“I can be a source of motivation”: Perspectives from stakeholders of the I’mPossible fellowship, a peer-led differentiated service delivery model for adolescents with perinatally acquired HIV in India

Abstract Youth living with HIV (YLHIV) face multidimensional challenges, including stigma, mental health struggles, and socioeconomic instability, which are further magnified among adolescents and young adults with perinatally acquired HIV (APHIV). Peer-led differentiated service delivery (DSD) models providing tailored support for this population have demonstrated improved outcomes, though their adaptation and implementation in India remain underexplored. We examined multi-stakeholder perceptions within a peer-support DSD intervention in India, the I’mPossible Fellowship, designed to address the health, educational, and livelihood needs of APHIV. Between May and December 2023, we enrolled three stakeholder groups involved in the I’mPossible fellowship intervention: (1) intervention deliverers (APHIV “fellows”), (2) facilitators (“supervisors” of APHIV), and (3) beneficiaries (APHIV “peers”). To examine fellows’ roles and growth, we conducted in-depth interviews with fellows (n=8; 75% female; mean age: 22.5 years) and supervisors (n=7). Aiming to explore fellow-peer interactions and perceived program impact, we conducted three focus group discussions with purposefully sampled peers (n=18; 66.7% male; mean age: 16.7 years). Data collected were audio recorded, transcribed, and translated from Kannada to English for coding and analysis. Thematic deductive analysis was combined with data triangulation across participant groups to synthesize findings. Five key themes emerged, highlighting the layered influences of the I’mPossible Fellowship. First, mentorship was an important theme that provided informational and emotional support for peers; second, peer influence arising from peer-to-peer interactions contributed to a sense of trust and affirmation. Third, personal growth experienced by fellows stimulated their motivation to fulfil their mentorship roles effectively. Fourth, complex systemic challenges, such as stigma and discrimination, hindered educational and employment advancement of APHIV. Fifth, sustainability, through robust post-fellowship systems and continued mentoring support, was emphasized by supervisors and fellows as crucial for supporting APHIV in transitioning to independent living. This study highlights the pivotal role of fellows and the bi-directional power of peer mentorships in addressing the multilevel factors that enhance outcomes for APHIV. By providing knowledge and empathy to their peers and serving as credible role models with lived experience of HIV, fellows within the I’mPossible fellowship exemplify a successful DSD model incorporating the three essential attributes of peer support: informational, emotional, and affirmative support. While these findings underscore the importance of integrating peer-led interventions into HIV care frameworks to support youth with HIV, this also reframes youth as active agents of change, recognizing their capacity for empowerment and meaningful societal contribution rather than passive recipients of care. Competing Interest Statement The authors have declared no competing interest. Funding Statement The study was partly funded through the Rishi Children’s Fund at the Department of International Health at Johns Hopkins Bloomberg School of Public Health and support received by LG from the National Institute on Drug Abuse of the National Institutes of Health (K23DA057151). Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study received approval from the Institutional Review Boards of the YR Gaitonde Centre for AIDS Research and Education in Chennai, Tamil Nadu (#YRG375) and the Johns Hopkins Bloomberg School of Public Health in the United States (#IRB00023077). Adult participants provided oral informed consent for their participation. For participants <18 years, oral consent was obtained from their parents or legal guardians, and oral assent from the minor participants themselves. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability The data analyzed in this study were collected as part of a qualitative research project. Relevant excerpts from participant transcripts are included within the paper. De-identified data used in this study may be accessed upon reasonable request to the corresponding author. Abbreviations - APHIV - Adolescents and Young Adults with Perinatally Acquired HIV - ART - Antiretroviral Treatment - CCI - Childcare Institution - DSD - Differentiated Service Delivery - FGD - Focus Group Discussion - HIV - Human Immunodeficiency Virus - IDI - In-Depth Interview - SEM - Socio-ecological Model - YLHIV - Youth Living with HIV