HIV Prevention Knowledge Base
Behavioral Interventions: Peer Outreach and Education
Impact of a Peer-group Intervention on Occupation-related Behaviors for Urban Hospital Workers in Malawi
Over 800 staff members at a Malawi hospital were evaluated regarding the impact of a peer-group intervention focused on observation of universal precautions, enhanced client teaching, and respect for people living with HIV (PLWH). Intervention effectiveness was evaluated by staff and client surveys, and direct observation. Six months after the Mzake ndi Mzake (Friend to Friend) intervention, which consisted of ten 90- to 120-minute sessions, staff knowledge of universal precautions increased marginally over their already high level of knowledge at baseline. Staff members were observed to use of gloves somewhat more frequently and clients reported that staff engaged them in some aspect of HIV teaching to a greater degree.
The Social Conditions for Successful Peer Education: A Comparison of Two HIV Prevention Programs Run by Sex Workers in India and South Africa
This critical review of two POE programs among sex workers – one successful and the other not – provides detailed insights into the factors that may be central to successful versus failed interventions. The authors provide extensive citations for their observations; give vivid examples of successful and unsuccessful approaches, and make a few counterintuitive observations. The authors review aspects of the “failed” intervention that were successful and vice versa. Overly optimistic and ambitious approaches, say the authors, may be less successful overall than more limited approaches; for example, they challenge the assumption that multi-stakeholder involvement necessarily improves success and they give an example of how one project’s progress was impeded by the engagement of multiple stakeholders with competing interests. In other ways, however, a more comprehensive approach can prove beneficial; for example, the program in which women organized a variety of social and economic supports for each other succeeded where another project, which remained narrowly focused on medical issues, failed. The authors measured success in terms of reduction in sexually transmitted infections and in program continuance versus closure.
Evaluation of HIV/AIDS Secondary School Peer Education in Rural Nigeria
The authors conducted a study of the efficacy of a peer education program for secondary school students in Nigeria from 2005 to 2007. The intervention included ongoing training of peer educators for the two-year period. Peer educators and trainers used the United Nations Population Fund/United Nations Joint Programme on HIV/AIDS Peer Education Toolkit; the Family Health International Peer-to-Peer Training guide; videos; and other resources. The intervention was assessed by cross-sectional surveys; a comparative case series; and qualitative assessment of students in the intervention arms vs. those who received no special HIV education. Students in the intervention arms increased their knowledge of HIV, and reduced the number of times they engaged in sexual intercourse and the number of sex partners they had. Although there was a trend toward increased condom use, it did not reach statistical significance.
Evaluation of a Peer Network Intervention Trial among Young Methamphetamine Users in Chiang Mai, Thailand
This 12-month clinical trial randomized 983 methamphetamine-using Thai youth aged 18 to 24 years to a peer-educator, network-oriented intervention or to a “best practice, life-skills” program. Both groups showed a “significant and dramatic decline in self-reported methamphetamine use (99 percent at baseline and 53 percent at 12 months). Condom use increased to the same degree in both groups. The authors note that unlike the peer educator group, the “best practice” group did not include social network members, however, the network members of the best practice group increased their use of condoms as well. The authors comment on possible study contamination due to diffusion of information and possible biasing effects on the study since the study was conducted in the wake of extrajudicial killings of over 2500 suspected drug users.
HIV/AIDS Prevention among the Male Population: Results of a Peer-education Program for Taxicab and Tricycle Drivers in the Philippines
Taxi and tricycle drivers in the Philippines are seen as a “bridging” group that can contract HIV infection from sex workers and bring it into the larger population through sex with their spouses or other sex partners. The authors conducted a two-year, randomized, peer-education program with the drivers and conducted near- and long-term follow up (up to 31 months) comparing the intervention arms with control arms, in which subjects received no special HIV education. HIV knowledge increased among the treatment arms. The authors state that condom use increased from baseline to follow-up, however, this claim is based on a subgroup analysis.
Long-term Follow-up Study on Peer-led School-based HIV/AIDS Prevention among Youths in Shanghai
Many studies of peer-education programs provide only short-term outcomes. The authors conducted a randomized study of 1950 senior high school students in Shanghai, China, to determine both short- and long-term (one year) outcomes. The researchers found that the percentage of students saying they would use condoms increased from 46 percent to 66 percent one month after the POE intervention and held at 62 percent one year later, representing a significant improvement over the control group. Actual behavior changes were not determined.
Study on Peer-led School-based HIV/AIDS Prevention among Youths in a Medium-sized City in China
Over 3,000 senior students in San-ming China were randomized to receive HIV peer education or usual teacher-led health education. Peer educators, aged 16 to 17 years old, were trained for four-days to help them “improve the knowledge, attitude, and behavior of their classmates” regarding HIV. Small sessions (44 to 66 students) showed greater benefit than those attending the large sessions (100 to 150 students). The authors cite other research showing that school-based HIV education reduced risky sexual behaviors. However, the authors comment that although students in the current study stated their intention to change their sexual behavior, actual changes in sexual behaviors were not tracked.
Impact of Five Years of Peer-mediated Interventions on Sexual Behavior and Sexually Transmitted Infections among Female Sex Workers in Mombasa, Kenya
A POE project for female sex workers (FSWs) in Mombasa, Kenya, was evaluated five years after its launch in 2000. Following intervention, FSWs were significantly more likely to use condoms and to refuse clients who declined to use a condom. However, FSWs were also far more likely to work full- rather than part-time in 2005 than in 2000 (increasing the number of sex partners they had per week). Poverty played a large role in the FSWs sexual behavior. The researchers conclude that “it is uncertain whether the balance between higher number of partners and increased condom use reduced the total number of unprotected sex acts.” HIV prevalence showed a non-significant increase from 31 percent in 2000 to 33 percent in 2005.
Report to the UNAIDS HIV Prevention Reference Group on Developing Minimum Quality Standards for HIV Prevention Interventions
This report grew out of the UNAIDS HIV Prevention Reference Group, which met in Geneva, Switzerland, in 2007. Participants in the conference concluded that there was a need for greater clarity in nomenclature for behavioral interventions (definitions, critical components and methodologies to assess interventions) and for minimal quality standards for HIV prevention interventions.
Guidance provided in this 30-page document is drawn from interviews with leading experts in various HIV prevention areas; from an in-depth literature review; and from examples of existing protocols and standards currently in use. The report discusses the tension between researchers and front-line health practitioners regarding the relative merits of outcome assessments and provides some insight into the differing perspectives of both.
Three intervention-specific programs are reviewed in detail: condom social marketing, peer education, and microcredit. The report authors give a basic description of each intervention; describe the conceptual theory or assumptions about how the intervention is expected to produce the intended effects; and give a brief summary of the current standard or typical kinds of data collection for monitoring and evaluation of the impact of the intervention. Common criticisms or intervention failings are described. Alternative approaches suggested by the key experts are included. Each section concludes with a brief summary of issues for program designers to consider in developing quality standards.
The Effectiveness of a Peer-led HIV/AIDS and STI Health Education Intervention for Prison Inmates in South Africa
This study of 357 pre-release prisoners in South Africa, measured their knowledge, attitudes, sex communication, self-efficacy, and intentions before and after instruction by either an HIV-negative or HIV-positive peer educator, with follow-up evaluations at 3, 6, 9, and 12 months in the community. Ninety-four inmates had to be excluded from the study due to an administrative problem at one of the prisons, leaving 263 evaluable inmates. Although improvements were seen with both HIV-negative and HIV-positive counselors, there was greater improvement with the HIV-negative peer counselor. The authors suggest that the prisoners may have found it difficult to look up to prisoners with “additional stigma.” The authors comment on a limitation of their study: only intentions and not actual behavior changes were measured.
Evaluation of SHAPE 1: Strengthening HIV/AIDS Partnerships in Education School Based Peer-Education Program
This 41-page evaluation study, funded by USAID, examined the Strengthening HIV/AIDS Partnership in Education 1 (SHAPE 1) project. The Ghanaian project was launched in September 2001 and concluded in late 2004, when it was replaced by a newly designed SHAPE 2 Project. The goal of the POE project was to prevent the spread and mitigate the impact of HIV among educational professionals and the youth and families served by educators in primary, junior secondary, and senior secondary schools.
Nearly 90 schools trained peer educators who promoted HIV prevention through clubs, health talks, skits, dramas, and one-on-one encounters. Approximately 70 schools maintained viable POE programs at the end of the project’s second year of operation.
Findings of the evaluation study indicate that there were “no significant differences between the SHAPE 1 students and comparison students (who had no special HIV education)” and that SHAPE 1 students were actually less likely to report using condoms to avoid sexually transmitted infections, although the researchers caution that the finding was based on a very small number of students. Between 40 to 50 percent of the students said their main reason for not using condoms was due to lack of availability.
Impact of Peer Group Education on HIV Prevention among Women in Botswana
The authors evaluate a workplace peer education program given to more than 300 women in Botswana. Half of the women were enrolled in an immediate intervention arm and the other half in a delayed intervention arm. The program addressed gender inequality, HIV risk reduction, and attitudes toward people living with HIV. HIV-transmission knowledge levels were “fairly high” among the women at baseline, and increased by a small percentage following the intervention. Accurate knowledge of behavioral changes increased from 62 percent to 90 percent, while those who self-reported practicing safer sex increased from 34 percent to 47 percent. The authors found the program to be “feasible and affordable” for replication in developing countries.
Impact of a School-based Peer Sexual Health Intervention on Normative Beliefs, Risk Perceptions, and Sexual Behavior of Zambian Adolescents
The authors studied Zambian secondary school students who were randomized to either a 1-hour-and-45-minute-long in-class peer sexual health intervention on “knowledge and normative beliefs regarding abstinence and condoms and personal risk perception of acquiring HIV” or to a 1-hour class on water purification. The authors found that students in the intervention arm, relative to students in the control arm, were more likely to score higher on HIV knowledge questions and on normative beliefs about abstinence and condoms. They also had higher personal risk perception of acquiring HIV than students in control arms.
Peer Education and HIV/AIDS: Past Experiences, Future Directions
This 53-page report grew out of a needs assessment of peer education program managers identified by an international consultation of 45 experts and conference participants that was held in Kingston, Jamaica, in 1999. The authors conducted a literature review of the key POE topics and include sections on: HIV peer education integration with other interventions; finding and keeping peer educators; training and supervising peer educators; gender, sexuality and the sociocultural context; program activities to foster behavior change; care for people living with HIV/AIDS; and program sustainability.
Peer Education and HIV/AIDS: Concepts, Uses and Challenges
Interviews were conducted with 30 program managers from Africa, Asia, Latin America, and the Caribbean regarding POE and support interventions in order to provide an overview of the uses and challenges in peer education in this 43-page document.
Do Peer Educators Make a Difference? An Evaluation of a Youth-led HIV Prevention Model in Zambian Schools
The youth-led School HIV/AIDS Education Program (SHEP) was evaluated to determine its effectiveness on students’ levels of HIV and reproductive health (RH) knowledge, attitudes, and protective behaviors. The cost of implementing the program was also evaluated. Peer educators were trained and had strong leadership, communication, and team building skills. Aged 18-25 years the peer educators were older than students but younger than teachers. SHEP used a comprehensive approach to HIV and RH education in addressing life skills and sexual behaviors. The study was non-randomized and quasi-experimental. Schools that implemented SHEP for a minimum of three years and had active peer educators were randomly selected to be in the study. About 2,000 students were interviewed from 13 intervention schools and 13 matched comparison schools. SHEP students were more likely to correctly answer HIV prevention and transmission and reproductive physiology questions compared to non-SHEP students. Positive attitudes towards people living with HIV were more likely among SHEP students compared to non-SHEP students. SHEP students also reported higher levels of self-efficacy in refusing unwanted sex and acquiring a condom compared to non-SHEP students. SHEP students were more likely to have had only one sexual partner in the last year or to report not having had sex in the past year compared to non-SHEP students. The cost of the program was about US$20 for each beneficiary. The SHEP model was found to be very effective and is recommended to be scaled-up in other settings.