Definition of the Prevention Area
Peer outreach and education (POE) typically involves members of a specific group to influence and support members of the same group to maintain healthy sexual behaviors, change risky sexual behaviors, and modify norms. Peer educators are thought to be more likely to influence the behaviors of their peers since they are seen as credible and less judgmental role models.
Epidemiological Justification for the Prevention Area
Certain populations, such as injecting drug users, sex workers, and out-of-school youth may be difficult to identify and reach through standard programs. They may also be reticent to trust those who are seen as being in a position of authority. Peer educators can bring a variety of assets to the task of HIV prevention; they may be able to contact hard-to-reach individuals, and to wary members of disenfranchised groups; and they may simultaneously be seen as more acceptable as educators and more credible (or less judgmental) than non-peers.
However, there are some limits to the credibility afforded to peers as evidenced by certain studies of youth and prisoners. Some program managers see peer education as a less expensive way to achieve HIV prevention, but other researchers caution that using POE to reduce expenses in HIV education can backfire since programs without a solid investment in development and oversight of peer educators can fail.
Core Programmatic Components
The core programmatic components of POE include facilitating discussions using a curriculum, counseling individuals, lecturing on behavior change, distributing materials such as condoms, and making referrals to services. HIV prevention-focused POE may incorporate or offer referral to programs that empower clients more broadly, such as microcredit.
Program design should take into account the context of the target group and its socio-cultural, political, and linguistic needs. Peer activities may be affected by shared characteristics between volunteers and contacts (such as gender, socioeconomic status, education level, ethnicity, and place of residence). Peer-led activities offer opportunities for members of shared networks to collectively define their needs and develop solutions.
Research shows that peer leaders need ongoing training, monitoring, support, and sometimes incentives to avoid high attrition rates. Moderate supervision is essential, but it should respond to the peers’ needs or else it may stifle opportunities for empowerment and leadership. Additional support may also result from the involvement of community groups and partnerships. These linkages provide much-needed resources and buy-in and contribute to long-term program sustainability, but such partnerships can create their own obstacles.
POE is one approach to HIV prevention that should be part of an overall strategic plan and linked to other programs and communication channels, such as mass media, community-based interventions, and individual-based projects. Linkages and referrals to HIV/AIDS care, support, and treatment services are also essential elements of prevention programs.
Current Status of Implementation Experience
Markers of effective POE include increased knowledge about HIV and its prevention; enhanced positive attitudes about people living with HIV (PLWH); increased skills related to health-protective actions, such as proper condom use and safer injection drug practices; positive gender and social norms; and maintenance of healthy sexual behaviors. These markers, however, are not always predictive of the desired outcomes as measured by reductions in sexually transmitted infections (STIs), HIV, or pregnancies. This has led researchers to call for more rigorous evaluations of biological outcomes related to POE.
Traditionally, peer-led interventions have been thought to be successful because of their organic nature and peers’ abilities to make strong connections with their contacts. However, HIV prevention-focused peer interventions have shown mixed results among various groups, including in- and out-of-school youth, people living with HIV, sex workers, injecting drug users, men who have sex with men, people in the workplace, and incarcerated individuals.
In Thailand, a peer project was launched among young methamphetamine users. The program resulted in reduced methamphetamine use, increased condom use, and reduced STI incidence over a 12-month period. However, the control arm showed a similar decline in STIs. Other programs have failed to show that POE participants reduce their number of sexual partners or that they experience any reduction in STIs or HIV.
One set of researchers compares and contrasts the features of a failed and a successful POE program among commercial sex workers, providing rich detail about the factors that appear to hinder success and that appear to promote successful, sustainable POE projects.
Sustainability of programs continues to be a challenge to this and other HIV prevention, care, treatment, and support approaches.