationship. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based, cost-effective approach to identifying people at risk of alcohol-related problems to deliver early intervention. We developed and deployed a cascading train-the-trainer model to promote SBIRT implementation in a large nongovernmental organization offering HIV services across South Africa. METHOD : Between 2021 and 2022, we completed preparatory activities including designing scalable training resources prior to rolling out the train-the-trainer model across two South African provinces. We conducted a comprehensive assessment of outcomes at the trainer- (knowledge, fidelity), provider- (attitudes, confidence, perceived implementation potential, adoption), and client-encounter (reach) levels over approximately one year. RESULTS : We trained 12 novice trainers who then trained 206 providers to implement SBIRT. Trainer SBIRT knowledge increased pre- to posttraining, and fidelity of training delivery was high (99.0% of elements covered across sessions). Provider attitudes, confidence, and perceived implementation potential increased over time, and 64% of providers adopted SBIRT. Reach of the model varied by component, with 41,793 clients screened by trained providers. Of those screening positive for risky alcohol use, 86% received brief intervention (BI) and 53% received referral to treatment (RT). Additionally, 15,353 clients who did not screen as having risky alcohol use received BI and 1,122 received RT. CONCLUSION : Results indicated that the cascading training model was delivered with high fidelity, associated with improvements in all provider outcomes, and reached high numbers of clients for the screening component of the model. Rates of BI and RT delivery were moderate to high, though data suggested over-application of these elements with some clients, highlighting the tension between reach and fidelity. Lessons learned will inform future scale-out of this model in HIV service settings in low- and middle-income countries.

PLAIN LANGUAGE SUMMARY Training the HIV-care workforce to deliver screening, brief intervention, and referral to treatment for alcohol use in a non-governmental service organization in South Africa In South Africa, rates of HIV and alcohol use are high, and they negatively impact one another. An approach known as SBIRT—Screening, Brief Intervention, and Referral to Treatment—is an evidence-based and effective way to identify individuals with risky alcohol use and provide them with interventions to reduce alcohol-related risks. The purpose of this research is to test whether a cascading train-the-trainer model can mobilize a large workforce to use SBIRT in HIV service settings. Our research team partnered with a large nongovernmental organization serving populations at high-risk for HIV in South Africa to test this training model. A small group of expert trainers from our team trained 12 novice trainers from the partner organization in how to instruct providers to use SBIRT with their clients. These novice trainers then trained 206 providers within the partner organization covering almost all (99.0%) training elements. Almost two-thirds of these providers used SBIRT, screening 41,793 clients over approximately one year. The reach of brief intervention was very high; 86% of indicated clients who were seen by trained providers received a brief intervention. Reach of referral to treatment was moderate, with 53% of indicated clients seen by trained providers receiving a referral to treatment. We also found that many clients received either a brief intervention or a referral to treatment when they did not screen positive for risky alcohol use. Our results are encouraging with respect to the feasibility of the cascading training model and its ability to mobilize a large workforce to reach clients with SBIRT, yet the fidelity of the application of brief intervention and referral to treatment warrants further research. This work highlights the tension between reaching large numbers of clients and maintaining fidelity.