HIV/AIDS Peer Education: Evolving with the Epidemic

Interviews with project managers, peer educators and target audiences reveal that peer education can be an effective strategy for HIV/AIDS prevention, but peer educators must develop new skills to meet the changing needs of their friends, neighbors and colleagues.

When John first became a peer educator for an HIV/AIDS prevention project at his workplace, he spoke to groups of fellow employees about how the virus is and is not transmitted. Holding weekly meetings during tea breaks, he answered basic questions about the HIV/AIDS epidemic and urged his coworkers to use condoms.

Five years later, John still spends many of his lunch and tea breaks working as a peer educator. But today, he is more likely to spend that time talking one-on-one with one of his peers or in a lively discussion with just a few employees.

In the beginning coworkers came to John with very basic questions about HIV/AIDS and how they could contract it. But now they know how HIV/AIDS is transmitted and how it can be prevented. They ask him much more difficult questions, such as "How can I talk to my partner about using a condom?" and "How can I tell my wife that I have the virus?"

John could be a peer educator in Brazil, or Tanzania, or Thailand -- or any of the many countries where peer education has become a mainstay of HIV/AIDS prevention during the past ten years. Many prevention programs have recruited and trained peer educators to help increase awareness of HIV/AIDS and knowledge of prevention measures. But John and his counterparts are finding that what their peers need now is a better understanding of their own risk of becoming infected, counseling, and other support to enable them to change their behavior and sustain that change.

A recent study of 21 projects that use a peer education strategy found that peer educators in a number of countries are beginning to make this shift from raising awareness to supporting behavior change. The study, conducted by the AIDS Control and Prevention (AIDSCAP) Project, identified factors essential to peer education and helped establish guidelines for designing projects using peer educators.

A total of 22 project managers, 80 peer educators and 121 target audience members were interviewed in 10 countries in Africa, Asia, Latin America and the Caribbean. The 21 projects, all funded by the U.S. Agency for International Development as part of the AIDSCAP Project, were aimed at various target audiences, including students, out-of-school youth, commercial sex workers (CSWs), men who have sex with men, transportation workers, military personnel and farm workers.

An Effective Strategy

Peer education has been a staple of HIV/AIDS prevention for the past decade. Designers of prevention projects assumed that one of the best ways to reach people with information about HIV/AIDS and and to influence their behavior would be through their peers -- respected friends, colleagues and neighbors.

AIDSCAP's findings suggest that this assumption is valid. Members of the projects' target audiences agreed almost unanimously that they were comfortable talking to peer educators about HIV and AIDS, and that talking to a peer educator was a good way to obtain HIV/AIDS information. Ninety-five percent of target audience members said the peer educators they had talked to were people like themselves.

Identification with the peer educators enables individuals to discuss sexual issues with little or no embarrassment. "Our thoughts are basically the same and I feel much better discussing the subject of sex with my peers," a Jamaican student said.

Statements by the target audience members confirm that they have acquired information and skills from the peer educators. Examples include a Dominican CSW who "learned how to use condoms and how to convince men to use them," and Jamaican students who learned how to practice safe sex and "not to rush into sexual activity."

The most dramatic examples of behavior change may be among the peer educators themselves. Ninety-five percent of the educators said that they had changed their own behavior since becoming a peer educator.

Many peer educators reported lifestyle changes like those made by an Ethiopian peer educator. "I got enough knowledge about the disease, I left my work as a CSW, and started a new life," she said. "I have only one partner now, and I am able to educate others on AIDS."

What Is Peer Education?

The peer educators interviewed had backgrounds that reflected the variety of target audiences involved in this study. In general, each peer educator had an occupation and lifestyle similar to those of his or her project's target audience. Although they were respected by their peers, most peer educators were not traditional "authority figures": only 13 percent had been employed in a position that might be identified with authority, such as a health worker, teacher, manager or "professional."

According to project managers, the ideal peer educator is respected, charismatic and literate, with good communication skills and an interest in self-enhancement. Some project managers look for peer educators chosen by members of the target audience.

Leadership is a particularly important characteristic. Managers, peer educators and target audience members all say peer educators should be role models in their communities. "They realize the importance of setting a good example in order to educate/convince fellow students," said a Nigerian project manager.

What does peer education consist of? Peer educators report a variety of activities, from informal discussion to video and drama presentations. Most talk to more than one person at a time for 30 minutes or less. These discussions and presentations occur in a variety of locations, including schools, workplaces and bars. Rural women are contacted at clothes washing points, playgrounds and markets, while young men are found at sports fields, beer halls and petrol stations.

Project managers expect peer educators to be routinely "on the job." Most believe that peer educators make contact with the target audience at least weekly, and the number of contacts reported by the educators suggests that this is the case. Seven out of ten peer educators said they talk to 30 or more peers each month. Target audience members also report a high level of contact with peer educators: 93 percent have had at least one personal conversation with a peer educator, and 55 percent had more than five of these conversations during the preceding year.

Peer education projects face numerous challenges. Among those identified by the study were time constraints, peer denial of the existence or importance of HIV/AIDS, a lack of money, medicine, educational materials, condoms or other resources, and transportation difficulties. Some peer educators report that they are harassed or intimidated while doing their work.

Despite these difficulties, the study indicated that AIDSCAP projects using peer education have made a definite impact in their target communities. More than nine out of ten of the target audience members interviewed reported that they had shared the information and skills they had learned from the peer educators with their families, partners, friends or colleagues.

Asked about the most important things they learned from peer educators, target audience members mentioned prevention, condom use, basic HIV/AIDS facts, safe sex, fidelity, self-esteem and negotiation skills. A Dominican woman said that she had learned to take care of herself and express herself. Others mentioned accepting people living with HIV/AIDS.

Some target audience members described the impact of their new knowledge on their behavior. "I love the teaching about condoms because it has saved my life," a Nigerian man said. "It has curbed my problems of STDs."

Toward Behavior Change

The study identified the strengths of peer education, but also raised some concerns. Comments such as, "The target audience is fed up with AIDS information," and "The women don't want to be bothered with talks," suggest that, in some instances, the usefulness of peer education may have reached a plateau.

"It may be that the peer educators who voiced these statements see their job as a one-way imparting of the same information over and over," said Donna Flanagan, AIDSCAP's associate director for behavior change communication (BCC). "Knowing when to enlarge the message, when to listen, when to empathize and how to bring STD/HIV information into conversations about other issues are skills that are not easily taught in a training course."

But peer educators need to learn those skills in order to be useful beyond the early, awareness-raising phases of the behavior change process. As the effects of AIDS become more and more apparent in communities around the world, people are looking to peer educators for skills training, counseling and support.

AIDSCAP project managers recognize the need to adapt their projects to meet the changing needs of their target audiences. When asked about the goals of their projects, AIDSCAP project managers were more than twice as likely to mention encouraging behavior change and risk reduction as they were to say increasing the target's audience's knowledge and awareness of HIV/AIDS.

One project manager in Zimbabwe summarized the changes that have occurred in a number of projects. The project has progressed from mostly information and condom distribution "into an aggressive peer education program [with] specialized training [in] counseling, drama and communication skills."

Many projects, however, still focus on providing information and handing out condoms. Some of the differences among these projects reflect the needs of different target audiences, Flanagan noted.

"In areas where the epidemic is still at an early stage, raising awareness is an appropriate role for a peer educator," she said. "In most of the countries studied, however, the epidemic has matured, and peer educators require more advanced skills to meet the needs of the target audience."

The AIDSCAP report recommends that project managers conduct training needs analyses and strengthen their training curricula to help peer educators meet these evolving needs. Many peer educators, for example, expressed a need for training in counseling and AIDS care.

"To respond effectively to the growing need for behavior change skills and support, training should be adapted to emphasize topics such as teaching negotiation skills, individual counseling, and care and support for people living with HIV or AIDS," Flanagan said.

The report also recommends that project managers reach out to appropriate health care providers in order to help create a cadre of professional support for peer educators. The AIDSCAP study found that projects using peer educators often overlook the opportunity to build ties with the formal health care system.

Such linkages are becoming increasingly important as projects begin to include home care, counseling, and referrals for HIV testing and AIDS treatment, according to Flanagan. "Peer educators can provide a valuable link to community members outside of the formal health care system, and health care professionals can be an additional source of informal training for peer educators, particularly on topics such as counseling and home care," she said.

The study findings suggest that efforts to create a professional support network for peer educators and provide training to equip them for new roles will be a worthwhile investment in sustainable HIV/AIDS prevention. Even though peer educators in nine of the 12 countries are volunteers, most consider it a long-term, if not a lifelong, commitment.

More than 90 percent of the peer educators intended to remain peer educators until at least the end of their projects or their departure from target community, and 44 percent said they would continue their peer education work for even longer periods -- as long as they are able, for their entire life, or, as a Thai peer educator said, "until they discover medicine to destroy AIDS."

"For me, this is a role I have to play forever," said a peer educator in Cameroon.

-- Chandler Williams

Chandler Williams is the program assistant for AIDSCAP's Behavior Change Communication Unit (BCC).

The results of the peer education study are available in the report Peer Education in Projects Supported by AIDSCAP and were used to develop the fifth in AIDSCAP's series of BCC handbooks, How to Create an Effective Peer Education Project.