Advancing a cascading train-the-trainer model of frontline HIV service providers in South Africa: protocol of an implementation trial

Background South Africa is marked by high rates of both HIV and alcohol use, and there is a detrimental synergistic relationship between these two epidemics. The Institute of Medicine recommends integrated care for alcohol use treatment and HIV, but implementation of integrated services remains a challenge in South Africa. This protocol describes a study designed to evaluate trainer, provider-, and patient encounter-level outcomes relating to the national rollout of a cascade train-the-trainer model of task-sharing to build capacity of the HIV workforce to deliver Screening, Brief Intervention, and Referral to Treatment (SBIRT) to address risky alcohol use. Methods This 5 year protocol consists of two phases. First, we will finalize development of a robust SBIRT train-the-trainer model, which will include an SBIRT Trainer Manual, Provider Resource Guide, fidelity observational coding system, case vignettes, and a curriculum for ongoing consultation sessions. Materials will be designed to build the capacity of novice trainers to train lay workers to deliver SBIRT with fidelity. Second, we will recruit 24–36 trainers and 900 providers in order to evaluate the effects of the SBIRT train-the-trainer model on trainer- (e.g., fidelity, knowledge), provider- (e.g., SBIRT attitudes, confidence, acceptability), and patient encounter- (e.g., proportion receiving screening, brief intervention, referral to treatment) level variables. Data on patient encounters will be tracked by providers on programmed tablets or scannable paper forms in real-time. Providers will report on SBIRT delivery on an ongoing basis over a 6-months period. Additionally, we will test the hypothesis that trainer-level factors will account for a substantial proportion of variability in provider-level factors which will, in turn, account for a substantial proportion of variability in patient encounter-level outcomes. Discussion This protocol will allow us to take advantage of a unique national training initiative to gather comprehensive data on multi-level factors associated with the implementation of SBIRT in HIV service settings. In the long-term, this research can help to advance the implementation of integrated alcohol-HIV services, providing lessons that can extend to other low-and-middle income countries confronting dual epidemics.