Peer Education in HIV/AIDS Care and Treatment Programs

Miriam Rabkin

International Center for AIDS Care and Treatment Programs, Columbia University Mailman School of Public Health, United States

Peer education is the transfer of knowledge and skills that occurs when members of a social group are trained to provide education and support to others. Used in programs seeking to shape health behaviors at the individual level and health-seeking norms at the family or community level, peer education includes a range of educational approaches such as counseling, formal classroom-based teaching, one-on-one instruction, and informal group facilitation.

Peer education can be used to accomplish a variety of goals. Examples include youth educating other youth about how to prevent HIV infection, mothers counseling new mothers about breastfeeding, patients receiving antiretroviral (ARV) drugs helping others take their medicines consistently and correctly, and men speaking out against domestic violence to other men.

Although peer education programs vary in content and structure, most share the following important characteristics: peer educators are trained laypeople; peer educators undertake specific and clearly defined activities with the clients and communities they are targeting; the peer educators’ goal is to foster specific behavioral practices among the individuals, families, and communities they are working with; and peer educators are used to complement, not to replace, the work of professional staff.

Why Use Peer Education?

There are several reasons to add peer education to health programs. First, it seems to work. Although evidence is limited, the data suggest that strong peer education programs can improve health-related behaviors and outcomes in a variety of settings. Second, peer educators bring unique characteristics to health programs. For example, peer educators may be more influential within a social group than people outside it and, as a result, may have a greater potential to effect change. Peer educators can also act as liaisons between program participants and program staff, and can provide insight into the style of communication and types of messages that are appropriate for the target group. Additionally, as a member of the group, a peer may be more aware of the group’s priorities than someone outside the group.

Peer education can provide lasting benefits to peer educators themselves, as well as to their clients, their communities, and the programs they support. For instance, clients have the opportunity to discuss their personal circumstances in a safe, comfortable environment with someone who can relate to their situation. This, in turn, can support clients’ adherence to medication and care, and their ability to navigate the health system. Peer educators can also play a role in community mobilization, helping to decrease stigma and increase support for patients enrolled in care and treatment.

Box 1. Definition of Terms

Site: Location of clinical care. May be a clinic, hospital, health center, or other venue.

Site staff: All professional, paid staff of the treatment site (doctors, nurses, medical officers, counselors, etc.).

Patients: HIV-positive people receiving care and treatment at the site.

Peer educators: Patients who carry out educational activities with other patients.

Peer clients: Patients who receive education from peers.

Working as a peer educator can increase self-efficacy, leading to behavior change among peer educators as well as their clients, and empowering them to take better care of their own health and that of their families. The training and work experience that peer educators receive may also improve their future job opportunities in the formal economic sector. In addition, by providing a mechanism for program participants and staff to communicate with each other, peer educators can help improve the overall quality and effectiveness of health-care programs.

Use of Peer Education in HIV Care and Treatment Programs

When care and treatment programs include peer education initiatives, HIV-positive individuals enrolled in the program work with patients in similar circumstances. In some programs, patients newly enrolled in care and treatment work with peers who are more experienced. In others, patients with specific problems or challenges—such as medication adherence—are paired with peer educators who can assist with those specific issues. Generally, treatment peer education programs strive to

  • increase treatment literacy;
  • provide practical and emotional support;
  • maximize adherence to care (attending appointments, tests, following instructions);
  • maximize adherence to medications, especially ARV treatment;
  • support internal linkages within health facilities (e.g., assisting patients as they go from the HIV clinic to the TB clinic, or between the HIV clinic and the laboratory or pharmacy);
  • support external linkages between health facilities and community-based resources (e.g., assisting patients enrolled in HIV clinics to access nutrition support services in the community, or assisting individuals in the community to identify which health-care facilities provide HIV services); and
  • encourage healthy behaviors and positive living, including secondary prevention of HIV transmission (i.e., “prevention with positives”).

Peer education can bring many additional benefits to treatment programs, such as reduced stigma and discrimination in the community, mobilization of community resources to support people living with HIV (e.g., food resources, social grants), and strengthened links between treatment programs and the communities they serve.

Peer Educators’ Activities

Peer educators in HIV care and treatment programs generally perform a variety of tasks related to patient care and support. These may include:

  • organizing and facilitating one-on-one and/or group sessions to educate patients, family members, and caretakers about aspects of care and treatment such as medications, adherence techniques, and side effects;
  • providing patients with information and practical tips for “system navigation” and optimal use of program resources;
  • providing specialized support to pregnant women and new mothers enrolled in prevention of mother-to-child transmission (PMTCT) and/or care and treatment services;
  • organizing and facilitating patient support groups;
  • Providing counseling and support for disclosure, “prevention with positives,” and couples counseling, as well as assistance with referrals of family members (partners, children) to testing and treatment services when necessary;
  • providing education regarding treatment options for substance abuse and alcohol abuse;
  • conducting home visits to support patients, or when patients miss appointments;
  • conducting community outreach activities to raise awareness about the treatment program and mobilize community resources in support of the program;
  • referring clients to psychosocial support services; and
  • fostering dialogue between patients and treatment site staff by maintaining regular communication with both.

Peer Education Program Models

Treatment peer education programs generally fall into one of three design categories: facility-based, community-based, and combination models.

Facility-based: The peer education program is based at the clinic, health center, or hospital where the treatment is provided. This is where the program supervisor and peer educators work and carry out their activities.

Community-based: The peer education program is based at a site in the community other than the treatment site, such as a nongovernmental organization (NGO), community-based organization (CBO), or faith-based organization (FBO) meeting hall or other location. Patients from the treatment site are referred to this location.

Combination: The peer educators are based at the treatment site but spend a great deal of time on home visits or community-based work, such as leading support groups or advocacy efforts in the community.

As a rule, the peer education program design will reflect the particular needs, priorities, and resources of each treatment program. The following section reviews ways in which program planners may choose to select peer education models.

Designing a Peer Education Program

Designing a peer education program generally involves five steps: (1) assessing stakeholder needs and priorities, (2) defining program goals and objectives, (3) determining what peer educators will do and how they will be supervised, (4) identifying program resources, and (5) finalizing the program design. Through these steps, the treatment program will gather the information it needs to determine what peer education model is most appropriate.

Assessing Needs

As with any other type of program, the first step is to assess needs. This will ensure that the program is designed to meet the real needs of its stakeholders, as identified by the stakeholders themselves. There are generally three key stakeholders in treatment peer education programs, in addition to the peer educators: patients enrolled in HIV care and treatment (sometimes called “clients”) and their families or caretakers, treatment site staff, and the surrounding community. The goal of the needs assessment is to find out how the program can best serve each group. Needs that can be addressed by a peer education program include the following:

  • Patients (clients) and their families or caretakers may have a need for

– improved understanding of HIV care and treatment, including the need for prophylaxis for opportunistic infections (OIs), regular clinical and laboratory monitoring, and ARV treatment when eligible (treatment literacy);

– improved understanding of clinic protocols (system navigation);

– adherence skills, techniques, and role models;

– someone to talk to who understands what they are going through; and

– information on where to go for services such as counseling, home-based care, and food assistance and/or social grants, when these are available.

  • Program (treatment site) staff may have a need for

– liaisons between staff and patients;

– help in promoting attendance at scheduled appointments;

– people to conduct home visits to follow up on facility-based care;

– laypeople who can participate in or lead support groups; and

– experienced patients who understand HIV and its treatment and can explain it to others.

  • The community around the treatment site may have a need for

– more information about HIV treatment;

– more information about the HIV services being provided at the treatment site;

– people to be open about their HIV status and speak out against stigma and discrimination;

– assistance with integrating issues of traditional medicines and cultural beliefs about HIV/AIDS with new information regarding prevention, care, and treatment; and

– advocates for more treatment-related resources.

Needs assessment tools include surveys, interviews, and focus group meetings with stakeholders. Each program must determine the type of needs assessment most appropriate to its setting. For some programs, this process will be relatively brief and informal. For others, especially for larger initiatives, this process may be quite lengthy. Periodic reassessments are strongly recommended, as needs evolve over time.

Defining Goals and Objectives

After the needs assessment is complete, the next step is to define the program’s specific goals and objectives. This will ensure that staff and participants understand exactly what the program is trying to accomplish, and will help clarify expectations and focus planning.

By definition, the patients receiving support from peer education initiatives linked to HIV care and treatment sites are all HIV-positive. The emphasis of these programs, therefore, is generally on care and treatmenta and on ensuring that patients get the most from their participation by supporting treatment literacy and adherence. Another focus is on secondary prevention of HIV infection—that is, preventing the transmission of infection from clients to their sexual partners or, in the case of pregnant and breastfeeding women, to their children. Peer educators also promote healthy behaviors and “positive living” as well as family and community involvement and support.

The reason to carefully define goals and objectives is that these will directly inform program monitoring and evaluation. For more information on how to evaluate a peer education program, see the “Monitoring and Evaluation” section later in this chapter.

Determining Peer Educator Activities

The specific activities carried out by peer educators will vary from program to program and will be based on the needs assessment and objectives of the individual program and on the resources available. For example, if the program finds that patients need treatment education, the peer educators may organize individual and/or group educational sessions. If the needs assessment finds that many patients are missing appointments, the peer educators’ activities might include home visits to remind patients of upcoming appointments or to follow up on missed appointments. Although a detailed plan is not required at this stage, a general idea of peer educator activities is required prior to finalizing the program design.

Identifying Resources

The fourth step in designing a program model is to review the resources available for a peer education initiative. In addition to direct financial support, programs should inventory staff time, as well as physical space and community assets. Existing patient support groups, advocacy programs for people living with HIV, home-based care programs, and organizations providing support to people living with HIV can all be important building blocks for a peer education program.

Useful questions about resources for a program planner to consider include the following:

  • What funds are available to support the project?
  • Is there a member of your staff with the skills needed to manage a peer education program and supervise the peers (see the “Supervision” section later in the chapter)?
  • If so, can a significant amount of his or her time be dedicated to the initiative? If not, how will you recruit and support such an individual?
  • Are the staff members at your site interested in starting a peer education program?
  • Does your clinic or hospital have sufficient physical space for the peer educators and their clients to hold peer education activities?
  • Are other organizations or groups in your community working on HIV/AIDS care and treatment issues? Are they already conducting peer education activities that could be built upon?
  • If so, are any of these organizations better equipped to house the peer education program (e.g., do they have more staff time, physical space, active counselors and peers, etc.)? Are they potential partners?

These questions will help the treatment site determine what resources are available and which program model is most appropriate (clinic-based, community-based, or combination).

Finalizing the Program Design

When finalizing the program design, it can be helpful to ask the following questions:

  • What are the main needs identified by stakeholders?
  • What are the goals and objectives of the program?
  • Who will supervise the program?
  • Where will the peer educators be based?
  • What will the peer educators do? How often?
  • How will the peer educators be incorporated into the larger treatment program? What will their role be?
  • How many peer educators are needed?
  • How will treatment site staff (other than the supervisor) be involved in the peer education program?
  • What funds will be used to support the program?
  • Will the treatment site collaborate with any other community organizations? If so, how?

A Peer Educator’s Story: Experience Working in HIV/AIDS Program Management and Advocacy as an HIV Peer Counselor in Nigeria

Mary Ashie

International Center for AIDS Care and Treatment Programs, Nigeria

My personal experience was what prompted me to start working in the field of HIV/AIDS and to later become a peer counselor. I lost my baby boy, Ovie, in the year 2000 to HIV. He was six months old. He had been ill and was tested for HIV without my prior consent. The result was disclosed to my boss, who fired me soon after. The stigma level was very high at that time, mainly due to a lack of information. I found myself in the situation many young people living with HIV have found themselves in shortly after they have been diagnosed with HIV: with very little support and sometimes without a job or a home. There was also little access to antiretroviral therapy (ART) in Nigeria. Much of the misinformation available was that antiretrovirals (ARVs) did not work, and that people died soon after starting treatment. When I saw how well I was doing on treatment, despite a very difficult emotional period, and also knowing that many people were receiving the same negative information I had when I was first made aware of my diagnosis, I decided to give a positive face to HIV.

I began by joining a support group for people living with HIV (AIDS Alliance in Nigeria), and then began to volunteer within the group in 2001. After participating in a counseling workshop organized by Family Health International (FHI) in August 2002, I became much more confident about offering peer education and support. I provided group counseling at a nearby maternity home as well as at the Lagos University Teaching Hospital (LUTH), where I also received care and treatment.

I have been an active member of the Treatment Access Movement (TAM) in Nigeria since 2002. It is a coalition of people living with HIV and members of civil society and the media who have fought for free access to ART in Nigeria—and achieved this in principle in December 2005. Since January 2006, there has been access to free care and treatment in almost all the states in Nigeria.

I joined the Nigerian Community of Women Living with HIV/AIDS (NCW+) in 2002, which provides group counseling for pregnant women attending the antenatal clinic at the Nigerian naval hospital at Ojo Barracks in Lagos state. In January 2003, with funding from the Center for Development and Population Activities (CEDPA), we started a peer counseling and support group for women and vulnerable children. As the field supervisor / counseling coordinator for this project, I met with vulnerable women of different backgrounds. Some were widowed and at the mercy of their husbands’ relatives and feared losing their homes due to stigma and discrimination. Many were afraid to disclose their status to their spouses for fear of being thrown out of their marital homes, and so would not access prevention of mother-to-child transmission (PMTCT) services, resulting in their babies becoming infected, getting sick, and even dying.

These experiences have contributed significantly to my growth and development as a peer health educator/counselor, supporter, and HIV/AIDS advocate. I worked with Médecins Sans Frontières (MSF) for three years as a peer educator and adherence counselor. Currently, I work with Columbia University’s International Center for AIDS Care and Treatment Programs (ICAP) as the central adherence adviser in Nigeria.

As the central adherence adviser, with technical support from my supervisors, I have developed and implemented the adherence counseling and peer education services for all the ICAP-supported sites in Nigeria. I continue to provide comprehensive adherence counseling, mentoring, supervision, and technical assistance to the health teams at the facilities where we work; included in this is periodic training and continuous mentoring of site adherence supervisors who report regularly to me. My other key responsibilities include the initiation and facilitation of support groups for mothers and children, in addition to the provision of psychosocial support to HIV-positive mothers through their support groups. My job also involves recognizing and managing obstacles to the provision of adherence counseling within the systems that operate at sites, and implementing a framework that addresses these problems so advisers can problem solve on their own

I recently received the Workplace HIV/AIDS Best Practice Award for workplace HIV/AIDS stigma reduction from the National Action Committee on AIDS (NACA). It is a national award that has practically impacted how HIV/AIDS is viewed in the workplace. Through the recipients of this award, organizations all over the country have now come to provide peer health education in the workplace and encourage counseling and testing among workers. They have also ensured implementation of policies on HIV in the workplace, including, for example, the prevention of termination of employment when a worker is determined to be HIV positive. I continue to advocate for organizations to amend employment policies to include noncompulsory screening for new employees, with the option not to disclose the results to the employer, while accessing care and treatment when necessary. I have been able to achieve all this because I received peer support from my support group and met other people living with HIV.

Managing a Peer Education Program

This section provides a very brief overview of some things to consider when preparing to manage a peer education program. It is intended to give program developers a sense of what types of challenges may arise, what measures can be taken to avoid and mitigate these challenges, and what activities can be undertaken to ensure that the programs implemented are of the highest quality. The information is based on experience and lessons learned from peer education programs.

Supervision

Ongoing supportive supervision of peer educators is critical to program success. Although peers are often effective proponents of behavior change, it is important to remember that they are laypeople, not professional counselors or clinicians. As a result, good supervision is beneficial to both the peer educators and the program as a whole, and lack of supervision is one of the most common reasons that peer education initiatives fail.

It is not sufficient to appoint someone who already has a full-time workload to supervise the peer education program in addition to his or her other work. The supervisor must have dedicated time for the peer education program. Experience has shown that it is preferable to have at least one staff person from the supervising organization (either the treatment program or NGO/CBO) who can dedicate at least half of his or her working hours to supervising the program.

In many programs, the supervisor is a nurse or counselor, but advanced training is not required to be an effective supervisor. Qualities that program developers may want to look for in a supervisor, in addition to knowledge of HIV care and treatment, are enthusiasm, patience, flexibility, resourcefulness, training skills, knowledge of community resources, a belief in the importance of involving people living with HIV, and the ability to communicate well with both peer educators and multidisciplinary team members.

Supervisory duties in peer education programs may include some or all of the following:

  • organizing and/or facilitating peer educator training sessions;
  • creating peer educator schedules and work assignments;
  • ensuring that peer educators have the supplies they need and that they are restocked as needed;
  • managing budgets and finances and overseeing peer educator reimbursement and stipends;
  • supervising peer educators’ work, providing feedback, and meeting regularly with peer educators, both individually and as a group;
  • answering questions and providing practical and emotional support to peer educators;
  • scheduling and facilitating meetings between peer educators and the multidisciplinary team;
  • collecting and compiling monitoring and evaluation data; and
  • corresponding with donors and partners.

Recruitment and Retention of Staff

Prior to recruiting patients to work as peer educators, it is important to be clear about what their activities and scope of work will be. One recommended approach is to detail roles and responsibilities in a simple “terms of reference” (TOR) document. This TOR can then inform a description of preferred and required qualifications, which will vary depending on the needs of individual peer education programs. The qualifications of peer educators should include being HIV-positive and enrolled in the care and treatment program. Many programs specifically recruit individuals who are on and adherent to ARV treatment. Individual programs will have varying needs—some sample criteria are listed in Box 2—but most attempt to develop a varied team of peer educators, recruiting both men and women and attending to issues of race/ethnicity, language skills, and age.

Box 2. Sample Peer Educator Qualifications

1. Local resident enrolled in HIV care and treatment

2. Good communication skills

3. Basic literacy and numeric skills

4. Open-minded

5. Able to work independently

6. Motivated

7. Open about HIV status

8. Encouraging to others

9. Has support of friends and/or family to participate in the program

Since enrollment in care and treatment is a prerequisite, recruitment activities will often take place at the clinic itself and at affiliated CBOs. Counselors and staff can generally recommend patients who are articulate and involved proponents of the program. Clinic receptionists can systematically inform patients of the opportunity, and written job postings may also be useful in some settings.

Setting Realistic Expectations

When starting any new program, it is important to ensure that participants clearly understand their intended roles and tasks (Box 3). Peer educators have an unusual position in treatment programs, in that they are both clients and service providers but are generally not clinic staff. Educators and program staff alike will benefit from clear and very specific descriptions of the intended activities and responsibilities of peer educators and their supervisors. It will be important to address the following issues:

Box 3. Setting Realistic Expectations

1. Be clear while recruiting.

2. Review the terms of reference (TOR) during training.

3. Have a meeting with each educator to review the TOR.

4. Have an “agreement form” for educators.

5. Hold a meeting with staff to explain peer educator roles.
  • tasks (i.e., what exactly the peer educators will be expected to do, where, and how often);
  • scheduling (i.e., who will be responsible for arranging meetings and visits);
  • compensation (i.e., stipends, salary, transportation allowance—see “Compensation” section);
  • number of hours of work expected or required;
  • supervision (i.e., role of the supervisor, availability, responsibility);
  • peer educator monitoring, evaluation, and feedback;
  • role of peer educators in making decisions about the peer education program; and
  • peer educators’ role in the larger treatment program.

The key to setting expectations is communicating early and often with peer educators. It is best to begin this communication during recruitment and training and to continue it throughout the duration of the program.

Compensation

By definition, peer educators are laypeople, not formally trained health-care professionals. There is no reason to assume, however, that peer educators are volunteers, or that they should work without appropriate compensation. Decisions regarding peer educator compensation can be difficult and are best made at the local program level. In some settings, peer educators receive a stipend based on hours worked or tasks completed. In others, transportation allowances, uniforms, training, meals, and/or other benefits are all that can be offered.

While it is important to keep long-term program sustainability in mind, we recommend that programs make every effort to pay peer educators for their work. Peer educators can have a significant impact on treatment programs and should be rewarded for their contributions. Peer educators are also less likely to drop out of the program if they are compensated. Conversely, peer educators are more likely to feel exploited and unhappy if they are not compensated for their work.

Decisions regarding peer educator compensation should be consistent, clearly communicated to participants, and periodically reassessed.

Training and Staff Development

Because peer educators are laypeople who play a unique role in treatment programs, peer educator training is an important factor in program success. Three main elements must be considered when developing a training program: content, design, and timing.

Content

Although peer educators are not meant to become or replace HIV treatment experts such as doctors, nurses, and counselors, it is important that they know the basics of HIV/AIDS and issues relating to treatment. It will be up to individual peer education programs to decide exactly which topics to address during training. Examples of training topics include:

  • basic concepts of HIV transmission, prevention, and disease progression;
  • using medications to prevent OIs (e.g., cotrimoxazole);
  • using medications to delay HIV disease progression (e.g., ARV drugs);
  • supporting patients’ ability to attend scheduled tests and appointments and to avoid loss to follow-up;
  • supporting treatment adherence, and its importance;
  • program “navigation” (e.g., how to make appointments, communicate with program staff, deal with problems, etc.);
  • nutrition and food and water hygiene;
  • condom use and secondary HIV prevention;
  • communication skills (i.e., listening, asking questions, speaking to groups);
  • organizing and running treatment support groups;
  • the role of the peer educator; and
  • processes for carrying out peer education activities.

Design

Several elements should be considered when designing a training program. These include how many days the training program will last, how the sessions will be structured, what kinds of activities will be included, and who will facilitate the sessions. There are several reasons to recommend against formal “didactic” training—that is, training structured around slide-based lectures or lengthy written materials. Counseling skills are best taught by role-playing, practice, and reflective observation, not PowerPoint! While each peer education program will design the training according to its own needs, expertsa recommend the use of interactive sessions rather than lectures, as well as the inclusion of activities such as case studies and role-playing, in which participants can practice using skills. The use of different facilitators for different sessions—such as nurses, doctors, social workers, nutritionists, counselors, pharmacists, and other peer workers—can provide an opportunity for participants to hear directly from the experts themselves. After classroom-based training, a supervised practicum can help peer educators transition into their “jobs” and continue to build skills. Finally, as with all training, regular (daily) opportunities for feedback and evaluation of the training methods and content ensure that adjustments can be made to improve the overall quality of training.

Timing

When planning recruitment and training strategies, it is important to remember that peer education programs generally have high turnover rates. Anticipating the need to train and initiate new educators is prudent, and may be required to ensure that the program has a steady supply of active peer educators. Some programs conduct training activities every three months, others every six months. While specific schedules will be program-specific, most programs will need to conduct repeat trainings in order to sustain the peer education program. Ongoing or “refresher” training courses can also be important tools to help peer educators reinforce their skills, add new or advanced skills, and maintain enthusiasm for the program.

Materials

Many programs use materials to support the work of the peer educators. Informational and behavior change communication materials can help reinforce knowledge and skills learned in training, and can also help peer educators transfer knowledge and skills to patients and their family members. Some examples include using posters or flip charts with drawings to inform and educate low-literacy audiences; handing out informational pamphlets or brochures in the clinic and/or community; showing videos to demonstrate certain skills to clients; distributing condoms for secondary prevention; and using pill boxes, treatment logs, and calendars to assist clients with adherence. Materials are most useful when they are developed or adapted within the local context, preferably with input from people within the target group—in this case, clients receiving HIV care and treatment services.

Staff Turnover

As mentioned above, one characteristic of many peer education programs is a high turnover rate. Peers leave the program for many reasons. Some transition to the formal economy. Others have competing priorities, including illness in the family or worsening personal health status. Inadequate supervision and/or a lack of consistent support may also result in frustration with the peer education program itself.

It is important for programs to be prepared for turnover among peer educators. Programs can do this by recruiting peer educator candidates regularly, offering the peer educator training course on a regular basis, communicating regularly with peer educators regarding their feelings about the program and future plans, and having alternate peer educators available to step in and help out if someone leaves the program or is temporarily absent.

Program features that can encourage peer educators’ ongoing involvement include adequate financial and other compensation, linkages to community resources, recognition of work performance and achievements through awards and prizes, flexible work schedules, opportunities to make meaningful contributions to the treatment program, and opportunities to interact with other staff members and other peer educators at the treatment site. When a peer educator does leave the program, it is important to document the date and reason he or she is leaving. This will give the program a formal record that the person is no longer a peer educator and help determine whether the reason for leaving is related to the program itself or to external circumstances.

Monitoring and Evaluation

The only way to determine whether the peer education program is achieving its goals and objectives is to monitor program indicators and evaluate program effects. Monitoring the program involves tracking and documenting what is being done. For example, programs generally monitor the number of peer educators receiving and successfully completing the training, the types of activities peer educators have carried out, the quantity and type of contacts educators have had with clients, the number of hours per week or month educators are working, and retention rates (i.e., how many educators have left the program).

Evaluation involves assessing whether the program has been successful in achieving the results it aims for. For example, if one objective of the peer education program is to decrease the workload of the treatment site staff, an evaluation would seek to find out whether that actually happened by surveying the site staff. Two levels of evaluation are generally used in peer education programs: basic evaluation and intermediate evaluation.

Basic evaluation includes assessment of measures such as satisfaction with the program on the part of clients, peers, and program staff; the effectiveness of training in preparing peer educators to do their work; and the proportion of clients being reached by peer educators. Most peer education programs conduct this type of evaluation. Examples of specific measures that may be looked at include

  • proportion of clients reached by peer education services;
  • peer educators’ satisfaction with their training (via interviews or questionnaires);
  • peer educators’ knowledge (via written or oral examinations);
  • peer educators’ skills (via observational checklists, interviews with clients, etc.); and
  • client, peer educator, and/or staff satisfaction with the peer education program (via interviews or questionnaires).

Intermediate evaluation includes more complex evaluation techniques, such as those designed to determine whether the program impacted psychosocial measures such as perceived stigma, social isolation, and/or depression; whether clients were successfully referred to other services; whether the program increased clients’ knowledge and improved attitudes toward care and treatment; and whether the program had an impact on clients’ behaviors, such as adherence. Examples of specific measures that may be looked at include

  • client knowledge, attitudes, or self-reported behaviors before and after implementation of peer education services (via interviews, questionnaires, focus groups, etc.);
  • client and/or peer educator utilization of HIV services before and after implementation of the peer education program (via interviews, questionnaires, appointment logs, registration records, and/or medical charts);
  • client and/or peer educator adherence to medications (via interviews, pill counts, pharmacy records) before and after implementation of peer education services;
  • client and/or peer educator self-efficacy before and after implementation of the peer education program (via interviews);
  • impact on staff workloads (via interviews); and
  • impact on stigma in the community (via focus groups, etc.).

Rigorous evaluation includes measures that can only be evaluated using scientifically rigorous methods, such as randomized controlled trials. Most peer education programs will not conduct evaluations at this level due to resource and time constraints.

Several tools can be used to monitor and evaluate peer education programs. These include surveys (written and oral), in-depth interviews, focus groups, supervision notes and checklists, clinic records, peer education logs/records, attendance records, and program entry/exit forms.

Funding and Sustainability

As with any program, securing funding to sustain a peer education program can be a challenge. Ongoing costs associated with peer education programs include training, peer educator stipends or salaries, supervisor salaries, travel, materials and uniforms as well as space and basic overhead costs.

There are several ways to raise funds and ensure that the peer education program is financially sustainable. These include

  • incorporating the peer education program into the clinic / treatment program budget;
  • developing income-generating projects that directly support the peer education program;
  • working with existing local NGOs, FBOs, and CBOs that are likely to have a sustained community presence and low operating costs; and
  • securing funding from private foundations, other donors, local businesses, or other community support channels.

One creative approach to promoting program sustainability is to provide skills training and seed money to peer educators and their clients, enabling the creation of income-generating projects such as sales of beadwork and other crafts. Formal partnerships with CBOs can also be beneficial to all involved.

Conclusion

Peer education initiatives can enhance HIV care and treatment programs by providing valuable input, perspective, and services. Clearly identifying specific program goals and objectives; designing programs to achieve these outcomes; and ensuring careful attention to training, supervision, compensation, and support will maximize outcomes for programs, peer educators, and clients.

aCare and treatment services include but are not limited to counseling; education; adherence support; regular clinical and immunologic staging; prophylaxis of OIs; preventive measures such as the provision of insecticide-treated bed nets and clean water; early diagnosis and treatment of OIs, including tuberculosis; nutritional counseling and support; palliative care; and ART when indicated.

aThese were adapted from Peer Support for HIV Treatment Adherence: A Manual for Program Managers and Supervisors of Peer Workers, produced in 2003 by the Harlem Adherence to Treatment Study at Harlem Hospital, New York.

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Recommended citation format for articles: [Author Name(s)]. [Article Title]. In: Marlink RG, Teitelman ST, eds. From the Ground Up: Building Comprehensive HIV/AIDS Care Programs in Resource-Limited Settings. Washington, DC: Elizabeth Glaser Pediatric AIDS Foundation; 2009. http://ftguonline.org.