In 2015, the President’s Emergency Plan for AIDS Relief undertook policy shifts to increase efficiencies in its programming, including transitioning HIV/AIDS funding away from low burden areas. We examine the impact of these changes on HIV outreach in Kenya and Uganda.Qualitative data collection was conducted as a part of a broader mixed-methods evaluation. Two rounds of facility-level case studies and national-level interviews were conducted in Kenya and Uganda, with health facility, sub-national and central Ministry of Health staff, HIV clients, and implementing partners.In both countries, the loss of outreach support affected community-based HIV/AIDS education, testing, peer support, and defaulter tracing.Loss of external support for outreach raises concerns for countries’ ability to reach the 90–90-90 UNAIDS target, as key linkages between vulnerable communities and health systems can be adversely affected.Development partners should consider how to mitigate potential consequences of transition policies to prevent negative effects at the community level. In 2013, the Joint United Nations Programme on HIV/AIDS (UNAIDS) established the 90–90-90 goal where 90% of all people living with HIV (PLHIV) will know their HIV status, 90% of people diagnosed with HIV receive sustained antiretroviral therapy (ART), and 90% of people receiving ART will achieve viral suppression by 2020  here, it is not an easy thing. So, if you do not conduct outreach, the number of clients who are going to come to VCT [voluntary counseling and testing] is very low. So, coverage has gone down.” – Kenya, County Health Officer, CS County (Round 1).“We used to go for outreaches during time [convenient to the clients] but now when they [IP] withdrew we don’t do mobile outreach for the HIV testing. We used to do moonlight HIV testing at night, but nowadays it is not conducted.”–Kenya, Facility In-Charge, CS County (Round 2).In both countries, respondents spoke at length during both rounds of case studies as to how their ability to find cases in the community has been reduced due to the end of support for outreach. Previously, outreach to the community allowed them to identify new cases of both HIV and tuberculosis (TB), but health facility staff reported seeing fewer new cases than before as they now relied on the client to come to the clinic for testing. In Kenya, this was reported in CS and Maintenance counties. Kenyan respondents also described how community-based testing had previously helped to overcome barriers to accessing tested.… now we were not reaching [undiagnosed clients] as we used to because we would go for an outreach and you get like three to five. But now we just wait for those ones who come here to the facility.” – Uganda, Facility Staff, CS District (Round 1).““We used even to go in bars at night looking for these sex workers … we used to bring them to us, or we organize seminars we go and address them at night, but now all that stopped … there is nothing being done compared to when [IP] was here … we also used to go to particularly boda-boda people [and] fishermen people, but now you can’t go there, who would pay for transport …” —Uganda, Expert Client, CS Facility, Round 1.In Uganda, respondents described specific barriers that prevented individuals from going to the clinic for testing, including transport challenges, and how clients may be more likely to undergo testing when they are in their own community. One respondent in Uganda also described how outreach allowed them to target key populations (KP) for testing, such as sex workers and fisherfolk, and that they were now unable to do so due to lack of financial support.Across both countries, facility respondents consistently described concerns of reductions in coverage of the surrounding community as a result of losing the ability to seek out new clients in the community. One local health official in Uganda also expressed concern on their ability to maintain accurate information on prevalence of the surrounding catchment population without support from ongoing monitoring.“At that time, you know we were dealing with HIV patients and there were a lot of defaulters from treatment … there were funds [ …] we could go for the clients and find them and bring them back to the facility for treatment” – Kenya, Facility In-Charge, CS County (Round 1).“USAID support came up to 2015 and we were particularly supporting HIV activities, ART where they would support follow-up of clients … and follow-up of lost children” –Uganda, Facility Staff, CS District (Round 1).Defaulting from treatment and loss-to-follow-up (LTFU) was one of the most cited concerns in both Kenya and Uganda, and appeared to have been experienced in very similar ways. Respondents extensively described the extent of support that was previously provided by IPs for defaulter tracing, and how loss of this affected the ability of providers to follow-up with clients in the community.“But now the funds are not there, when a client defaults you cannot reach them. If her phone is not going through you can’t go there because there are no funds.” – Kenya, Facility In-Charge, CS County (Round 1).“Right now we have a very big workload because [expert clients] went away … so the workload is now high and that’s why you see tracing for clients is hard, that’s why indirectly there are deaths, some are dying.” – Uganda, Facility In-Charge, CS District (Round 2).Respondents described both the loss of financial support for allowances, airtime, and fuel for transport, and the loss of informal health workers . Without the support and resources, respondents in both countries described how it was no longer possible to conduct follow-ups, with one facility in-charge in Uganda linking loss of follow-up to client deaths.“… we had the structure of the mentor mothers who were so vital to the HIV structure that they could support the clients with follow-up and would link them [to services] and [ …] the positivity in children was going low … Even that follow-up of clients was lost.” –Uganda, Facility In-Charge, CS District (Round 1).“In case this child turns positive [ …] the [PI] used to follow-up the mothers at home [ …] to bring the child for enrollment. But right now, nobody is there to support these staff to go to look for those mothers when their children turn positive, so they end up missing.” –Kenya, Health Records Officer, CS County (Round 1).Respondents also highlighted the specific issue of following-up on children who test positive and do not come back to the clinic. Previously, there were mechanisms to follow-up with mothers at home, but this was not maintained after GP.In general, support for follow-up and defaulter tracing appeared to be highly valued by both providers and HIV-positive clients in both countries. Inability to continue follow-up with clients was perceived by respondents to have direct effects on health outcomes, with some respondents even attributing client deaths to loss of follow-up.“It used to happen in the morning before we were given the drugs. We would meet and do introductions, we would know each other, we would share challenges.” —Kenya, Client, CS County (Round 2).Loss of PEPFAR-funded peer support groups and/or treatment support groups was more frequently described by respondents in Kenya where the main program previously supported “expert clients” in six out of seven CS counties. Respondents discussed how expert clients led psychosocial groups where HIV-positive clients were able to meet monthly to support each other and share challenges.“These patients they understand more when their fellow [patient] is just talking to them. Rather than me standing there and just telling them ABCD … But somebody who has experience of the drugs they can really listen to her. So she was telling them everything, the lady who was here as the expert patient.”–Kenya, Facility Staff, CS County, Round 1, Kenya.“There are those PLHIV support groups that were being supported, that support has ended. So it has actually affected the key uptake of key services.”–Kenya, County Health Officer, CS County, Round 1, Kenya.Respondents in Kenya described how new clients were better able to relate to other clients who had experienced the same thing. With the loss of funding to continue this programming, one county health officer connected this to a decrease in uptake of key health services.“… because we are not following these mothers, these mothers are now not in a group where they know what to do and which month they’re supposed to come and what to do with their children.” —Uganda, District HIV Focal Point, CS District (Round 2).In Uganda, the issue of peer support was discussed more specifically in the context of mentor mothers during Round 2, who had previously assisted with retaining children in treatment by encouraging mothers to bring their children to the clinic. One district health official described how they previously provided support groups for mothers that helped them keep track of appointments while providing guidance on how to care for their children.Although more predominantly seen from respondents in Kenya, overall, respondents in both countries reiterated similar themes on how previously IP funded peer support groups provided forums for support and knowledge sharing, and that the loss of this has implications for retention, follow-up, and awareness generation.“… The [TB] treatment success rate has reduced … we are seeing that clients are not getting cured. Although not yet confirmed but it’s a suspected MDR now. It’s also increasing because of [lack of] follow-up. We used to have community treatment supporters who would take the medicines to the communities but right now we wait for clients to come to the facility.” —Uganda, Facility In-Charge, CS Facility (Round 1).Respondents at various levels also brought up the disruptions to general community-based services, and how this has further affected the HIV care continuum. In Uganda, respondents described how facilities previously were able to provide services such as home delivery of medicine through informal health workers. This appears to have ceased when support for outreach was terminated. One respondent in Uganda in Round 1 described how TB treatment and follow-up services had been affected, while another in Round 2 also described how they used to piggyback malaria treatment delivery and family planning services with HIV outreach.“In terms of facility utilization, bringing the mothers from the community to deliver in the facility, that has reduced … we had a pool of community health volunteers and mentor mothers who we used to support. We had to part with them so we did not have the foot soldiers in the community to bring [mothers to the facility].” —Kenya, IP Staff, CS District (Round 2).In Kenya, respondents highlighted how CHWs previously encouraged expectant mothers to attend facilities for birth while conducting outreach, which allowed them to also initiate prevention of mother-to-child transmission  (PMTCT) services, but without CHWs they were seeing fewer women delivering in facilities.In general, loss of support for other community-based services were described as being linked to loss of support for outreach, whereby informal health workers were previously able to leverage HIV funded outreach to provide additional information and support for non-HIV related care while working in the community.“… ARVs are supposed to go with a package of educational services, training and so on and so forth, that is what is not available. So, if you are talking about ARVs then the coverage stays the same, but if you are talking about these other services that go with ARVs then the scope has narrowed” –Kenya, CSO (Round 2).National-level respondents in both Kenya and Uganda spoke similarly to the loss of outreach at a much broader level compared to facility respondents. They corroborated the loss of outreach services that emerged from the facility case studies, although with fewer details as to how this was experienced, highlighting an overall disconnect between those who work at the national policy level versus providers and clients at the facility level. In Kenya, a representative from a Civil Society Organization (CSO) noted that ART coverage had remained, but the supporting services to ensure that clients can access and use ARTs had not.So the major effect [was] when we had to drop the community health strategy and structures because that had a huge knock-on effect in terms of better access to HIV services and reproductive, maternal, and newborn child services”. – Kenya, IP (Round 1).““Those are the big challenges we are facing, we have [clients] lost- to- follow up because those people were being facilitated, now they are not. So, the onus is on the patients themselves but some patients need some pushing and some supervision and all that work cannot be done by health workers” –Uganda, AIDS Control Program (Round 1).Of those at the national level who spoke of outreach, there was an acknowledgement that without these services ongoing, there would be an effect on access to care. In Kenya, a national level IP staff member noted that they had already seen cascading effects on the ability of clients to access both HIV and non-HIV services, while in Uganda, there was an acknowledgement that clients were being lost.I may know that the ministry is responsible for taking care of the services of some in the community but if the ministry can also only do so much, then there’s very little they can do.” –Uganda, National Level IP Staff (Round 1).“Respondents broadly reflected on the need and importance of outreach services, and the important role that such programs play in the overall strategy to prevent and treat HIV/AIDS. There was acknowledgement that without support from donors, it was unlikely that such programs could continue, and that quality of services would likely decrease.To date, there has been extensive research conducted around the effects of community-based HIV services across the treatment cascade. Such research has found, with some consensus, that community and home-based care may increase rates of testing for HIV, and support sustained uptake of HIV treatment , 41–45. Our findings indicate that recent shifts in PEPFAR funding and strategy for HIV/AIDS programs in Kenya and Uganda, specifically the transitioning of certain facilities and jurisdictions to CS, resulted directly and indirectly in a loss of financial and technical support for outreach. Based on study findings, local health systems were unable to re-hire, replace or absorb informal staff or reinvigorate community-based programs that had been established with the support of PEPFAR, despite official expectations. According to our respondents, the loss of support for outreach had direct and immediate effects on the ability of facilities to provide certain services. Respondents of all types in both countries consistently indicated that CS facilities have experienced challenges in (i) conducting general education and awareness campaigns to their surrounding communities, (ii) providing testing outside of their facilities, including amongst target populations, (iii) tracing clients who default, (iv) providing clients with psychosocial support through expert clients, peer mentors, and mentor mothers, and (v) facilitating non-HIV related services within the community.1st 90, community-based testing, across modalities, has been shown to achieve high coverage and higher testing rates across KPs compared to facility-based testing [Our respondents’ concerns about how the loss of outreach may affect PLHIV and their communities over time links closely to existing data on the value of outreach services across the treatment cascade in support of reaching the 90–90-90 targets. In relation to the  testing . Testing testing . In addi testing . The los2nd 90, loss of support in the form of expert clients, peer mentors, mentor mothers, and PLHIV support groups has implications for the ability of facilities to initiate and maintain clients on treatment. Psychosocial support through support groups and expert clients or peer mentors has been found to be a significant factor in treatment adherence across studies in SSA, including in Kenya, Swaziland, Lesotho, Namibia, Botswana, Uganda, Malawi, and Ethiopia [For the Ethiopia –52. In aEthiopia , 53. Our3rd 90, suppressing viral load is contingent on the ability of clients to maintain sustained treatment. In a multi-faceted community-based program implemented in Kenya and Uganda that included universal testing, linkage to care, treatment, and community-based follow-up, viral suppression increased by 35% over the 2-year intervention [Finally, for the rvention . Authorsrvention , 55. TheIn losing support for outreach without adequate replacement by local/national governments or other donors, there is concern that a critical linkage into communities will be lost and exacerbated by existing stigma, changing migration patterns and ongoing health system decentralization. In Kenya, new infrastructure development brings concerns for increased migration and evolving patterns of disease transmission, in an ongoing setting of instability due to conflict and violence , 27. In There are a number of lessons that can be learned from the experiences documented in Kenya and Uganda for future funding transitions in HIV programming as well as other disease areas. Firstly, improved communication down to the sub-national and facility level may have provided opportunity for existing outreach programs to be better integrated into local budgets, or for alternative donors to be identified. In Kenya, it was found that although GP was well communicated at the national level, there was little to no communication down to the counties, resulting in abrupt cessation of services at the facility level . In UganMore broadly, PEPFAR’s GP process reflects the need for development assistance partners to reflect critically on the outsized role they have played in shaping country responses to the HIV epidemic over the decades and to take this into consideration when planning transition efforts. Foreign aid and development assistance for health has heavily influenced health programming, and some argue that DAH has detracted from country level efforts to invest in building up robust health systems, instead prioritizing spending to align with donor objectives and short-term projects . Donor fThere is a need for further research on how losing existing outreach impacts not only immediate health service delivery but also client physical and mental well-being, disease patterns, and epidemiology in the longer term, particularly for KPs and marginalized populations. Further study into how outreach services have or could rebound after transition are also needed to help with successful transition planning. Finally, research and experimentation to understand how integrated outreach efforts may be carried out across services, such as TB, maternal, neonatal, and child health, or other chronic diseases is critical to identifying ways in which such services can be maintained without the same levels of donor support. As global funding levels stagnate, such research is needed to ensure that countries can adequately achieve global targets for ending the HIV epidemic and achieving the UNAIDS 90–90-90 goal.This study presents a number of limitations. Firstly, outreach was not a key focus of the original evaluation but the loss of support and the attendant effects emerged as an important theme across data sources early on. Secondly, in both countries, other ongoing events at the national level took place during the study period, possibly affecting respondents’ views. In Kenya, two health worker strikes caused notable service disruption across the country during the study period making it difficult, at times, to reach relevant respondents. In Uganda, the process of rationalization whereby districts were transferred between PEPFAR agencies  in an attempt to improve overall efficiency and avoid duplication took place simultaneously with GP. Respondents were often confused by the two processes due to their similarity, potentially affecting their recall. Thirdly, it is possible that respondents may have overstated the effects of losing outreach services in the hope that this would lead to a resumption of support, however interviewers introduced themselves in a manner which did not associate them with potentially influential stakeholders such as USG. Fourthly, while no respondents refused to speak during the facility level case studies, a number of invited FGD respondents did not come to the actual focus group. Key voices and experiences at the client level may therefore have been missed. Finally, this study took place in the period immediately following GP, with relatively short periods of time between rounds. It is possible that the effects of the GP had yet to be fully experienced, and additional follow-up research may elucidate longer term effects.This article provides early explorations on how the loss of support for outreach has potential implications across the HIV care continuum. While the findings from this study cannot estimate long-term effects, evidence on the positive effect of outreach services on outcomes linked to the 90–90-90 goals raises concerns for communities that have been transitioned away from PEPFAR support without sufficient replacement of services. Outreach services act as a key linkage between communities and the health system, in particular for the most vulnerable populations and populations that are geographically isolated, such as the sites included in this study. In regions with low prevalence and incidence rates of HIV/AIDS, it is important to retain efforts to prevent changes to the epidemiology of the disease through ongoing education, and maintaining links between the health system and the community. Future donor transitions should ensure engagement with the local health systems, sufficient timelines to prepare and identify alternative funding for outreach, and commit to supporting M&E to capture shifts in service provision and disease patterns. As countries work toward achieving the 90–90-90 goals in the context of declining donor funds and a greater need for efficiency, policy-makers should continue to consider the longer-term benefits of supporting outreach programs.


This study explored the internal and external factors affecting the first drinking experience during Korean adolescence. To achieve this, we collected 34 cases revealing specific drinking experiences during adolescence in Alcoholic Anonymous (A.A.), Korea. The collected data were analyzed using a qualitative case study method, and the analysis focused on the internal and external factors influencing drinking in adolescence. As per the results, internal factors that influenced drinking in adolescence were “curiosity” and “elevated mood and stress relief”, and external factors were “family”, “friends”, “older friends at school”, “neighbors”, “Korean tradition of alcohol making”, “workplaces that encourage alcohol consumption”, and “a generous drinking culture.” Based on these findings, we suggested several practical alternatives, such as a stringent alcohol punishment system, government-led campaigns to overcome the generous alcohol culture, monitoring the drinking status of working and intern youths, and using local crime prevention guards to curb youth drinking. In future research, it is necessary to quantitatively verify the results of this study to develop theories related to adolescent drinking behavior. Excessive drinking causes several problems. Individuals who drink excessively may experience physical and mental problems and accidents such as drunk driving . AdditioThe social service sector deals with alcohol abuse problems in all age groups, but we need to pay more attention to adolescents’ drinking problems. This is because adolescent drinking behavior can lead to other delinquent behaviors . In manyAdolescence is also a period of rapid physical growth; the risk of damage to organs such as the brain, liver, and kidneys, and sexual dysfunction due to alcohol consumption is higher than that in adults . ConstanTo better understand and intervene in the drinking experience of adolescents, the individual and the surrounding environment must be considered together. Ecological systems theory emphasizes the understanding of interactions between humans and the environment  and regaDemographic factors such as gender and age can be considered internal factors affecting adolescents’ drinking. In general, the drinking rate in men is higher than that in women, and it increases with age ,8,16,17.Environmental factors include family, peer group, school, and culture. Reportedly, relations with family and family history affect adolescents’ drinking habits. Dysfunctional interactions within the family, such as conflicts, neglect, and inconsistent parenting attitudes have been reported to be closely related to drinking in adolescents ,27. PareBecause adolescents are influenced by peer groups, drinking and peer pressure are important variables predicting adolescents’ drinking ,22. PartSociocultural factors have also been reported as predictors of drinking in adolescents. It was found that the price of alcohol and the drinking rate of adolescents were inversely proportional , and thePrevious studies presented above suggest that various factors influence adolescents’ drinking. However, they have some limitations. First, prior studies did not address the causes of alcohol initiation in adolescents. Additionally, existing studies mainly analyzed quantitative data to identify factors that influence adolescents’ drinking, so they did not reveal specific drinking contents and experiences. To overcome these limitations, we focused on why the first drinking experience occurred in adolescence. Therefore, we collected cases related to the first drinking experience of adolescents and tried to determine the internal and external factors that act as the first drinking trigger. Through this process, it is possible to contribute to the establishment of prevention strategy by specifically revealing the drinking pathways of adolescence.We used a purposeful sampling method for data collection because it was necessary to select cases that fit the purpose of the study and to explore adolescents’ first drinking experience. We collected alcoholic recovery notes published from January 2015 to March 2021 in Alcoholic Anonymous (A.A.), Korea, to identify cases of adolescent drinking experiences. A total of 236 cases of actual experiences were secured, and among them, 34 cases were analyzed as they contained first alcohol experiences during adolescence in detail. In our data, alcohol consumers in adolescence drank various types of alcohol between the ages of 5 and 18 and were influenced by internal and external factors such as curiosity and recommendations from friends .We used a qualitative case study method to analyze the collected data . QualitaTo conduct qualitative research, the rigor of research and ethical issues should be considered together. Because this study analyzed secondary data called casebooks, ethical issues that might have otherwise risen during interviews or observations did not arise. Therefore, we focused on securing the rigor of the study. To do so, we used strategies such as triangulation, peer support groups, and audit trails . First, As a result of the analysis, two internal factors were found, including “Curiosity” and “Elevated mood and stress relief”. External factors were found, including “Family ”, Friends”, “Older friends at school”, Neighbors (adult)”, “Korean tradition of alcohol making”, “Workplaces that recommended alcohol” and “Generous drinking culture”.Curiosity acted as an internal factor in that those who drank alcohol in adolescence drank out of curiosity. As suggested by previous studies, curiosity serves as a motive for drinking alcohol during adolescence ,22. Some“I remember drinking for the first time when I was in the freshman of high school. I secretly drank out of curiosity with my friends, and when I became an adult, I drank every day with my acquaintances.” (case 1)soju.” (case 2)“The first time I drank alcohol was when I was 17 years old. At first, I started drinking beer out of curiosity, and after a few months, I drank “The first time I drank alcohol, I was in the freshman of high school, and I drank out of curiosity. After drinking, I felt like I owned the whole world, and I felt a sense of freedom from not having to hide myself anymore.” (case 3)Those who experienced drinking alcohol in adolescence did not drink simply out of curiosity. Alcohol served as a tool to elevate their mood and relieve stress. Previous studies have also noted that emotional factors such as emptiness, emotional instability, thrill-seeking behavior, and impulse control problems are related to drinking in adolescence ,23,25. I“After drinking, I felt like I owned the whole world, and I felt a sense of freedom from not having to hide myself anymore. I was afraid of people because I had an introverted personality. However, I was not afraid anymore.” (case 3)“When I drank, I kept smiling and felt very good, and I felt my usual introvert personality became bold.” (case 4)“The first time I drank alcohol was when I was 16 years old. A relative ran a liquor dealership in the neighborhood, when I had the time, I went to work there. There, I learned that drinking made me feel good, and I started to drink more and more.” (case 5)“I had a conflict with my friend in middle school, but I was upset that I could not resolve it and could not get angry properly. I suffered from lethargy, and my academic performance decreased. So, I drank for the first time when I was in the sophomore of middle school.” (case 6)“When I drank alcohol, my nervousness, anxiety, and frustration seemed to disappear. Alcohol cured me faster than medicine.” (case 7)“When I was 16 years old, my close friend died, and my parents broke up. I was very shocked. So, that’s when I started wandering. I drank with my friends for the first time, and alcohol caused my stress, irritation, depression, and anxiety to disappear.” (case 8)The old Korean maxims have a saying, “Drinking should be learned from adults,” meaning adults in the household teach drinking etiquette, which shows the family’s influence on adolescent alcohol drinking. Of course, existing studies also point at “family” as a factor in drinking alcohol in adolescence. However, previous studies have shown that dysfunctional family relationships  lead to drinking ,26,27,29“I started drinking in earnest when I was a sophomore in high school. A relative taught me how to smoke cigarettes and drink alcohol.” (case 9)“I had a good relationship with my dad, and when I was 5, my dad gave me the leftover alcohol, and I drank it pleasantly.” (case 10)“My family had many Korean ancestral rites, so I was lucky as I drank alcohol during Korean ancestral rites every time. Family who saw me drinking thought I was cute, so they recommended me to drink more.” (case 11)“I first started drinking when I was 15 years old, and my grandfather suggested that I drink.” (case 12)In Korea, a friend refers to a person of the same age. In Korean culture, where age is important in relationships, people tend to communicate more comfortably with other people of the same age. In previous studies ,21,22, ““When I was in the sophomore of high school, I drank with my friends in the mountains in the neighborhood, calling it a rite of passage.” (case 11)“When I was 18 years old, I drank a large amount of alcohol with my friends for the first time.” (case 13)makgeolli with my friends during the winter vacation and vomited a lot. I rarely talked to my friends when I did not drink.” (case 14)“When I was in the sophomore high school, I drank soju with my friends at a park in the village and drank yogurt as a snack.” (case 15)“The first time I drank alcohol was in the fall when I was 15 years old. I had three bottles of “I drank for the first time when I was in the sophomore of middle school. I hated studying and naturally hung out with juvenile delinquents.” (case 16)“I drank for the first time when I was in the junior of middle school. I liked to play with my friends and hated studying.” (case 17)“When I was in the junior of high school, I drank with my friends for the first time. I felt that the draft beer I drank with my friends for the first time tasted worse than coke, but I drank it at once seeing my friends drink.” (case 18)The recommendation and coercion of older friends at school also served as a trigger for drinking alcohol during adolescence. As mentioned earlier, in Korean society, where age is important for the formation of relationships, high and low authority relationships are formed around the same age . Particu“I did not think that the drinking habits I learned from older friends in middle school would be the trigger for alcoholism until I was 44 years old.” (case 19)“The first time I drank alcohol was when I was 15 years old. I went to my friend’s house and drank the beer that my friend’s sister bought for the first time. Dancing drunk all night made me feel better.” (case 20)“The first time I drank alcohol was when I was in the sophomore of middle school. My friends and I drank because older friends at school told us to come to drink.” (case 21)makgeolli recommended by older friends at school in celebration of the freshmen.” (case 22)“The first time I drank alcohol was when I was in college, and I drank “When I was in the second year of middle school, older friends at school ordered me and my friends to buy alcohol. Older friends started drinking, then assaulted me and my friends who did not drink with the club, forcing us to drink.” (case 23)Along with family, friends, and older friends at school, neighbors also influence alcohol drinking in adolescence. Adolescent alcohol users drank alcohol as recommended by local adults that they were close to . These examples specifically illustrate the government’s findings that 24.6% of the 3595 teenagers surveyed were recommended to drink by adults outside their families at restaurants . Althougmakgeolli. Alcohol overwhelmed my small body and immature mind.” (case 4)“I had my first drink when I was in elementary school. The man who owned the laundromat offered me a shot of “When I was a senior in high school, a local man gathered the kids and made them drink. I drank until I was blacked out.” (case 6)makgeolli were excited and poured into my bowl. I was hungry and thirsty, and the makgeolli was just the drink and food for me.” (case 24)“I first drank alcohol during the autumn harvest of rice farming in 12 years old. The elders who had been eating In the past, many families in Korea made their own alcohol . Althoug“When I was a middle school student, I stole alcohol, which my mom soaked from home and drank. My face burned red, and an indescribable ecstasy came to me, and I drank whenever I had a chance.” (case 25)makgeolli with sugar. I drank it secretly, and every time I drank it, I would wander around and fell asleep.” (case 26)“I saw my grandmother drinking after working on a hot summer day when I was in elementary school. She drank homemade Most students who drop out of school or attend vocational high schools find employment in early jobs or internships. During this process, people encountered alcohol . As they watched adults working together drink alcohol, they naturally imitated it, and also drank at the recommendation of adults. This suggests that even adolescents can be easily exposed to alcohol if they live together in a space centered on adults. Additionally, like in case 31 that “Even if you are young, you are adult when you are work!”, the possibility of drinking at work increases if you are recognized as an adult.“When I was a senior in high school, I went on vocational training. It started then. I was exposed to alcohol easily because I was a student and worker. Alcohol was my friend in difficult situations where I had to work overtime.” (case 27)haejangsul  in a workplace restaurant in the morning. I drank too much a day ago, but after drinking the haejangsul, I felt like I would live.” (case 28)“I decided to give up on graduating from high school and learned vocational skills. As I was working, I always saw people drinking the “At a young age (from a senior high school), I ran away from home and boarded a tuna fishing ship. Then, for the first time on a ship, I learned to drink liqueur.” (case 29)“When I was 16, I dropped out of school and got a job at a factory. While hanging out with seniors, I started drinking for the first time at the age of 19.” (case 30)“At the age of 17, I had to drop out of high school after several months due to difficult family conditions. I got a job as a deliveryman at a Chinese restaurant and started to follow the grown-ups by having a drink or two. Adults said, ‘Even if you are young, you are an adult in social life!’ Then, they gave me a drink.” (case 31)“I drank for the first time when I dropped out of high school as a sophomore and started working in a factory. At first, after the night shift, I could not sleep, so I drank a glass or two at the recommendation of my senior colleagues.” (case 32)As mentioned in several previous studies ,42,43, tmakgeolli kettle in my mouth.” (case 10)“The wrong drinking culture and tolerance for alcohol made me alcoholic. From junior high school days, when I was running errands, it was fun to hold the “A bottle of soju, which I started drinking at the age of 16, led me to addiction. I thought big and small mistakes were caused by alcohol and not by me.” (case 33)makgeolli or beer during adolescence is a natural idea. Many people drank that way.” (case 34)“Drinking In summary, curiosity, elevated mood, and stress relief were internal factors that enabled adolescent drinking, and family , friends, older friends at school, adult neighbors, Korean tradition of alcohol making (homemade), workplaces that recommended alcohol, and generous drinking culture were the external factors. This is illustrated in Compared to existing studies, the internal factors identified in this study were similar to those identified in the existing studies. However, school seniors, neighbors (adults), drinking culture, and workplaces encouraging alcohol were not pointed out in previous studies but served as a trigger for drinking in adolescence. The commonality of these factors is that older drinkers recommended or forced alcohol. From an ecological systems theory perspective, an individual adapts by interacting with surrounding environmental systems, such as family and neighbors . To adapAlthough this study discovered internal and external factors that influenced Koreans’ first drinking experience in adolescence, there are several limitations. First, because we extracted data from the alcoholic recovery notes, we could not examine phenomena other than the contents in the notes. Additionally, the contents of the collected data were written around past experiences. The research participants were unable to look at a series of changing life processes because the data were not collected during adolescence. Therefore, in future research, it is necessary to specifically explore the drinking experience of adolescence through 1:1 in depth interviews. Second, this study does not have quantitative figures. Thus, it is not shown the tendency of drinking experience among adolescents. Therefore, in future research, it is necessary to confirm the tendency of adolescent drinking through quantitative research. A follow-up study can be conducted based on these limitations.First, strengthening the regulation of adolescent drinking is necessary. This study found that adolescent drinkers were influenced by adults and older friends at school, who recommended alcohol. Currently, in Korea, only restaurant operators who sell alcohol to teenagers are punished. To improve the system, it is also necessary to consider punishment for adults who recommend and youth who drink alcohol. In case of difficulty in amending the law, it is necessary to revise school regulations to manage the consumption and recommendation of alcohol.Second, a government-led campaign is needed to overcome the generous alcohol culture. To solve this problem, a government-led campaign to stop drinking alcohol is needed, such as the smoking cessation campaign. Previously, Korea experienced a reduction in the smoking rate of citizens through active government-led anti-smoking campaigns. To change the tolerant drinking culture that negatively affects youth, various activities such as TV advertisements, mandatory education on the dangers of drinking, and counseling support through community health centers should be carried out by applying the smoking cessation campaign model. Particularly, the culture of making and drinking alcohol at home was also related to drinking opportunities during adolescence. Therefore, it is necessary to take this into account when campaigning. The culture of making alcohol at home should be protected because it is a traditional Korean culture. Even so, because homemade alcohol is also alcohol, the government needs to guide parents so that they can be aware of this and pay attention to its storage.Third, the status of early employment and youth training should be checked. Results showed that young people in early employment and industrial training were more exposed to alcohol by hanging out with adults at work. Considering these factors, a survey should be conducted on the drinking conditions of working youth. Based on this, it is necessary to develop a strategy to prevent alcohol consumption by youth who work in industries.Fourth, it is necessary to use a local crime watch. As a result of the study, those who experienced drinking alcohol in adolescence drank at local hills and parks. In Korea, there is a network of local crime watches. It is necessary to make the most of this and manage adolescents who drink outdoors at night.Finally, an integrated approach to the adolescents’ drinking problem is needed. As a result of the study, various factors, internally and externally, were influencing adolescent drinking behavior. Therefore, mental health experts need to take a comprehensive look at the drinking problem of adolescents by considering various internal and external factors at the same time.The purpose of this study was to explore the factors that affect adolescent alcohol drinking. The study found that the internal factors that influenced drinking in adolescence were curiosity, elevated mood, and stress relief, and external factors included family, friends, older friends at school, neighbors, Korean tradition of alcohol making, a workplace that recommended alcohol, and generous drinking culture. Among these, the newly identified factors were older friends at school, the neighbors, Korean tradition of alcohol making, and the workplace that recommended alcohol.We understood the findings from an ecological systems theory perspective that emphasizes the interaction between individuals and the environment. Therefore, to understand the drinking of adolescents, it is necessary to consider not only the individual’s internal motivation but also the ecological environment that affects it.


Hepatitis C virus reinfections in HIV-positive men-who-have-sex-with-men (MSM) challenge the effectiveness of antiviral treatment. To fight this problem, an adapted sexual risk reduction intervention was implemented within a hepatitis C treatment trial. Following this, the current study had two aims and describes 1) how the program was received by participants; and 2) their responses to the program regarding sexual risk taking. Based on the participants’ input, we hoped to judge the intervention’s potential for scale-up.Seventeen participants who received the sexual risk reduction intervention in addition to hepatitis C treatment were recruited for semi-structured interviews six to 12 months post-intervention. We evaluated the responses via reflexive thematic analysis and applied the concept of sense-making.Giving hepatitis C a place and living without it again illustrates how participants received the program and how their experiences were altered by the impact of sense-making. Based on their responses, we allocated participants to three groups: 1. Avoid risks: get rid of hepatitis C for life. For these men, hepatitis C remained a life-threatening disease: they actively modified their risk behavior and felt supported by the intervention in maintaining their behavioral changes. 2. Minimize risks: live as long as possible without hepatitis C. In contrast to group 1, these men saw hepatitis C as a manageable disease. The intervention facilitated reflection on risks and how to develop behavioral changes that suited them individually. 3. Accept risks; live with the risk of hepatitis C. These men perceived behavioral changes as much more difficult than “easy” medical treatment. They expected to either undergo repeated rounds of treatment or stay HCV re-infected.These results illustrate the diversity of men’s responses and their decisions regarding sexual risk behavior after participating in a combination of antiviral treatment and a sexual risk reduction intervention. Two major aspects were identified: 1) Teachable moments, particularly at the time of diagnosis/treatment, could offer an opportunity to develop openness for behavioral change; 2) adapting sexual risk reduction interventions to sense-making patterns could help to improve its effectiveness. Support for reducing infection risk and raising awareness of preventative measures are additional benefits.NCT02785666, 30.05.2016.Clinical Trial Number:  Since 2014, chronic hepatitis C virus (HCV) infection has been easily curable with direct acting antivirals (DAAs), leading to enhanced survival, reduced liver-related morbidity, improved quality of life, and prevention of extrahepatic complications . AccordiIn order to reach these targets, one key population for multiple HCV prevention strategies was identified: men who have sex with men (MSM) and who are living with HIV. Members of this group have a high anti-HCV prevalence 3–39%); and, as early as 2007, their incidence of infection was increasing by 2.34–5.11 per 100 person-years (py) –39%; and, 9.Swiss HCVree Trial to test a micro-elimination strategy in this population. Micro-elimination involves precise targeting of a single sub-group’s needs  No one said, you should do this or that—not at all! And that was something new. While the intervention sessions were positive, the experience of being cured of hepatitis C was also tremendously important. However, this was not necessarily interpreted in a positive way: Some reported that being cured evoked a feeling of personal vulnerability from being newly infected with HCV, which they had to learn to cope with. As one man explained,I have to deal with this whole crap again. Now, one has to be careful again. So a lot of stuff came up again. A lot of dark stuff and fears. And yeah, almost a little of the feeling that I don’t go through this again. While the main theme (Giving hepatitis C a place and living without it again) was central for all participants, the following paragraphs describe how the three explanatory models reflect the wide range of belief systems and sense-making, all of which were influenced by the contextual realities of participants.For all interviewed men, their hepatitis C diagnosis was unexpected. They reported trying to understand not only how they became infected, but also how they could evaluate the disease’s severity and its meaning for their lives. How they dealt with this phase influenced their later strategies to reduce the risk of possible reinfection. While some developed explanations that they considered valid, others reported lasting uncertainty, especially regarding transmission. One man said:Avoid risks: get rid of hepatitis C for life refers to a sense-making work shared by men who saw hepatitis C as serious and who took active steps to modify their risk behavior—even before beginning treatment and counseling in most cases. These individuals had already initiated lifestyle changes, which were felt to be supported by the intervention, and aimed to avoid risks and stay free of hepatitis C for the rest of their lives.where in the past you went wild with drugs, in the scene, drugs and party culture. Where night after night you took Ecstasy and went wild dancing. And then of course you had a relatively large number of sex partners, which changed up a lot. That was before [my current] relationship. They assigned these risk situations to time periods characterized by carelessness and eagerness to experiment sexually. Three gave particularly noteworthy reports of their lifestyle adjustments—of how they had to cut their risks partly because of their hepatitis C diagnoses and partly because they had formed lasting partnerships. As all but a few had received their diagnoses before any reliable therapy (DAAs) became available (median time since diagnosis: 5.8 years) most had tried to come to terms with the thought that they carried a serious communicable chronic condition.Men who used this sense-making work found themselves confronted with an illness that they had not even considered before their diagnosis. They reported considering HCV infection something alien—a virus relevant for intravenous drug users, not for them. The diagnosis forced them to think about hepatitis C seriously, to identify risk situations where they had been exposed, and to explain the reason for their infection. One man recalled a situation as one, hepatitis C was always on their mind. One recognized it as a “serious and socially limiting problem.” For example, “HepC gobbles up energy,” leads to liver damage, and poses a huge problem for any sexual partner because of the danger of transmission.For many, from the moment they were diagnosed“a stroke of luck,” “an immense chance.” A 45-year-old man said “the therapy has given me a new life.” Even after study screening and before treatment started, this group’s appreciation appeared to motivate them toward intervention-independent behavioral changes. Two men had already tried to practice sex with multiple partners only with condoms or to stop sexualized drug use because they had observed themselves becoming more reckless in recent years. Two others said they had stopped all sexual contact when their participation in the trial began.These men embraced the possibility of being cured as wonderful. They viewed DAAs as “If it doesn’t help, it at least won’t make things worse.” After all, they already had considerable knowledge and did not expect any personal gains. Many related how they had been positively surprised by the intervention, perceiving it as an environment in which they felt personally cared for and understood regarding the challenge of changing their sexual risk behavior. How one individual described it:[The counseling] was very informative and what did it bring? You also thought about yourself again a little. That had maybe gotten a little lost lately. And it was also nice somehow to know that there are people who are at all interested. And that is for me also a nice aspect of the story. At the time of the intervention, the participants generally felt they were already moving in the right direction, but wanted to achieve and maintain “the strict practice of safer sex.” In the long run, they saw absolute avoidance of risk as the only way to maintain their health. This is why they used the intervention to discuss situations that were awkward and difficult for them: they wanted to be better prepared.Upon entering the intervention, based on their early reflections about the disease, transmission routes of hepatitis C and their behavioral changes, their attitude was: “previous high-risk sex life”—the lifestyle that had led them to acquire the disease. They recognized during the interview that their experiences with risks were something useful, an important resource in the current situation:The light went on for me. In the sense of just thinking before you do something. Before, I didn’t have any knowledge of where you can get hepatitis C. You simply go too far and now you say to yourself: I won’t let it go so far again. A general consensus among members of this participant group was that, combined with the behavioral intervention, their successful treatment had reinforced their intention to build on and maintain the lifestyle changes. For them, using condoms for anal intercourse, while avoiding both mucosal trauma and drugs, made sense. They saw the cure of their hepatitis C as a unique chance and decided to avoid any contact with the virus in the future. Feeling relieved and happy, they experienced the cure as liberating.They also appreciated that during the intervention, according to their own personal interests, they could decide on the direction of their discussions. Among the intervention’s other benefits, they appreciated the opportunity it offered to reflect on their “a success that [he] was permitted to experience thanks to the therapy.” They considered a reinfection as a personal failure, as a disgrace not only to themselves but to their doctors. One man described how the risk of reinfection was a source of fear that led to increased caution after cure:It was strange in the beginning after the treatment. I was overly careful. I wasn’t even able to enjoy it, because I was afraid. That it turned out so well and that I don’t have it anymore. That was always a topic. Men in this group believed that their only hope for staying free of HCV was to avoid risks. Therefore, they had resolved not to expose themselves further. Their shared goal was never to be infected with hepatitis C again—to get rid of hepatitis C for life.One described it as This theme showed a sense-making process prevalent in men who considered hepatitis C a problematic but manageable disease. They described the behavioral intervention as helpful to facilitate thinking about risks and how to develop behavioral changes suitable for their long-term aim of living well without hepatitis C.[I regularly participated in sexual practices] without a condom. I did it like this for a long time before that, and hepatitis C didn’t happen until 2015. I surely didn’t use … [condoms] for ten years. And I had unprotected sex just as often during these ten years. Like the earlier group, these men were concerned about infecting their sex partners. However, they adhered to their original explanatory model—that they had contracted HCV during a single exceptional situation—and did not report any changes in their behavior prior to the start of the intervention program.Compared with the first group, these men had only recently become aware of hepatitis C (median time since diagnosis: 1.6 years), with diagnoses received, in most cases, during regular STI testing. Unlike the earlier group, before their diagnoses, they had had vague knowledge of hepatitis C, but had paid little attention to it until they tested positive. The diagnosis had typically come as a surprise because, compared to their peers, they did not consider to be at high risk. Their diagnoses had made them uncertain of how to gauge the relative risks of various behaviors. They concluded that they must have contracted the virus in an exceptional situation. They further said that they had practiced condomless anal sex with multiple (HIV-positive) partners for years. Since the hepatitis C diagnosis was made after such a long time, they concluded that this behavior couldn’t be particularly risky and were uncertain about how to protect themselves and others:“hepatitis C can cause issues that are to some extent manageable.”Similar to the first group, these men were pleased to take part in the study, and to receive the highly-effective and expensive medication free of charge. They said that when they learned of the new DAAs treatment, which was both simpler and more effective than its Interferon-based version, they concluded that “to return something because [they were] receiving DAAs with voluntary participation.” Some also hoped to learn more about hepatitis C:The knowledge, that’s what I was looking for. The knowledge about this, also in our community, is not really succinct or firmly understood. And for that reason, the probability of taking risks is much higher. All participants had enjoyed the behavioral intervention. In addition to the medical treatment, they appreciated the possibility of talking to a highly-knowledgeable nurse counselor who did not judge them. For this group, the knowledge gained during the intervention was a sudden insight. They were impressed by the fact that various situations could result in infection — for example, use of anal douching equipment (the act of flushing out one’s rectum with water or other liquids) or even of straws for intranasal drug consumption. From the information they received, they concluded that one of the intervention’s main messages was that “HepC is easy to get and can also return.” One even described the virus as particularly “malicious.”Unlike the earlier group, these men agreed to the intervention mainly because they saw it as a possibility Another difference between this group and the first was that the behavioral intervention motivated them to reflect on their own sexual preferences and the associated risks. During discussions with the counselor, they reflected on their personal risk situations and openly discussed possible changes to their behavior.“using gloves when fisting in a safe way “or “not sharing sex toys with other people.”With their counselling sessions, they were supported in their choices for or against certain changes which could be considered by them easier to make—a dynamic reflected clearly in their perception of practicability. For example, these men did not see regular condom use as feasible, because they did not feel ready for it. Instead, members from this group chose changes they considered easily made, such as “trying and choosing behavioral changes suitable for myself.” They felt that the intervention supported them in maintaining feasibly judged behavioral changes. Some said they participated less often in sex parties, opting instead to organize non-sexual leisure weekends with friends for diversion. Others cut back on their drug consumption by carrying less money with them, or by deleting their dating apps to avoid spontaneous blind dates. One explained:With the life I lead, it [the risk] can only be minimally reduced. And I’d rather have, for example, one encounter less and with that have the risk only once instead of twice. Rather that than … use a rubber and then not have any fun anymore. Men in this group were also tremendously impressed by the effectiveness of the new medical treatment options. However, if the behavioral changes were insufficient to prevent reinfection, they could definitely imagine another round of medical treatment as an option. Aware that they were only partially changing their risk behavior—and that this might not be enough—they changed what they believed was feasible to achieve success. One participant explained:What I want or should do, I am absolutely still aware. I knew it before, but the program has created more awareness. But I am not so good at implementation, or actually not good at all so to speak. But I do think, I do some of the things, but just not all that I have wanted to do. For this group, risk reduction contributed importantly to living as long as possible without hepatitis C. Having chosen to minimize risks (to the best of their perceived ability) they knew this strategy left them vulnerable to reinfection. Compared with the first group, they made few compromises, but hoped to live as long as possible without hepatitis C.Regarding behavioral changes, this group’s members also had less strict ideas than the first, adhering instead to the strategy of The third sense-making group included men who were highly concerned with hepatitis C more for fear of sexual rejection than health problems. They described the intervention as useful to help them reconsider their own sexual risk behavior and to realize that further behavior changes would require considerable effort to avoid reinfection—in contrast to medical treatment, which they perceived as “easy.” In this sense, they expected to either undergo repeated rounds of treatment or, if necessary, stay HCV re-infected.avoiding fisting.”As in the second group, men with this sense-making style had only known of their hepatitis C infection for a relatively short time (median 1.5 years); however, as in the first group, the diagnosis had elicited an intervention-independent, active and intensive search for information to explain and understand the infection. Two stated, for example, that they had already undergone at least one successful Interferon-based therapy and that they had then sought information to allow them to consciously protect themselves against reinfection. Based on the extent of their knowledge at that time and how they viewed the first (successfully treated) infection, they had decided on certain behavioral changes, such as “What was easy for us was that we had the same thing. He was positive [HIV and HCV] and me, too. That’s why we got together, because we supported each other. Because how do you want to find a life partner that doesn’t have it, that doesn’t understand the problems? We complemented each other well. We each respected each other, supported, showed affection to one another. It was probably just as hard for him to find a life partner as it was for me—someone that accepts and takes you as you are. Among members of this group, attitudes toward the behavioral intervention reflected their intense personal search for hepatitis-C-related information prior to the study. Similar to the first group, they had low expectations of the behavioral intervention and mainly participated to please their physicians, who they believed truly worried about them. However, having already gained considerable knowledge and practiced changing some of their behavior, they did not see themselves as the right people for an intervention. Unlike the first group, but analogous to the second, they had not tried to completely eliminate the risk of reinfection but had selected easy risk-reduction adaptations. Still, two members of this group who contracted HCV again despite such changes were dumbfounded. As one said:When you can’t pin it [the infection] down—you know, I mean—the first time it was so nice, because I knew exactly where it [hepatitis C] came from, where I got it, from whom. I knew out of which situation it came. Then it’s easy to say, ‘Ok, I’ll change something.’ But when later I stand there and the liver values are high and I can’t link it to any specific situation, then it’s difficult to change anything. These men did not participate in the intervention primarily to learn and expand their knowledge, but rather as a place where they could openly talk about past difficult situations and about their failures. Therefore, they talked with the counselor, for example, about the difficulty of disclosing their HCV status. While they acknowledged that this was an important preventive measure, they found it difficult because of the rejection they experienced as a result:It’s hard to change much. Because in the moment you don’t want to talk about it. Because that’s when you want to party, have sex, you want to enjoy and you don’t want to say, ‘Hey stop! Hepatitis C!’ Then everything would be over. The men in this third group saw little possibility of protecting themselves more effectively in the future: similar to those in the second group, they considered strict use of condoms, monogamy or even total rejection of sexualized drug use as effective protective measures, but considered such adaptations too extreme and difficult. This was described particularly succinctly by one participant—a self-professed “sex and drug addict”—who acknowledged that, while the intervention made sense, it was not intensive enough for his needs.Two men living together as partners reported other experiences. As both had HIV/HCV co-infection, they saw no need to change their behavior. They described their joint status even as a relief. They could set the topic of hepatitis C aside:“having fewer sexual encounters.” Unlike the second group, these men knew how easily they could be infected with HCV, but insisted on continuing risky “non-negotiable behaviors” and expected to be re-infected at any time. One man called this approach—taking risks to enjoy sex—“Russian roulette.” This group considered the new DAAs a good and important option compared to the challenges of behavioral change. One man exemplified this attitude:That would probably also go in that direction with hepatitis C. … It will become less expensive to treat and then it will become even less a topic for some people, like myself, to think about having sex with a condom. They recognized the great benefit of successful therapy: “the liver gets a break.” At the same time, though, the cure appeared to elicit ambivalence. While it greatly decreased their potential liver-related morbidity, it also meant “having to watch out again.” One described it anxiously as “feeling put back to the time with HIV before the [2008] Swiss Statement”. At that time, when condom use was strongly promoted, he experienced his sexual life as more limited and less pleasurable.This group saw only one feasible restriction: live with the risk of hepatitis C, i.e., they believed that their only reasonable course of action was to accept the risks.Thanks to the availability of curative therapy, members of this group hoped that all MSM would regularly be tested for HCV and receive treatment as necessary. They were convinced that this would reduce the danger of HCV infection for their sexual partners. Having rejected major behavioral changes, they intended to This study adds considerably to the understanding of how HIV/HCV co- and/or re-infected men responded to one of the first HCV-specific sexual risk reduction interventions to be implemented in combination with DAAs treatment. Results show the processes engaged by participants in how they position themselves in relation to the program, as well as their sense-making regarding the intervention thereafter. We identified three sense-making groups that helped to summarize the variety of responses regarding individual sexual risk reduction appraisal, decision-making, strategies to avoid re-infection and challenges to behavioral change.Giving hepatitis C a place and living without it again, covers the continuum of sense-making, with the lasting effects from the intervention program influenced by two specific factors: the time of hepatitis C diagnosis and the effectiveness of the program—including counseling and pharmaceutical treatment—regarding the prospect of curing their HCV.The main theme, We noted that the first experience of hepatitis C diagnosis was usually unexpected and often a shock. Diagnosis led first to reflection, then to individual explanatory patterns regarding transmission and the perceived consequences of particular sexual practices. In line with previous studies , 44, theThe second important experience inherent in the main pattern was the prospect of being cured of HCV. Interestingly, and in contrast to other studies’ findings, the prospect of cure also induced negative feelings in participants for various reasons. Whereas some men described feelings of shame (in relation to their physician) if a reinfection were to occur, others expressed ambivalence about once more taking the responsibility to not get infected with hepatitis C again. To our knowledge, this is the first time that negative feelings towards an HCV cure have been noted in the perceptions of MSM. This contrasts sharply with the results of a study during the era of interferon-based therapy, in which all interviewed HIV-positive MSM spoke completely positively about their HCV-free status . Underst1) Avoid risks: get rid of hepatitis C for life; 2) Minimize risks: live as long as possible without hepatitis C; and 3) Accept risks: live with the risk of hepatitis C , one did not. This finding might explain certain differences in the likelihood of behavior changes . For exas et al.  describeAvoid risks group seemed convinced that condomless anal intercourse or past sexual drug use had led to their HCV infection. As a consequence, they intended to protect themselves by avoiding virtually any risky situations. In contrast, many from the other two groups were convinced that it was not condomless anal intercourse that led to their HCV infection but other, more complex behaviors, e.g., using drugs, sharing sex toys or fisting without gloves. Therefore, they perceived that only changing such high-risk behaviors would offer adequate protection.Another meaningful difference between these groups was in the risk perception of participants, namely what they experienced as their personal risks regarding re-infection. For example, men from the The risk minimizers, who first recognized the risks entailed by many behaviors during the sexual risk reduction intervention, perceived the elimination of those practices as feasible. In contrast, as the risk accepters had already tried such changes without success, they saw no net value in renewing their earlier attempts. Importantly, this finding is consistent with Bandura’s concept of self-efficacy , i.e., tThe groups were further differentiated regarding the timing and delivery of behavior changes after study recruitment. For this intervention, we recruited only men who reported condomless anal intercourse with non-steady partners in the last year. Whereas the risk avoiders had already initiated behavior change by the start of the behavioral intervention, the other two had not. According to the Transtheoretical model of change (TTM) , which dAccept risks group described no motivation for a new attempt at behavioral change but reported reflection of their behavior during the intervention. These men either relied completely on access to successful therapy or resigned themselves to life with chronic HCV infection. Accordingly, they seemed to be trapped between the TTM phases of “precontemplation” and “contemplation.”In contrast, the risk minimizers responded to their counseling with their first serious reflection on their risk behavior. This led them to target and implement behavioral changes as encouraged via motivational interviewing techniques . In relaAvoid risks group, we could focus more on maintaining behavioral change; and for those reporting sexualized drug use behavior, extending the behavioral intervention would allow a sharper focus on overcoming their ambivalence and initiating change towards lower-risk practices.The diversity of responses to each step of the program illustrates that, in research studies, as in clinical practice, screening, diagnosis and treatment all offer teachable moments. That is, participants’ openness to information and reflection can arise at any point of contact; and when it does, it can serve as a fulcrum for motivational support by clinicians , 50. AddConsidering the strengths and weakness of the methods described above, although the participant interviews were conducted 6 to 12 months post-intervention, the stories from the interviewees reflected rich, meaningful, well-remembered experiences regarding the intervention. One clear limitation was our decision to use a purposive sampling strategy instead of interviewing all 51 participants. Whereas the used strategy worked well to include individual characteristics , we did not reach maximum variation between centers, as we were unable to recruit participants from Switzerland’s French-speaking region. Therefore, our results fail to represent one major region. However, the diversity of responses to the complex intervention program  should be sufficient to support not only a subsequent mixed-methods quantitative outcome evaluation, but also the advancement and tailoring of an intervention program focusing on HCV micro-elimination.In summary, this study’s findings indicate a need for further development regarding related interventions and clinical practice. It is essential to bear in mind that, for this subgroup of MSM co-infected with HIV and HCV, both the sexual risk reduction intervention and curative DAAs treatment influence future behavioral changes.Via an inductive interpretative approach to explore responses to a comprehensive HCV prevention initiative, this study helped us both to understand the diversity of participant responses and their decisions regarding sexual risk behavior. Participants responded to all aspects of the study, including HCV screening, diagnosis, treatment and counseling, with reflection toward behavioral change. The variety of experiences also impacted participants. Our results provide important insights into the wide range of responses after receiving a combined prevention intervention including treatment and counseling.The results will facilitate ongoing development of this and similar programs’ behavioral interventions, particularly by identifying intervention components that can be tailored to fit each target group’s attitudes/beliefs. Impact can be tailored by adjusting how much of the intervention is received and/or how long the intervention lasts. These results also imply important recommendations for clinical practice to enhance the effectiveness of infection prevention components. Participants appreciated individual counseling; and clinicians were well-positioned to first initiate and stimulate risk-related discussions, and then in turn those discussions into teachable moments by addressing and planning concrete behavioral changes.


Although many success stories exist of Village Health Workers (VHWs) improving primary health care, critiques remain about the medicalisation of their roles in disease-specific interventions. VHWs are placed at the bottom of the health system hierarchy as cheap and low-skilled volunteers, irrespective of their highly valued social and political status within communities. In this paper, we shed light on the political role VHWs play and investigate how this shapes their social and medical roles, including their influence on community participation.The study was carried out within the context of a malaria elimination trial implemented in rural villages in the North Bank of The Gambia between 2016 and 2018. The trial aimed to reduce malaria prevalence by treating malaria index cases and their potentially asymptomatic compound members, in which VHWs took an active role advocating their community and the intervention, mobilising the population, and distributing antimalarial drugs. Mixed-methods research was used to collect and analyse data through qualitative interviews, group discussions, observations, and quantitative surveys.‘health diplomats’, valued and appreciated by community members, and potentially increasing community participation in the trial. We argue that VHWs aspire to be politically present and be part of the key decision-makers in the community through their health diplomat role.We explored the emic logic of participation in a malaria elimination trial and found that VHWs played a pivotal role in representing their community and negotiating with the Medical Research Council to bring benefits  to the community. We highlight this representative role of VHWs as It is thus likely that in the context of rural Gambia, supporting VHWs beyond medical roles, in their social and political roles, would contribute to the improved performance of VHWs and to enhanced community participation in activities the community perceive as beneficial. The declaration of Alma-Ata highlighted the importance of primary health care and the community’s “full participation” to bring health care close to the ground . In respHowever, there have been longstanding critiques that lay health workers are, by design, conceived as ‘cost-effective’ and lowly skilled interfaces between under-resourced health systems and the communities –15, and To understand and improve lay health worker programmes, numerous studies have investigated their social and medical roles and their unique position as the bridge between the health system and the communities. Some studies highlight positive health outcomes linked to social networks, norms, and trust that surround lay health workers –23. OtheHowever, lay health worker relationships to their communities remain somewhat unclear , despitehow VHWs political role and status shape their social and medical roles, and consequently influence the community’s participation in health interventions such as malaria elimination programmes. To understand to what extent, how, and why VHWs’ status is valued in the community, we draw upon the analysis of their symbolic capital – a form of capital that is produced and reinforced within a group of people believing its quality and value, such as prestige and reputation  will not be forced because of the social cohesion , will/desire (bëgbëg), and/or obligation/responsibility . These elements of participation have personal ‘my’ (sama) and communal ‘our’ (sunu) aspects. The value of sunu, such as social cohesion , is considered necessary leverage for community participation, and is associated with increased participation in healthier acts  It’s not easy for the doctors to identify all sick persons in the communities. If there is a representative in the village who can support [sick persons] is good. – VHW, village-17VHWs are an important link between communities and health systems. Often they are perceived as being a ‘facilitator’, ‘mediator’, or ‘broker’ to deliver health care on behalf of health systems or vertical health interventions  is from you (MRCG nurses/fieldworkers), we will take it. But if [the VHW] gives us the medicine, we will be more comfortable with that because he is the one we know. – Compound head, village-17However, community embeddedness alone is insufficient to bridge the community and health system  with the government. When we delegate him, he always does his best. – Alkalo, Village-4Moreover, in the study area, VHWs were often linked to influential personages in society such as the Alkalo or the head of Village Development Committee (VDC). Similarly, they often had reputations of being active in community development. In this manner, VHWs were endowed with structural advantages  to execute their role and responsibility as health diplomats. This structural advantage was likely to allow VHWs to advocate to address health disparities and related economic, social, and political issues of communities  staff coming to collect data from me. They have more trust [in me] now because they are seeing (MRCG) doctors coming to me. – VHW, village-7Nonetheless, going up the political ladder does not happen in an instant. For instance, a relatively young (~late 20s) and newly appointed VHW usually relied on higher powers and the hierarchy above him to enhance his role.Alkalo about it. […] You know if I mention my name probably many would not come. So, if I want a meeting, I just go to the Alkalo and inform him about it. [Then] meetings [are] always successful. – VHW, village-4Whenever I want to summon a meeting, I inform Throughout countless interactions with VHWs in the study area, we encountered many situations where VHWs advocated community health and through these acts simultaneously claimed their political position. We witnessed a VHW actively advocating to get water pumps in the village, in front of influential community members, stating: To serve as functional health diplomats who advocate to address health disparities, VHWs should be able to perform social and medical roles, such as mobilising local populations to receive antenatal care, vaccination, or malaria treatment . Indeed,Table Table Table He (VHW) is doing great work here. You know, if you are sick you can go to him or he would pack his stuff and come to your compound. He is very willing and active. That is the reason why some people who were not interested in the [trial] are now all willing to participate. – Marabout/Compound head, village-4While well-equipped VHWs in general tend to improve access to care, they can also contribute to intra-village inequalities. VHWs, as village residents, depended on their social networks  said, “when you [become VHW] there is no payment, but the villagers would help and weed your farm for you”. But when it starts raining and you have not sown your farm, will you think of helping another person? The farm is spoiled before you realise. […] People will not [support] me because even today after you (MRCG) leave, they will think you have given me money. – VHW, village-2Moreover, some community members perceived that VHWs were not sharing but “eating” the benefits  People will perceive that I always don’t have medicine so it’s better not to go to [VHW]. – VHW, village-5Naturally, many VHWs expressed that they ogrammes , 42 and ogrammes .Lack of Accounting for the political status of the VHWs and integrating their socio-political dynamics in health programmes is vital for reinforcing community participation. We used an iterative and interactive community participatory approach, the Community Lab of Ideas for Health (CLIH)  to gain Finally, a stronger political commitment to support VHWs, not only in technical/medical support but also in their socio-political environment, is required , 6, 16. In the rural Gambian context, VHWs are trusted representatives of a community who have the capacity to negotiate with external institutions and advocate a community’s healthy living. Our study showed that VHWs could contribute to reducing health-related burdens in their community, by campaigning for better access to health care services and adequately being equipped with medical tools. We noted VHWs aspiration to take a political role and furthermore acknowledged them as health diplomats – respected and valued members of their communities who are capable to bring benefits. We argue that, in the context of rural Gambia, supporting VHWs beyond medical roles but also in social and political roles contributes to the improved performance of VHWs and community participation in activities that communities perceive beneficial.