Bridging systems and selves: a qualitative exploration of peer navigation as a developmentally tailored engagement strategy for adolescent HIV services

Abstract

BACKGROUND: Adolescent peer navigation is a promising strategy to improve engagement and health outcomes among adolescents living with HIV (ALHIV), yet youth-focused models remain underdeveloped and poorly documented, particularly in low- and middle-income countries. The Moi Teaching and Referral Hospital (MTRH) Rafiki Centre in Eldoret, Kenya-one of Africa's largest adolescent health centers-employs young adults living with HIV as peer navigators to support clients aged 14-24. Peer navigators meet defined eligibility criteria, including secondary school completion, ART adherence, and viral suppression, and are employed until age 25. Their compensation is supported primarily by USAID/PEPFAR-funded annual stipends, placing them outside formal health workforce structures and limiting access to employment benefits. This study addresses a critical evidence gap by providing an in-depth analysis of the structure, functioning, and perceived impact of this adolescent peer navigator model. METHODS: In June 2024, we conducted semi-structured qualitative interviews with 23 participants: eight current peer navigators, six former navigators, and nine health care workers who supervise or collaborate with peers. Interviews explored peer roles, training, supervision, program strengths and challenges, and perceived effects on adolescent outcomes. Audio-recorded interviews were transcribed and analyzed using reflexive thematic analysis, combining deductive codes based on interview domains with inductively generated themes. RESULTS: Participants described peer navigators as central to adolescent engagement, trust-building, and improved clinical and psychosocial outcomes. Shared lived experience allowed peers to normalize HIV, promote adherence, reduce stigma, facilitate disclosure, and strengthen adolescents' self-acceptance and coping. Peer navigation functioned as a bidirectional bridging mechanism: peers guided adolescents through clinical and social systems while conveying youth realities back to providers, enhancing responsiveness and equity. Peers, however, reported significant emotional burden, safety concerns during community visits, and challenges maintaining boundaries with clients. Structural vulnerabilities were prominent; reliance on donor-funded stipends without formal recognition, living wages, or benefits created job insecurity, undermined professional legitimacy, and threatened program sustainability. CONCLUSIONS: The Rafiki Centre's program demonstrates how adolescent peer navigation can advance youth-friendly HIV care by integrating lived experience into health systems in ways that improve adherence, reduce stigma, and enhance psychosocial well-being. Yet the same features that make peer navigation effective also create vulnerabilities that require institutional support. Strategic frameworks and institutional structures that allow timely and honorable entry and exit of peer roles, support in transitioning to other opportunities, and protections for physical, emotional and financial safety are essential for sustaining and scaling this developmentally attuned, equity-promoting model of adolescent HIV care.