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HIV Prevention Knowledge Base
Behavioral Interventions: Peer Outreach and Education
I. 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.
II. 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.
III. 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.
IV. 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.
Updated: March 2011
Peer-led Interventions to Reduce HIV Risk of Youth: A Review
Maticka-Tyndale, E., & Barnett, J.P. Evaluation and Program Planning, (2009), Vol. 33 No. 2, pp. 98-112.
The researchers review 24 youth HIV POE programs in developing nations and report that the programs overall led to improved HIV knowledge and social norms but there was no corresponding increase in condom use, except among subgroups. Similarly, there was no clear evidence of a reduction in symptoms of sexually transmitted infections. The authors note that the “greatest successes were reported in studies with the weakest designs.” They comment on the findings of Kim and Free in which benefit from adolescent POE programs was not found. They suggest some reasons for the lack of positive findings, including the large number of studies from high-income nations, such as the U.S. and U.K., and the attitudes in low- and middle-income nations where program outcome assessments are seen as “unnecessary, costly and time consuming…with little or no benefit to the program itself.” The authors cite other research suggesting that poor monitoring could contribute to weak delivery.
Effectiveness of Peer Education Interventions for HIV Prevention in Developing Countries: a Systematic Review and Meta-analysis
Medley, A., Kennedy, C., O'Reilly, K, et al. AIDS Education and Prevention, (2009), Vol. 21 No. 3, pp.181-206.
Although peer education for HIV prevention is commonly recommended and used in developing nations, the authors of this meta-analysis (a study of studies) say that the effectiveness of this approach has not been systematically evaluated. The authors analyzed 30 relevant studies published from 1990 through late 2006 and found that peer education programs led to increased knowledge and reduced equipment sharing among injection drug users. However, there was no significant benefit detected in terms of a reduction in sexually transmitted infections. The researchers comment that study heterogeneity limited the strength of this meta-analysis and they recommend a “standardized set of measures for condom use, HIV knowledge, and other behavioral and biological outcomes” for further research.
Reducing Sexual Risk Behaviors and Alcohol Use Among HIV-positive Men Who Have Sex with Men: A Randomized Clinical Trial
Velasquez, M. M., von Sternberg, K., Johnson, D.H., et al. Journal of Consulting and Clinical Psychology (2009), Vol. 77 No. 4, pp. 657-667.
The researchers conducted a randomized clinical trial of 253 alcohol-using men who have sex with men (MSM) to see whether POE using a “transtheoretical model” with motivational interviewing would reduce the men’s use of alcohol and risky sexual behavior. A control group was given referrals to standard services. The control group reported taking a slightly greater number of drinks per day and were twice as likely engage in risky sex behaviors compared to the intervention group. There was no difference between groups on the number of drinking days per 30-day period or on the number of days of unprotected sex. The protective effect in the intervention group leveled off over time and was indistinguishable from the control group by the tenth month.
Recent Evaluations of the Peer-Led Approach in Adolescent Sexual Health Education: A Systematic Review
Kim, C.R. & Free, C. International Family Planning Perspectives (2008), Vol. 34 No. 2, pp. 89-96.
The authors of this systematic review provide a critical analysis of 13 published studies of the efficacy of adolescent POE programs to promote sexual health. Studies were appraised for four critical study biases (selection-, performance-, attrition-, and detection bias). Randomized and quasi-experimental programs from high- and low-income nations were included. The authors found that the methodological quality of the studies was low and they urge caution in interpreting the results of this review. Of the three studies reporting consistent condom use, none showed statistically significant results. Nor was there clear evidence, say the authors, that adolescent POE reduced the odds of pregnancy or having a new partner. Despite their findings, the authors state that POE “should not be abandoned but rather fine-tuned.”
Modeling the Impact and Cost-effectiveness of the HIV Intervention Programme Amongst Commercial Sex Workers in Ahmedabad, Gujarat, India
Fung, I.C., Guinness, L., Vickerman, P., et al. BMC Public Health (2007), Vol. 7, p. 195.
This article uses mathematical modeling to determine cost-effectiveness of the Jyoti Sangh HIV prevention program in Gujarat, India. The program was initiated in 2003 when HIV prevalence among commercial sex workers was found to be 13 percent. The authors, using multiple assumptions and surrogate markers for the outcome of interest (HIV infections), determine that the intervention “averted 624 and 5,131 HIV cases” among sex workers and their clients respectively. They conclude that the intervention was cost effective at a cost ranging between $56 and $219 per averted case.
Creating Environments that Support Peer Education: Experiences from HIV/AIDS-prevention in South Africa
Campbell, C. Health Education (2004), Vol. 14 No. 3, pp. 361-373.
The author of this editorial reviews her own work and that of others regarding POE among South African youth. She discusses the work of Paulo Freire, the underpinnings of effective POE, and obstacles that have led to mixed results with POE. She cites her own 2001 study in which young people, despite high levels of HIV knowledge, continued to engage in high-risk sex. Barriers cited include low perceived level of personal risk; peer pressure to engage in unprotected sex; limited access to condoms; and poverty that made transaction sex attractive to some young women. The author concludes that program success will be difficult without parallel efforts to change the social environment.
Peer Education for HIV Prevention in the Socialist Republic of Vietnam: A National Assessment
Khoat, D.V., West, G.R., Valdiserri, R.O., et al. Journal of Community Health (2003), Vol. 28 No. 1, pp.1-17.
This report on a governmental assessment of HIV peer education programs finds that in 2000 “very limited” numbers of people were reached. Only 20 of Vietnam’s 61 provinces had programs. Most targeted injecting drug users and many targeted commercial sex workers, however, few targeted their sex partners. The nature of education was also incomplete; while some programs distributed condoms, few demonstrated their correct use, and access to clean needles and syringes were often not provided. The authors say that small surveys of clients indicated continuing high-risk behaviors despite repeat contacts with peer educators, suggesting inefficiencies in peer education. The authors end with six recommendations to expand and improve peer education initiatives.
Training Outreach Workers for AIDS Prevention in Rural India: Is It Sustainable?
Sivarma, S. & Celetano D.D., Health Policy and Planning (2003), Vol. 18 No. 4, pp. 411–420.
The authors review a POE program in the rural state of Karnataka in India, two years after external funding was withdrawn to determine factors associated with program sustainability. The program initially trained 5,000 community-based outreach workers (CBOWs). However, only 39 of the 5,000 appeared to sustain POE activities. The authors interviewed program staff and both sustaining- and non-sustaining CBOWs. Several factors were found to be related to sustained engagement: volunteers who were already leaders in community organizations were most likely to become sustainers; focusing on community organizations (which can aid in ongoing support for volunteers) over individual volunteers may improve sustainability; and the withdrawal of stipends to volunteers when external funding ends leads to significant attrition among impoverished volunteers.
The Influence of Peer versus Adult Communication on AIDS-protective Behaviors among Ghanaian Youth
Wolf, R.C., & Pulerwitz, J. Journal of Health Communication (2003), Vol. 8 No. 5, pp. 463-474.
In order to determine who most influences youth’s risk reduction behaviors; peers, adults, or a combination of both, the authors of this paper queried nearly 500 Ghanaian youth aged 11 to 26 years about the people they spoke with about reproductive health and contraception during the previous three months. Overall, 58 percent of youths said they had taken action during the preceding three months to protect themselves from HIV. Those who spoke with adults were no more likely than those who spoke with no one to take precautions. Those who spoke with peers were more likely to have taken a preventive measure than those who spoke with no one, while those who spoke with both peers and adults were most likely to have taken a protective measure. The author state that cause and effect could not be proven by this observational study.
Exploring Similarity between Peer Educators and Their Contacts and AIDS-protective Behaviours in Reproductive Health Programmes for Adolescents and Young Adults in Ghana
Wolf, R.C. & Bond, K.C. AIDS Care (2002), Vol. 14 No. 3, pp. 361-373.
The authors examine the similarities and differences between the age, ethnicity, gender, and school status (in or out of school) of peer educators with those of their contacts and how those similarities or dissimilarities affect the outcome of POE. Outcome was assessed by asking contacts: “Have you done anything to protect yourself from AIDS in the past three months?” Unadjusted results showed no statistically significant difference in outcome based on the closeness of peer-contact characteristics. After adjusting for “other potential co-factors,” such as age, whether the program was school-based “and other variables,” peer educators who more closely resembled their contacts had a statistically significant, albeit modest, effect on the outcome.
Impact of a Peer-group Intervention on Occupation-related Behaviors for Urban Hospital Workers in Malawi
Chimango, J. L., Kaponda, C.N., Jere, D.L., et al. Journal of the Association of Nurses in AIDS Care (2009), Vol. 20 No. 4, pp. 293-307.
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
Cornish, F. & Campbell, C. American Journal of Community Psychology (2009), Vol. 44, pp. 123–135.
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
Maas, F. & Otte, W. M. Health Education Research, (2009), Vol. 24 No. 4, pp. 547-557.
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
Sherman, S.G., Sutcliffe, C., Srirojn, B., et al. Social Science & Medicine (2009), Vol. 68 No. 1, pp. 69-79.
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
Ang, A., Morisky, D.E., Nguyen, C., et al. Health Education and Behavior (2008), Vol. 32 No. 1, pp. 43-57.
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
Cai, Y., Hong, H., Shi, R., et al. International Journal of STD & AIDS (2008), Vol. 19 No. 12, pp. 848-850.
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
Huang, H., Ye, X., Cai, Y., et al. International Journal of STD & AIDS (2008), Vol. 19 No. 5, pp. 342-346.
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
Luchters, S., Chersich, M.F., Rinyiru, A., et al. BMC Public Health (2008), Vol. 8, pp. 103.
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
Medlin, C., Balkus, J., & Padian, N. Joint United Nations Programme on HIV/AIDS (2008).
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
Sifunda, S., Reddy, P.S., Braithwaite, R., et al. Health Education & Behavior (2008), Vol. 35 No. 4, pp. 494-508.
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
Adamchak, S.E., Wong, E., Tucker, H., et al. Family Health International (2005).
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
Norr, K.F., Norr, J.L., McElmurry, B.J., et al. Health Care for Women International (2004), Vol. 25 No. 3, pp. 210-26.
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
Agha, S. AIDS Education and Prevention (2002), Vol. 34 No. 5, pp. 441-452.
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
Population Council/Horizons (1999).
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
Denison, J.A., Tsui, S., Bratt, J., et al. 2012. Health Education Research Vol. 27 No. 2, pp. 237-47.
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.
Peer Education and Support in HIV/AIDS Prevention, Care, and Treatment: A Comprehensive Training Course for Expert Clients in the Kingdom of Swaziland
International Center for AIDS Care and Treatment Programs (ICAP), (2007).
This comprehensive training course is designed to train expert clients working in clinic- and hospital-based maternal-to-child transmission programs and treatment sites in Swaziland. This training consists of 16 training units that are conducted over 6.5 days. The course prioritizes the care and treatment of pregnant women in addition to providing services and outreach to their family members. The project incorporates people living with HIV as active implementers in prevention, care, and treatment programs. It can be adapted for use in training other types of lay counselors and peer educators.
Tuko Pamoja (We Are Together): A Guide for Peer Educators
Population Council/PATH, (2007).
This on-line manual was developed as part of the Kenya Adolescent Reproductive Health Project (KARHP) Tuko Pamoja ("We are together") series. It can be used by peer educators facilitating discussion groups with in- and out-of-school youth. The manuals gives guidance on facilitating group discussions and addresses topics such as physical and emotional changes during adolescence, staying healthy, planning for the future, making good decisions, and preventing pregnancy and HIV. It is divided into 26 chapters with a reference section and can be downloaded in its entirety or each chapter can be downloaded individually.
Assessing the Quality of Youth Peer Education Programmes
Assessing the Quality of Youth Peer Education Programmes
This 45-page aid to assessing youth POE programs is based on eight checklists, which were developed and validated in a two-phase research study on the productivity, sustainability, and effectiveness of youth POE programs. The first phase involved development of the checklists; the second phase involved testing and validation of the checklists. The research was conducted in Zambia and the Dominican Republic.
The eight checklist topics are: stakeholder involvement; parental involvement; youth involvement; youth-adult partnerships; peer educator cooperation; gender equity and equality; community involvement; and technical frameworks.
Female Condom and Dual Protection: Training for Community-Based Distributors and Peer Educators
Centre for Development and Population Activities (CEDPA), (2003).
This 87-page report discusses methods of dual protection (prevention of pregnancy as well as prevention of sexually transmitted infections and HIV). Graphic depictions of male and female anatomy and explicit guidelines for the use of both female and male condoms are provided.
Peer-to-Peer: HIV & AIDS Peer Educators Trainers’ Guide for IMPACT Implementing Agencies
Family Health International/Nigeria Impact Project, (2003).
This 128-page guide is a Nigerian adaptation of various training guides for peer educators that was developed to help peer educators develop useful skills for POE programs for the prevention of sexually transmitted infections, including HIV. The Peer-to-Peer guide is intended for trainers who will train peer educators.
Peer Education Kit for Uniformed Services
Joint United Nations Programme on HIV/AIDS (UNAIDS), (2003).
As young people comprise the majority of those newly infected with HIV, there is a critical need to find effective ways to lower risk-taking behaviors that can lead to sexually transmitted infections and HIV among the uniformed services populations (i.e. military, peacekeepers, police). This 266-page kit provides a comprehensive review of topics, including an introduction to peer education; training peer educators; monitoring and evaluation; basic information on HIV and AIDS; risk assessment; condom use; sexually transmitted infections; alcohol and drug use; gender, coercion and sexual violence; voluntary counseling and testing, stigma and discrimination; mother-to-child transmission; and professional conduct. Four sets of picture cards are included as discussion aids.
Peer Education: Module 1
United Nations Office on Drugs and Crime (2003).
This 20-page module is part of a larger manual, Life Skills Training Guide for Young People: HIV/AIDS and Substance Use Prevention. Module 1 describes methods for designing, developing, and implementing POE groups and could be used to address any issue, from HIV prevention, and/or substance abuse, to pregnancy prevention.
Guide to Implementing TAP (Teens for AIDS Prevention)
Fothergill, K., Hauser, D., Jackson, K., et al. Advocates for Youth, (2002).
This 197-page comprehensive guidebook to planning, developing, and implementing a youth POE program provides practical advice on every aspect of running a POE project. The authors cover topics such as selecting and training youth educators and responding to common objections and misperceptions about youth HIV POE. The manual includes a list of reliable sources of information, 15 references, and a variety of forms that can be copied for use, including consent forms, survey questionnaires, a project-planning form, and volunteer contract.
YouthNet, Youth Peer Education Toolkit
Family Health International/YouthNet, Arlington, VA (series: various dates).
This series of tools includes “The Training of Trainers Manual”; “Standards for Peer Education Programmes”; “Theatre-Based Techniques for Youth Peer Education: A Training Manual”; “Performance Improvement: A Resource for Youth Peer Education Managers”; and “Assessing the Quality of Peer Education Programmes.”
How to Create an Effective Peer Education Project
Family Health International/YouthNet, (No Date).
This 33-page pamphlet is aimed at those who are planning a new peer education project, and/or who want to strengthen or energize ongoing projects. The information is based on interviews with more than 200 subproject managers, peer educators and peer beneficiaries in ten countries and provides guidance on appropriate activities for peer educators; recruiting and selecting peer educators; community acceptance and support for peer educators; training topics for peer educators; supervising and supporting peer educators; and the role of educational materials and condoms in peer education projects.
Peer Education for Kinshasa’s Sex Workers
Department for International Development, (2007).
This web document gives a brief overview of a Congolese sex worker and her involvement in POE. Links are provided to related articles and reports.
Young Peer Educators Raise Awareness of HIV/AIDS Prevention in Gujarat Youth
This short article describes a youth awareness project in India.
Effectiveness of Interventions to Address HIV in Prison
World Health Organization (2007)
This comprehensive report on HIV prevention efforts and challenges among male and female prisoners around the globe is heavily referenced and provides detailed information about the extent of HIV risk factors in prisons, such as rape or coerced sex, injection drug use, and consensual sex. Study summaries are provided and intervention programs including POE are overviewed. The report concludes with a list of recommendations for effective HIV prevention programs in prisons.
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Frequently Asked Questions on Peer Education
Family Health International/YouthNet, (2002).
This web-based guide answers the following frequently asked questions (FAQs): What are the advantages and benefits of peer programs? What criteria are commonly used when selecting young people to become peer promoters? Is there evidence that peer programs are successful? What are the lessons learned from peer programs? Are peer programs cost-effective? Detailed responses with examples and references are provided. The FAQs guide can be downloaded.
A Review of the Effectiveness and Appropriateness of Peer-delivered Health Promotion Interventions for Young People
Harden, A., Weston, R., & Oakley, A., Social Science Research Unit, Institute of Education, University of London, (1999).
The authors of this report conducted a systematic review of the published literature regarding youth POE. They examine the claim that POE is superior to more traditional forms of education and prevention. Full reports for 462 studies of POE programs were available for review. The authors provide citations and discuss research methodologies, study outcomes, and recommendations for future program evaluations.
After classifying each study for research design and scientific soundness, they found that only 12 of the 49 outcome evaluation studies were methodologically sound and only 5 of 12 studies directly compared peers and teachers. Of the five studies, “two found peers to be more effective than teachers, two found them to be no more or less effective, and one concluded that neither peers nor teachers were effective.” (179 pages)
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World Education Publications, HIV and AIDS
JSI/World Education Center for HIV and AIDS.
This web-based resource provides numerous publications related to HIV prevention and intervention. Some of the documents are locale-specific for various countries or states in the U.S. Others documents address topics from the care and treatment of pediatric HIV and AIDS to workplace prevention programs and peer education. Other topics include planning services, determining site readiness to initiate antiretroviral treatment, and business coalitions to prevent HIV.
National Organization of Peer Educators, Kenya
NOPE, Nairobi, Kenya
This website provides information about the Kenyan non-governmental organization, NOPE, which is active in POE programs to prevent HIV in Kenya.
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