‘What a pity!’ – Exploring the use of ‘pitilho’ as harm reduction among crack users in Salvador,Brazil

Aims: The aim of this study was to explore the use of ‘pitilho’ (the co-smoking of crack and marijuana in a cigarette-like form) among crack users in Salvador, Brazil as a potential harm reduction measure.

Methods: In-depth interviews were conducted with two outreach workers who frequently encountered the use of ‘pitilho’ as part of their community outreach programme work, as well as four ‘pitilho’ users who were clients of the programme. Daily field notes were also collected. Transcribed data were analysed for common reasons for ‘pitilho’ use.

Findings: Several key reasons crack users have adopted the ‘pitilho’ as a harm reduction tool were uncovered: it was reported to reduce the negative pharmaco-behavioural and physical effects of crack use, is more economical, provides users with better control over their behaviours, and decreases their vulnerability for violence and betters their sub-cultural position.

Conclusions: ‘Pitilho’ may offer several relevant short-term benefits to users and therefore may constitute a potentially important ‘harm reduction’ tool in an area where little other targeted prevention measures exist. Our exploratory data need to be investigated in depth by appropriate and rigorous methods.     

Applying a diffusion of innovations framework to the scale-up of direct-acting antiviral therapies for hepatitis C virus infection: Identified challenges for widespread implementation

Background and AimsInterferon-free, direct-acting antivirals (DAAs) for hepatitis C virus (HCV) offer much promise to achieve World Health Organization targets by 2030. However, impediments at the practitioner and health-system level will continue to obstruct the scale-up of DAAs worldwide unless identified and acted upon. Applying a diffusion of innovations framework, the aim of this study was to identify structural factors impacting practitioner experiences of managing HCV treatment.MethodsIn-depth, semi-structured, telephone interviews took place between September 2018 and April 2019 to investigate barriers and facilitators for engaging in HCV management and DAA therapy amongst general practitioners (GPs) who prescribe opioid agonist therapy and drug and alcohol specialists in Australia. Interviews were transcribed verbatim, de-identified, and coded, and data were analysed with iterative categorisation and thematic analysis using Everett Rogers's diffusion of innovation framework.Resultsamongst 30 participants (12 GPs, 18 drug and alcohol specialists), several structural factors were reported to impede practitioner efforts to deliver optimal HCV care. Two primary themes were explored: contextual factors for the diffusion of DAA therapies, including attempts by participants to shift clinic culture and respond to siloed health structures, and adopter factors. Some participants chose to ‘rock the boat’ by circumventing clinic protocol and HCV guidelines to treat more clients, effectively shifting adopter categories to become greater advocates in HCV care. Also, while a role for GPs as the ‘new adopters’ in HCV management was discussed, many participants expressed uncertainty as to how much GPs should become involved in the diffusion of DAA therapies more widely.ConclusionsReducing the global burden of HCV infection will not be possible without the widespread delivery of HCV treatment amongst practitioners. Practitioners and health workers require leadership and resources from health authorities so that the individual and population-level benefits of DAA therapy are realised.     

Making legitimacy: Drug user representation in United Nations drug policy settings

BackgroundThe importance of engaging people who use drugs in drug policy development is increasingly acknowledged including in recent UN documents. Little scholarly attention has been paid to ‘drug user representation’ in the global drug policy setting of the UN such as the Commission on Narcotic Drugs (CND). This paper examines ‘drug user representation’ in key UN drug policy processes over three decades.MethodA mapping process was undertaken using a corpus of publicly available documents from the UNGASS on Drugs and associated CND processes to identify relevant policy processes from 1987 to 2019 (n = 15) which were then assess for presence/absence of ‘drug user representation’. Those processes with positive evidence of ‘drug user representation’ (n = 9) were critically interrogated across three co-constitutive domains of the subjects, objects and forms of ‘drug user representation’.ResultsOur analysis shows that despite calls for greater involvement, dominant UN drug policy discourses and other practices delimit both the political subjectivities available to people who use/have used drugs and their capacity to bring their voices to bear in this context. The analysis also highlights that human rights-based discourses, employed by ‘drug user representatives’, have emerged as an important practice of resistance against the problematic and delimiting power effects of existing UN discourses, governing practices and modes of engagement.ConclusionsIn addition to the practices of resistance being undertaken by ‘drug user representatives’, we suggest there is a need to improve how ‘drug user representation’ is being made possible and done in the sites of UN drug policy deliberation and, that these sites should be opened for questioning. This we argue will not only have a positive impact on political legitimacy for ‘drug user representation’, but on the health and human rights of people who use/have used drugs.     

New Zealand community pharmacist attitudes toward opioid-dependent clients

Aim: To survey New Zealand community pharmacists to explore levels of training, attitudes towards providing services for drug users, and associations with current and past practice.

Methods: Postal survey of 898 randomly selected community pharmacists. Questions included demography, training and a 20-question attitude scale. Principle component analysis was conducted to identify the main attitude factors. Multiple linear regressions were used to model the effect of different independent variables on the factors.

Findings: Twenty-six percent of respondents had previously undertaken training about the management of opioid misuse. Four principal factors explained 57% of the variance within the attitude questions. These were attitudes towards: ‘the general results of dispensing methadone to opioid misusers’; ‘the effect of opioid-dependent clients on a pharmacy’; ‘reducing harm associated with drug use’; and ‘engaging with drug users’. Training (having it or wanting to have it) was positively associated with the four attitude factors.

Conclusions: The results of this study indicate that attitudes towards various aspects of service provision to drug misusers may not be as simple as previously perceived.     

Initial outcomes of integrated community-based hepatitis C treatment for people who inject drugs: Findings from the Queensland Injectors’ Health Network

BackgroundIntegrated treatment and harm reduction services provide a unique opportunity to facilitate direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV)-infected people who inject drugs (PWID). We examine outcomes of community-based delivery of DAA therapy for PWID.MethodsThe Queensland Injectors’ Health Network (QuIHN) is a community-based agency providing harm reduction and treatment services. Data (including current injecting, involvement in opioid substitution therapy and other treatment, level of case management support) for participants initiating DAA therapy were collected. The primary endpoint was sustained virological response at 12 weeks (SVR) after the end of therapy.ResultsBy the end of February 2017, 127 treatment clients who consented for research had completed therapy and were due for post-treatment sustained virological response (SVR) testing. In an intent-to-treat analysis, 96% completed their course of prescribed treatment, 80% had confirmed SVR and 92% adhered to treatment. There were no confirmed cases of treatment non-response. The clients without confirmed SVR (20%) had not attended their post-treatment test. No client characteristics, including involvement in less-than-daily (odds ratio (OR) 0.27, 95% confidence interval (CI): 0.06–1.17) or daily injecting drug use (OR 0.65, 95% CI: 0.17–2.43) were associated with non-attendance at the SVR test.ConclusionPWID can be effectively treated for HCV and comply with DAA therapy in an integrated community-based service. However, strategies are required to support client retention until SVR is confirmed.     

Computer tablet or telephone? A randomised controlled trial exploring two methods of collecting data from drug and alcohol outpatients

ObjectiveBoth computerised and telephone surveys have potential advantages for research data collection. The current study aimed to determine the: (i) feasibility, (ii) acceptability, and (iii) cost per completed survey of computer tablet versus telephone data collection for clients attending an outpatient drug and alcohol treatment clinic.DesignTwo-arm randomised controlled trial.MethodClients attending a drug and alcohol outpatient clinic in New South Wales, Australia, were randomised to complete a baseline survey via computer tablet in the clinic or via telephone interview within two weeks of their appointment. All participants completed a three-month follow-up survey via telephone.ResultsConsent and completion rates for the baseline survey were significantly higher in the computer tablet condition. The time taken to complete the computer tablet survey was lower (11 min) than the telephone condition (17 min). There were no differences in the proportion of consenters or completed follow-up surveys between the two conditions at the 3-month follow-up. Acceptability was high across both modes of data collection. The cost of the computer tablet condition was $67.52 greater per completed survey than the telephone condition.ConclusionThere is a trade-off between computer tablet and telephone data collection. While both data collection methods were acceptable to participants, the computer tablet condition resulted in higher consent and completion rates at baseline, therefore yielding greater external validity, and was quicker for participants to complete. Telephone data collection was however, more cost-effective. Researchers should carefully consider the mode of data collection that suits individual study needs.     

The Role of Physician and Nurse Attitudes in the Health Care of Injecting Drug Users

In 2005, 60 health care workers were recruited through services that attract injecting drug users (IDUs) and asked to complete attitude measures regarding IDU clients. Mediation analyses indicated that conservative health care workers displayed more negative attitudes toward their IDU clients because they believe that injecting drug use is within the control of the IDU. Negative attitudes toward IDU clients, in turn, were associated with worry about IDU clients’ behavior in the clinic and with beliefs that IDU clients should disclose their hepatitis C status to their health care worker. Perceptions of controllability of drug use were also associated with the belief that IDU clients’ ailments were caused by their IDU status. The study's limitations are noted.     

Factors Contributing to Retention of Not-in-Treatment Drug Users in an HIV/AIDS Outreach Prevention Project

SUMMARY

Studies have attempted to identify the characteristics of substance-abusing clients that are related to premature termination from alcohol and drug treatment. Few studies, however, have looked at predictors of loss to follow-up among drug users participating in HIV/AIDS prevention projects. This paper develops and tests models of program retention employing data from approximately 250 not-in-treatment drug users enrolled in an outreach based HIV risk reduction program. Logistic regression was used to fit a model which included measures of: (1) demographic characteristics including: age and ethnicity; (2) social environmental factors including: living situation and type of network connection; (3) risk behaviors including: composite scores for drug use in the past 30 days and history of Sexually Transmitted Diseases (STDs); and (4) program factors including: outreach workers' knowledge of clients and number of intervention sessions received. Findings suggest that social environmental and program factors are most predictive of client retention in the program. Implications for ways in which to monitor retention of out-of-treatment drug users participating in AIDS prevention programs are addressed.     

‘Surfing the Silk Road’: A study of users’ experiences

IntroductionThe online drug marketplace called ‘Silk Road’ has operated anonymously on the ‘Deep Web’ since 2011. It is accessible through computer encrypting software (Tor) and is supported by online transactions using peer to peer anonymous and untraceable crypto-currency (Bit Coins). The study aimed to describe user motives and realities of accessing, navigating and purchasing on the ‘Silk Road’ marketplace.MethodsSystematic online observations, monitoring of discussion threads on the site during four months of fieldwork and analysis of anonymous online interviews (n = 20) with a convenience sample of adult ‘Silk Road’ users was conducted.ResultsThe majority of participants were male, in professional employment or in tertiary education. Drug trajectories ranged from 18 months to 25 years, with favourite drugs including MDMA, 2C-B, mephedrone, nitrous oxide, ketamine, cannabis and cocaine. Few reported prior experience of online drug sourcing. Reasons for utilizing ‘Silk Road’ included curiosity, concerns for street drug quality and personal safety, variety of products, anonymous transactioning, and ease of product delivery. Vendor selection appeared to be based on trust, speed of transaction, stealth modes and quality of product. Forums on the site provided user advice, trip reports, product and transaction reviews. Some users reported solitary drug use for psychonautic and introspective purposes. A minority reported customs seizures, and in general a displacement away from traditional drug sourcing (street and closed markets) was described. Several reported intentions to commence vending on the site.ConclusionThe study provides an insight into ‘Silk Road’ purchasing motives and processes, the interplay between traditional and ‘Silk Road’ drug markets, the ‘Silk Road’ online community and its communication networks.     

Famciclovir: a focus on efficacy and safety

Importance of the field: Famciclovir is the prodrug of penciclovir, a guanosine analogue that inhibits viruses of the α sub-family of the Herpesviridae, as well as hepatitis B virus. It is indicated for management of mucocutaneous herpes simplex virus disease and acute herpes zoster, and has been investigated for management of hepatitis B virus infection.

Areas covered in this review: Data for this review were identified by searches of papers published in English on Medline and Scopus, spanning the years 1975 through 1 February 2010 with the key words: ‘famciclovir’, ‘famvir’, ‘penciclovir’, ‘herpes’, ‘oral’, ‘genital’, ‘varicella’, ‘zoster’ and ‘virus’ in association with ‘safety’, ‘toxicity’, ‘tolerability’, ‘efficacy’ and ‘indications’. Relevant references were also obtained from articles acquired through the search strategy.

What the reader will gain: Readers are also provided with up-to-date information on the use of famciclovir for infections due to herpes simplex, varicella zoster and hepatitis B viruses. Clinical data pertaining to the safety and tolerability of famciclovir are also reviewed.

Take home message: Famciclovir is a safe, convenient, and well-tolerated drug when used for its approved indications. The most common side effects indicated in the majority of studies were headache and nausea. Data for its use in childhood and pregnancy are limited.     

How to build trustworthy hepatitis C services in an opioid treatment clinic? A qualitative study of clients and health workers in a co-located setting

BackgroundGiven the increasing burden of hepatitis C (HCV) related liver disease, innovative health care models are required to extend the reach of HCV care and treatment. Opioid substitution treatment (OST) clinics are places of high HCV prevalence. The OST clinic is a complex environment, quite distinct to other health care settings, with punitive regulations and practices, and a client population likely to be mistrustful of systems of authority. Nonetheless, trust is widely documented as essential to effective therapeutic encounters. This paper examines what is required to develop a trustworthy service in a place, the OST clinic, described by some critics as a site of “social control”.MethodsIn-depth interviews were conducted with 57 clients and 19 staff from four NSW pilot clinics participating in the Australian ETHOS study.ResultsInterview data were examined using Hall's framework of trust, involving five principle domains: fidelity, competence, honest, confidentiality and global trust. ‘Honesty’ was found to be key to participants’ establishing trust in the co-located service and its staff. However, the clinic site was also found to be a place of rationed trust, in which the themes of OST as “ruling peoples’ lives” and the fear of repercussions resulting from perceived transgressions against clinic rules, threatened to over-ride or undermine the development of trust in HCV services. Client participants described trusting health workers “to a point”. They expressed concerns about the fidelity of co-located HCV and OST services and described fears of “institutionalised lies” and breaches of confidentiality. Anxieties around the latter revealed a sense of “us and them” held by some clients, one in which health workers were perceived to “stick together” by putting their own interests before those of the clients.DiscussionAlthough the co-location of HCV and opioid treatments makes intuitive policy sense, HCV health workers in the OST space may be seen as representatives of a deeply mistrusted system. For the effective development of a trustworthy HCV care service, policy and practice activities are required to engender trust through clearly articulated explanations of service boundaries and the promotion of “success stories” through trusted peer networks.     

The role of evidence and the expert in contemporary processes of governance: The case of opioid substitution treatment policy in England

BackgroundThis paper is based on research examining stakeholder involvement in substitution treatment policy which was undertaken as part of the EU funded FP7 ALICE-RAP (Addictions and Lifestyles in Contemporary Europe – Reframing Addictions Project). In England, the research coincided with a policy shift towards a recovery orientated drug treatment framework and a heated debate surrounding the role of substitute prescribing. The study aimed to explore the various influences on the development of the new ‘recovery’ policy from the perspectives of the key stakeholders involved.MethodsThe paper is based on documentary analyses and key informant interviews with a range of stakeholders, including representatives of user organisations, treatment providers, civil servants, and members of expert committees.ResultsDrawing on the theoretical insights offered by Backstrand's ‘civic science’ framework, the changing role of evidence and the position of experts in the processes of drugs policy governance are explored. ‘Evidence’ was used to problematise the issue of substitution treatment and employed to legitimise, justify and construct arguments around the possible directions of policy and practice. Conflicting beliefs about drug treatment and about motivation for policy change emerge in the argumentation, illustrating tensions in the governance of drug treatment and the power differentials separating different groups of stakeholders. Their role in the production of evidence also illustrates issues of power regarding the definition and development of ‘usable knowledge’. There were various attempts at greater representation of different forms of evidence and participation by a wider group of stakeholders in the debates surrounding substitution treatment. However, key national and international experts and the appointment of specialist committees continued to play dominant roles in building consensus and translating scientific evidence into policy discourse.ConclusionSubstitution treatment policy has witnessed a challenge to the dominance of ‘scientific evidence’ within policy decision making, but in the absence of alternative evidence with an acceptable credibility and legitimacy base, traditional notions of what constitutes evidence based policy persist and there is a continuing lack of recognition of ‘civic science’.     

Barriers to hepatitis C treatment among secondary needle and syringe program clients and opportunities to intervene

BackgroundAt least 160,000 Australians are living with hepatitis C (HCV), many of whom are people who inject drugs and access needle and syringe programs (NSP). Secondary NSPs provide injecting equipment via health services that are not dedicated to the provision of services to people who inject drugs; these sites could be a suitable space to increase engagement of people who inject drugs in HCV treatment. Drawing on data from a pilot study exploring the potential of upscaling linkage to HCV care in secondary NSPs, the aim of this research was to explore barriers and enablers to HCV treatment for clients who use these services.MethodsWe interviewed 34 people who inject drugs (who self-reported HCV positivity) from six secondary NSPs in urban and regional Victoria, Australia in 2018. Fifty per cent were male, with ages ranging from 33 to 58. Twenty-two (65%) had never received HCV treatment and none had experience with direct-acting antiviral (DAA) treatment. Interviews were transcribed and analysed thematically. Field notes from a program evaluation with feedback from secondary NSP staff was also used as a secondary data source.ResultsFive themes encompassing a set of contrasting barriers and enablers to accessing HCV care through secondary NSPs were uncovered. Themes included ‘misinformation’ vs. ‘multiple trusted information sources; ‘lack of symptoms and motivation’ vs. ‘benefits of cure’; ‘competing priorities’ vs. ‘willingness and readiness to be cured’; ‘unsupportive relationships with staff’ vs. ‘supportive relationships with staff’; and ‘inaccessibility and stigma in health services’ vs. ‘enhanced support’. Secondary program evaluation data also highlighted that secondary NSP staff were under-resourced and had limited capacity to implement HCV care linkage and information.ConclusionWe identified contrasting barriers and opportunities for accessing DAAs among a sample of secondary NSP clients and staff. Interventions that consider individual, provider and health system level factors are needed if secondary NSP services are to become a suitable setting to initiate conversations with clients around HCV treatment and provide linkages to care.     

Exploring factors of uneven use of telehealth among outpatient pharmacy clinics during COVID-19: A multi-method study

BackgroundTo enable services to be provided at a distance during the COVID-19 pandemic, outpatient pharmacy services in Australia underwent near-immediate reform by moving to telehealth, including telephone and video consults.ObjectiveTo investigate how telehealth was used in a metropolitan outpatient pharmacy setting before and after the start of the COVID-19 restrictions and the various influences on the uptake of phone and video modalities.MethodsA multi-methods approach was used including: (1) quantifying administrative activity data between July 2019 to December 2020 and, (2) semi-structured interviews with key stakeholders (n = 34).ResultsActivity data: Between July 2019 to December 2020 16,377 outpatient pharmacy consults were provided. Of these, 13,543 (83%) were provided in-person, 2,608 (16%) by telephone and 226 (1.4%) by video consult. COVID-19 impacted how these services were provided with telephone activity more than four-times higher in April 2020 than March 2020 and slight increases in video consults. Pharmacists have heavily favoured using the telephone despite the recommendation that video consults be used as the primary mode of contact and that telephone only be used when a video consult was not possible. As soon as COVID-19 restrictions eased, clinicians gradually returned to in-person appointments, maintaining some use of telephone and very limited use of video consult. Semi-structured interviews: Whilst clinicians recognised the potential benefits of video consults, challenges to routine use included the additional administrative and planning work required pre-consult, perceptions that patients were unable to use the technology, and the belief that in-person care was ‘better’ and that the telephone was easier.ConclusionOrganisational strategies that encouraged the use of video over telephone (e.g. through financial incentives) did not appear to influence clinicians’ choice of care modality. Implementation studies are required to co-develop solutions to embed telehealth options into outpatient pharmacy settings that provide the best experience for both patients and clinicians.     

Pharmacological management of osteoporosis – when to treat and when to stop

Introduction: Bisphosphonates are antiresorptive drugs of proven efficacy which are widely used for osteoporosis. After stopping bisphosphonate therapy, residual therapeutic effects persist for an undefined period; thus, some osteoporotic patients could benefit from a temporary discontinuation, the so called ‘drug holiday’.

Areas covered: We reviewed the effects of discontinuing various anti-fracture treatments in order to clarify both clinical features of patients for whom a drug holiday from an initial bisphosphonate treatment period could be offered and a possible approach to the management of the drug holiday. A PubMed search was undertaken using the following main search terms: ‘bisphosphonates’, ‘drug holiday’, ‘treatment discontinuation’, ‘anti-fracture drugs’.

Expert commentary: After an initial bisphosphonate treatment period of 3–5 years, fracture risk should be reassessed in order to decide if a drug holiday could be offered to patients. Those at high fracture risk should continue treatment; those at moderate-mild fracture risk could temporarily discontinue treatment.     

First insights into community pharmacy based buprenorphine-naloxone dispensing in Finland

BackgroundFinnish community pharmacies have been permitted to dispense buprenorphine-naloxone since February 2008. This study explored the dispensing practices, service experiences, problems encountered and opportunities for future development.MethodsIn August 2011, a questionnaire was mailed to all Finnish community pharmacies dispensing buprenorphine-naloxone (n = 69).ResultsSixty-four pharmacies responded (93%), of which 54 had dispensed buprenorphine-naloxone to 155 clients since 2008. Forty-eight pharmacies had 108 current clients (10% of all buprenorphine-naloxone clients in Finland). Overall satisfaction with buprenorphine-naloxone dispensing was high, with all respondents indicating dispensing had gone ‘well’ or ‘very well’. Fourteen pharmacies (26%) had experienced one or more problems, predominately in relation timing or non-collection of doses. Problems were more common in pharmacies with more than one buprenorphine-naloxone client (odds ratio 1.39, 95% confidence interval 1.05–1.86). Most pharmacies (n = 43, 80%) identified opportunities for improvement, including the need for more education and financial remuneration. Forty-six pharmacies (85%) were willing to dispense buprenorphine-naloxone to more clients; however, 43 pharmacies (80%) perceived that supervision of buprenorphine-naloxone dosing is not a suitable task for pharmacists in Finland.ConclusionProvision of buprenorphine-naloxone in Finnish community pharmacies has remained relatively small-scale. As experiences have been generally positive and problems rare, it may be possible to expand these services.     

Peer outreach point-of-care testing as a bridge to hepatitis C care for people who inject drugs in Toronto,Canada

BackgroundPeople who inject drugs have high rates of hepatitis C (HCV) and yet many remain undiagnosed and untreated. HCV treatment guidelines and elimination strategies recommend task-shifting to expand where, and by whom, HCV testing and care is delivered.MethodsA randomized controlled trial design was used to evaluate if point-of-care (POC) HCV antibody testing by peer outreach workers outside of health and social service spaces would improve engagement in HCV care. People with a lifetime history of injection drug use without prior knowledge of HCV antibody status were randomized to receive HCV outreach plus either POC or referral to community-based HCV program for testing as usual. The study was co-designed by people with lived experience of HCV.Results920 people were approached to participate over 14 weeks. After refusals, withdrawals and removal of duplicates, there were 380 study participants. Outreach took place primarily in public spaces (66%) such as parks, coffee shops and apartment lobbies. Participants reported very high rates of poverty, housing instability and recent injection drug use. Despite being at high risk for HCV, 61% had no history or knowledge of past HCV testing (n = 230). Of those who received a POC test 77/195 (39%) were positive for HCV antibodies. There was no change in rates of engagement in HCV care among those who received the POC (n = 6; 3%) compared to those who did not (n = 5; 3%).ConclusionPeer outreach workers were able to efficiently reach a marginalized group of individuals who had a high HCV antibody prevalence and low rates of prior HCV testing. This improved participants’ knowledge of their HCV antibody status, but that knowledge in itself did not lead to any change in participant's subsequent engagement in HCV care. Future work is required to evaluate strategies such as incentives or peer navigators to improve linkage to HCV care after diagnosis.     

Peer to peer communication about hepatitis C treatment amongst people who inject drugs: A longitudinal qualitative study

BackgroundLittle is known about how information on direct-acting antiviral treatment for hepatitis C circulates through peer networks of people who inject drugs. In this study we aimed to explore what and how treatment-related information is shared between people undergoing treatment and their peers.MethodsParticipants were recruited from two general practice clinics and the community-based hepatitis C Treatment and Prevention Study. Semi-structured interviews were conducted with each participant (N = 20) before, during and following treatment. Interviews explored hepatitis C treatment experiences, key sources of DAA information and the impact of receiving and sharing knowledge. Inductive thematic analysis was conducted. Time sequential matrices were generated to understand thematic change over time.ResultsFifty-four interviews were conducted with 20 participants across seven field-sites in Melbourne, Australia. Key themes were: ‘peers as a source treatment information’, ‘do it together’ and ‘becoming a treatment advocate’. Peers were a crucial trusted source of information. Positive treatment anecdotes were important for building confidence in and motivation to initiate treatment. Many participants adopted a ‘treatment advocate’ role in their close peer networks, which was described as empowering. Some participants described benefits of undertaking treatment alongside members of their close network.ConclusionFindings illustrate the importance of close peers in shaping treatment perceptions and engagement. This will be important in designing health promotion messaging and interventions to increase treatment uptake.