The peer paradox: Perspectives from HIV service providers to inform the implementation of an enhanced social network strategy for black sexual and gender minorities-a qualitative study.

Background: The CDC's Social Network Strategy (SNS) is an evidence-supported approach to increase reach for HIV testing among members of marginalized populations. Leveraging social networks could improve access to HIV services, like pre-exposure prophylaxis and antiretroviral therapy, particularly for members of Black sexual and gender minority (BSGM) groups. We explored key barriers and facilitators prior to implementing an enhanced SNS (eSNS) to increase access to a broader range of HIV prevention and treatment services among BSGM in an Ending the HIV Epidemic jurisdiction in the US South.

Methods: Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted four focus groups with 19 HIV services staff members and 12 in-depth interviews with local health department officials, clinicians, and community-based organization leaders pre-implementation. Transcripts were coded by applying constructs from the CFIR and we identified themes about potential barriers and facilitators to implementing eSNS from potential implementers.

Results: We identified three themes, each of which reflect a delicate and paradoxical balance between trust and mistrust that operates within social networks. Each theme represents a "Peer Paradox", wherein eSNS core components may have unpredictable effects on trust and mistrust within peer networks. The Incentives Paradox captures how financial incentives work synergistically with interpersonal ties to strengthen engagement with HIV services but also introduces a transactional element into peer-to-peer interactions. The Readiness Paradox is the perception that BSGM individuals best positioned to recruit peers who could most benefit from HIV services may require the greatest amount of additional support in delivering eSNS. The Credibility Paradox reflects a concern that although trust among peers may be harnessed to disseminate health information and increase acceptance of HIV services, peers may not be considered credible sources of HIV information.

Conclusions: Disruptions to the interplay of trust and mistrust within peer networks may influence the effectiveness of the eSNS intervention. These findings suggest that public health practitioners implementing SNS or similar social networking interventions should identify and address specific obstacles to fostering trust before and during implementation. We recommend considering strategies that address peer credibility, readiness, and the impact of financial incentives in social network interventions.