Tensions in relation: How peer support is experienced and received in a hepatitis C treatment intervention.

Peer support and involvement is recognised as a vital component of hepatitis C (HCV) treatment provision for marginalised populations, such as people who inject drugs (PWID). Developments in HCV treatments enable increased provision in community settings - expanding the possibilities for meaningful peer involvement in HCV treatment plans. To date, HCV peer support has generally been viewed as a positive intervention, with little critical reflection on the ways social structures, policies, health and drug services and social identity impact on how peer support is experienced and received.

We report on the qualitative component of a UK-based intervention designed to increase HCV diagnosis and treatment in primary care and drug treatment settings. Data were collected between 2014 and 2016. Pre-intervention, a total of 35 PWID clients took part in nine in-depth interviews and four focus groups. In addition, 22 drug services and intervention providers took part in two focus groups and nine interviews. Post-intervention, one focus group and eight interviews were conducted with 13 PWID clients, and four focus groups and ten interviews were conducted with 26 drug services and intervention providers. Our data generation and thematic analysis focused on the peer education and buddy support component of the intervention.

Participants had common expectations of the peer role (to 'just be there') and its occupants' attributes (empathy, trustworthy, etc.). However, in practice, peers faced constraints on realising these expectations. A 'recovery' dominated drug treatment ethos in the UK appeared to influence the selection of 'recovery champions' as peers for the intervention. This created tensions in relations with clients, particularly when risk-adverse discourses were internalised by the peers. Peers were poorly integrated and supported within the service, affecting opportunities to relate and build trust with clients. Thus, the scope for peer support to impact on the nature and extent of clients' testing and treatment for HCV was limited.

The efficacy of peer involvement can be constrained by organisational structures and boundaries - especially regarding who is deemed to be 'a peer'. Peer programmes take time and care to implement and weave into wider recovery and harm reduction frameworks.