What experienced HIV-infected lay peer educators working in Midwestern U.S. HIV medical care settings think about their role and contributions to patient care

The relationship between access to peer support programs and quality of life among people living with HIV in Australia

Peer support services for people living with HIV (PLHIV) serve varying functions and are a unique resource for support. Peer support programs are considered an important strategy for achieving better quality of life (QoL) for PLHIV and there has been substantial investment in provision of such programs. The present study asks whether being connected to other PLHIV is associated with better QoL for PLHIV in Australia and; whether involvement in formal peer support programs is associated with QoL among people newly diagnosed with HIV. A sample of 816 PLHIV participated in a nationwide survey. Regression analyses showed that having a friend living with HIV who they could talk to about HIV was significantly associated with better QoL. However, a multiple regression analysis showed that use of peer advice/support and peer navigator programs was associated with lower QoL among PLHIV who had been living with HIV for more than five years. This suggests that people experiencing poorer QoL are more likely to access these programs long after diagnosis. It is therefore critical that peer support continue to be available and accessible to PLHIV beyond initial diagnosis and treatment as a means of ongoing HIV-related care.

Exploring the Impact of an Integrated Trauma-Informed HIV and Vocational Intervention for Black/African American Women Living with HIV

Given the increased recognition of the role of social determinants of health on the prevalence of HIV in the United States, interventions that incorporate and address social determinants of HIV are essential. In response to the health disparities facing Black/African American women living with HIV, HIV activists and mental health specialists developed an innovative integrated HIV prevention and vocational development intervention, Common Threads, that underscores and addresses key economic and other social determinants of health experienced by Black/African American women within a trauma-informed care (TIC) framework. This research study applied grounded theory methods to conduct a qualitative study of Common Threads based on interviews with 21 women who participated in the Common Threads intervention. Participants shared several critical aspects of program components that reflected the TIC principles, endorsing a safe environment, trust building, and a sense of belonging. These components also encouraged transparency and promoted autonomy. Additionally, participants shared perceived program outcomes, including changes of knowledge and skills in four considering work domains (i.e., medical, psychosocial financial/legal resources, and vocational) that facilitate health and vocational development.

Trends in U.S. HIV Peer Health Worker Training Strategies and Approaches: A Scoping Review of the Literature

ABSTRACT

Peer health workers (peers) are commonly engaged interventionists in the HIV care spectrum. The objective of this scoping review was to examine the range of evidence on training strategies and approaches for peer-led HIV behavioral interventions in the United States. Four electronic databases (Medline, CINAHL, EMBASE, and PsycINFO) were searched for peer-reviewed published literature (2010-2021) of peer-led HIV behavioral interventions directed to improving antiretroviral therapy adherence and/or retention in care. Eighteen studies met the inclusion criteria. Eleven studies referenced manualized training materials, and nine used role-play as part of their curricula. Peer training content and duration varied across studies, as well as evaluation of intervention fidelity, and peer competency. Findings highlight heterogeneity in peer training strategies and approaches. The expansion and sustainability of peer engagement in the HIV care continuum will require greater consensus among members of the research community on best practices for training.

Engagement in HIV Care Among New York City Transgender Women of Color: Findings from the Peer-Led, TWEET Intervention, a SPNS Trans Women of Color Initiative

Transgender women (TW) have higher HIV prevalence rates than cisgender (i.e., non-transgender) women. However, utilization of healthcare for transgender people in the U.S. is low. As part of a multisite initiative to facilitate entry and retention in HIV care for TW of color, we compared health outcomes between participants who became Peer Leaders and those who did not. From 2013 to 2016, 163 New York City, mostly Latina, TW enrolled in the Transgender Women Engagement and Entry to Care Project (TWEET). The TWEET intervention included peer-led, group-based educational sessions called Transgender Leader-Teach Back; 39% completed Peer Leadership requirements. Comparing pre-post change by Peer Leader status, Peer Leaders had a significant decrease in viral load and significant increase in CD4 at the last HIV care visit compared to the first. In multivariable logistic regression, predictors associated with Peer Leadership included having at least some college education, being in a relationship, stable housing, receiving legal assistance for political asylum, and having two or more HIV care visits during the intervention. Findings suggest that, for trans women who have completed at least secondary school education, participating in a peer-led intervention can lead to improved HIV care engagement. Understanding which program components lead to becoming a Peer Leader, and how to better engage non-Peer Leaders, are important next steps.

The effectiveness of peer-support for people living with HIV: A systematic review and meta-analysis

BACKGROUND

The practice of involving people living with HIV in the development and provision of healthcare has gained increasing traction. Peer-support for people living with HIV is assistance and encouragement by an individual considered equal, in taking an active role in self-management of their chronic health condition. The objective of this systematic review was to assess the effects of peer-support for people living with HIV.

METHODS

We conducted a systematic review in accordance with international guidelines. Following systematic searches of eight databases until May 2020, two reviewers performed independent screening of studies according to preset inclusion criteria. We conducted risk of bias assessments and meta-analyses of the available evidence in randomised controlled trials (RCTs). The certainty of the evidence for each primary outcome was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

After screening 219 full texts we included 20 RCTs comprising 7605 participants at baseline from nine different countries. The studies generally had low risk of bias. Main outcomes with high certainty of evidence showed modest, but superior retention in care (Risk Ratio [RR] 1.07; Confidence Interval [CI] 95% 1.02-1.12 at 12 months follow-up), antiretroviral therapy (ART) adherence (RR 1.06; CI 95% 1.01-1.10 at 3 months follow-up), and viral suppression (Odds Ratio up to 6.24; CI 95% 1.28-30.5 at 6 months follow-up) for peer-support participants. The results showed that the current state of evidence for most other main outcomes (ART initiation, CD4 cell count, quality of life, mental health) was promising, but too uncertain for firm conclusions.

CONCLUSIONS

Overall, peer-support with routine medical care is superior to routine clinic follow-up in improving outcomes for people living with HIV. It is a feasible and effective approach for linking and retaining people living with HIV to HIV care, which can help shoulder existing services.

TRIAL REGISTRATION

CRD42020173433.

Positive Side Effects: The Perceived Health and Psychosocial Benefits of Delivering an HIV Self-Management Program for Peer Educators Living With HIV

Although there is evidence that peer-led HIV treatment interventions are effective in improving health outcomes of people living with HIV (PLWH), few studies have assessed the health and psychosocial benefits of being a peer living with HIV. Qualitative interviews were conducted with nine PLWH who were peers of an HIV self-management intervention, to examine how this experience was perceived to impact their health behaviors, social support, and professional development. Peers reported improved HIV self-management and reduced health risk behaviors, which were attributed to increased self-efficacy and the desire to be a role model for participants. Peers described the experience as an opportunity to expand social networks and develop professional skills that could be leveraged for future employment. Our findings suggested that the benefits of being a peer could be enhanced in trainings and supervision by linking the importance of health-promoting behaviors to being a role model for other PLWH.

A Scoping Review of the Empirical Literature on Peer Support for People Living with HIV

People living with HIV receiving antiretroviral therapy need support related to linkage to care and self-management in everyday life. Peer support has been found to provide varied support according to the unique needs of the group. This scoping review aims to provide an overview of research on peer support provided to people living with HIV. A search was conducted in eight databases until May 2021, and two reviewers independently screened all identified studies. We sorted the included studies into categories and conducted descriptive analyses. For this communication, we included 34 studies representing three study categories: the experiences of peer support (n = 23), program descriptions (n = 6), and training of peer supporters (n = 5). The studies were published between 2000 and 2021 and included 4275 participants from 10 countries. The flexibility of peer support complements healthcare services, but there is a need to clarify and adjust the ongoing support when living with HIV.

Peers Keep It Real: Re-engaging Adults in HIV Care

Background:

After diagnosis, a substantial number of people with HIV disease fall out of care. Effective interventions are needed for this priority population.

Methods:

The “Peers Keep It Real” study aimed to help adults who were disengaged from HIV treatment. Peers, lay individuals living with HIV, facilitated intervention sessions. Participants were randomized to immediately receive the peer-facilitated intervention or were wait-listed.

Results:

Considerable attrition occurred in the control group. Pre-/postanalyses showed that among participants (n = 23) who received the intervention, 65% had viral load suppression and 100% remained in care at 12 months postintervention. Impact on viral load was significant (P = .0326), suggesting that peers are effective change agents who positively impacted outcomes for individuals struggling with adherence to HIV treatment.

Conclusion:

Future endeavors should consider providing all individuals from this priority population with an active peer intervention from the onset to enhance retention and adherence.

I Don't Want the Tray to Tip: Experiences of Peer Evaluators in a Multisite HIV Retention in Care Study

Numerous studies demonstrate the efficacy of peer-delivered interventions to improve HIV prevention and care outcomes, yet few explore the role of peers in evaluation and data collection. We conducted qualitative interviews with providers in a multisite HIV Retention in Care initiative to explore peers' evaluation roles, challenges, and strategies for success. We found peers' responsibilities included data collection, client assessments, and data entry. Their rapport with clients was considered an evaluation asset. However, peers struggled with balancing rigorous evaluation and data collection demands with the needs and comfort of clients. Recommendations for peer-based evaluation include ensuring self-care, streamlining workflow, and involving peers in evaluation development and reporting processes. Additional research is needed to explore the extent to which peers participate in evaluation activities and to ensure rigor in peer-based evaluation. Given that peers are well-positioned to collect client-level data, best practices, standards, and trainings for peer-based evaluation should be developed.

Association Between Internalized HIV-Related Stigma and HIV Care Visit Adherence

BACKGROUND

Internalized HIV-related stigma acts as a barrier to antiretroviral therapy (ART) adherence, but its effects on other HIV care continuum outcomes are unclear.

METHODS

Among 196 HIV clinic patients in Birmingham, AL, we assessed internalized HIV-related stigma and depressive symptom severity using validated multi-item scales and assessed ART adherence using a validated single-item measure. HIV visit adherence (attended out of total scheduled visits) was calculated using data from clinic records. Using covariate-adjusted regression analysis, we investigated the association between internalized stigma and visit adherence. Using path analytic methods with bootstrapping, we tested the mediating role of depressive symptoms in the association between internalized stigma and visit adherence and the mediating role of visit adherence in the association between internalized stigma and ART adherence.

RESULTS

Higher internalized stigma was associated with lower visit adherence (B = -0.04, P = 0.04). Black (versus white) race and depressive symptoms were other significant predictors within this model. Mediation analysis yielded no indirect effect through depression in the association between internalized stigma and visit adherence (B = -0.18, SE = 0.11, 95% confidence interval: -0.44 to -0.02) in the whole sample. Supplemental mediated moderation analyses revealed gender-specific effects. Additionally, the effect of internalized stigma on suboptimal ART adherence was mediated by lower visit adherence (B = -0.18, SE = 0.11, 95% confidence interval: -0.44 to -0.02).

CONCLUSIONS

Results highlight the importance of internalized HIV stigma to multiple and sequential HIV care continuum outcomes. Also, findings suggest multiple intervention targets, including addressing internalized stigma directly, reducing depressive symptoms, and promoting consistent engagement in care.

Improving Engagement in the HIV Care Cascade: A Systematic Review of Interventions Involving People Living with HIV/AIDS as Peers

Improving patient engagement in HIV care is critical for maximizing the impact of antiretroviral therapy (ART). We conducted a systematic review of studies that used HIV-positive peers to bolster linkage, retention, and/or adherence to ART. We searched articles published and indexed in Pubmed, PsycINFO, and CINAHL between 1996 and 2014. Peers were required to be HIV-positive. Studies were restricted to those published in English. Nine studies with n = 4658 participants met the inclusion criteria. Peer-based interventions were predominantly focused on improving adherence to ART, or evaluations of retention and adherence via viral suppression. Five (56 %) were conducted in sub-Saharan Africa. Overall findings were mixed on the impact of peers on ART adherence, viral suppression, and mortality. While positive effects of peer interventions on improving linkage and retention were found, there were limited studies assessing these outcomes. Additional research is warranted to demonstrate the impact of peers on linkage and retention in diverse populations.

Enroling and retaining human immunodeficiency virus (HIV) patients in their care: A metasynthesis of qualitative studies

OBJECTIVES

To report the findings of a metasynthesis review of qualitative studies on patient and provider experiences and perspectives on linkage and retention in HIV care.

DESIGN

The review is an extraction, aggregation, interpretation and synthesis of qualitative findings based on the Sandelowski and Barroso method.

DATA SOURCES

A search of the literature was conducted in the databases Cumulative Index to Nursing and Allied Health, PubMed and PsycInfo for articles published from 2008 to 2013. Inclusion criteria were qualitative research articles published in English from across the world and in peer-reviewed journals. Literature reviews, conference abstracts and grey literature were excluded from this metasynthesis.

REVIEW METHODS

The review consisted of a) comprehensive search, b) study classification, c) abstraction of findings, d) synthesis. Of the 4640 citations screened, 69 articles were included for this metasynthesis.

RESULTS

69 unique articles from 44 countries were included. This metasynthesis takes into account the perspectives of at least 2263 HIV-positive participants (740 men, 1008 women, 78 transgender individuals and 437 unspecified sex) and 994 healthcare providers, family members and community members. The most salient barriers and facilitators to HIV linkage and retention in HIV care affirm ecological factors that are mostly beyond individual patients' control. Triadic streams of influence concurrently affect care engagement that include a person's psychological state upon diagnosis and their informational challenges (intrapersonal stream); one-on-one interactions with providers and their immediate community (social stream); and life demands, overall quality of care experiences and other structural barriers (cultural-attitudinal stream). Each stream's influence on HIV care engagement varies at any given point to reflect an individual's evolving and unique experiences with HIV infection throughout the illness trajectory.

CONCLUSION

There is sufficient evidence that detail how to best link and retain patients in HIV care. Themes identified indicate going beyond individual-level factors and towards shifting attention and resources to systems that patients navigate. Forceful structural-level actions are needed to correct these long-identified barriers and enhance care engagement facilitators.

Peers as Facilitators of Medication Adherence Interventions: A Review

BACKGROUND

Difficulty taking essential medications as prescribed is a prevalent problem among people living with chronic diseases. Numerous interventions to enhance medication adherence have been developed; the majority facilitated by health care professionals.

OBJECTIVE

This review examined medication adherence interventions delivered by peers (ie, lay individuals living with the same chronic disease) and reports what is known about the impact of peer-facilitated interventions.

DATA SOURCES

PubMed, CINAHL, Google Scholar, Google, and PsychInfo, and ancestry searches.

STUDY SELECTION

Solely peers delivered the intervention and follow-up occurred for at least 24 weeks postintervention. Electronic databases were searched from their start date to December 31, 2014.

RESULTS

Eleven studies were located that reported 10 different interventions focused on 6 chronic disease conditions. Most interventions were delivered in clinical settings and grounded in a theoretical framework. Formats were evenly split between individual and group level, with one intervention using both. Length of training for the interventionists and the number of intervention sessions that subjects received varied across studies.

LIMITATIONS

Self-report was frequently used as a measure of adherence. Biomarkers were sometimes used to assess medication adherence; however, lifestyle modification may have also affected biomarker levels.

CONCLUSIONS

Overall, the interventions had positive effects and attrition was quite low. Peer-facilitated interventions appear to enhance medication adherence as well as other healthful behaviors, such as exercise.

Peer supporter experiences of home visits for people with HIV infection

Purpose

This study’s purpose was to explore the experiences of peer supporters regarding their work in a home visit program for people with HIV infection.

Patients and methods

A qualitative descriptive study was conducted using focus groups. Participants were 12 HIV-positive peer supporters conducting home visits with people living with HIV/AIDS in South Korea. Thematic analysis was used to analyze the data.

Results

Six major themes emerged: feeling a sense of belonging; concern about financial support; facing HIV-related stigma and fear of disclosure; reaching out and acting as a bridge of hope; feeling burnout; and need for quality education. The study findings indicate that although peer supporters experience several positive aspects in the role, such as feelings of belonging, they also experience issues that make it difficult to be successful in the role, including the position’s instability, work-related stress, and concerns about the quality of their continuing education.

Conclusion

The findings suggest that to maintain a stable and effective peer supporter program, such positions require financial support, training in how to prevent and manage stress associated with the role, and a well-developed program of education and training.

A Peer-Led HIV Medication Adherence Intervention Targeting Adults Linked to Medical Care but without a Suppressed Viral Load

BACKGROUND

Non-adherence to antiretroviral (ART) treatment remains a prevalent problem even among the segment of the U.S. HIV population that is 'linked' to medical care.

METHODS

Controlled pilot feasibility study with ART experienced adult patients (n = 20) linked to HIV medical care without suppressed viral load. Patients were randomized to a peer-led HIV medication adherence intervention named `Ready' or a time equivalent `healthy eating' control arm. Lay individuals living with HIV were trained to facilitate `Ready'.

RESULTS

Patients had been prescribed a mean of three prior ART regimens. The group randomized to `Ready' had significantly improved adherence. MEMS and pharmacy refill data correlated with viral load log drop. Higher readiness for healthful behavior change correlated with viral load drop and approached significance.

CONCLUSION

A peer-led medication adherence intervention had a positive impact among adults who had experienced repeated non-adherence to HIV treatment. A larger study is needed to examine intervention dissemination and efficacy.

When it comes to lifestyle recommendations, more is sometimes less: a meta-analysis of theoretical assumptions underlying the effectiveness of interventions promoting multiple behavior domain change

A meta-analysis of 150 research reports summarizing the results of multiple behavior domain interventions examined theoretical predictions about the effects of the included number of recommendations on behavioral and clinical change in the domains of smoking, diet, and physical activity. The meta-analysis yielded 3 main conclusions. First, there is a curvilinear relation between the number of behavioral recommendations and improvements in behavioral and clinical measures, with a moderate number of recommendations producing the highest level of change. A moderate number of recommendations is likely to be associated with stronger effects because the intervention ensures the necessary level of motivation to implement the recommended changes, thereby increasing compliance with the goals set by the intervention, without making the intervention excessively demanding. Second, this curve was more pronounced when samples were likely to have low motivation to change, such as when interventions were delivered to nonpatient (vs. patient) populations, were implemented in nonclinic (vs. clinic) settings, used lay community (vs. expert) facilitators, and involved group (vs. individual) delivery formats. Finally, change in behavioral outcomes mediated the effects of number of recommended behaviors on clinical change. These findings provide important insights that can help guide the design of effective multiple behavior domain interventions.

"Keep it simple": older African Americans' preferences for a health literacy intervention in HIV management

PURPOSE

Health literacy is lower in minorities and older adults, and has been associated with nonadherence to medications, treatment, and care in people living with human immunodeficiency virus (HIV). Likewise, African Americans with HIV are more likely to be nonadherent to their HIV medications, less likely to keep their clinic appointments related to HIV treatment and care, and more likely to die during hospitalizations than their ethnic counterparts. The present study explored the preferences of older African Americans with HIV for a health literacy intervention to promote HIV management.

PATIENTS AND METHODS

In this qualitative study, 20 older adult African Americans living with HIV were recruited from an HIV/acquired immunodeficiency syndrome outpatient clinic in the southeastern region of the US. Using patient-centered participatory design methods, semi-structured individual interviews were conducted to determine patient preferences for intervention development and design. Health literacy was also measured using the Rapid Estimate of Adult Literacy in Medicine - Revised (REALM-R).

RESULTS

Four major themes emerged related to intervention development and design: keep health information simple; use a team-based approach for health education; tailor teaching strategies to patients' individual needs; and account for patients' low experience, but high interest, in technology. Forty-five percent of the study population had low health literacy based on the revised Rapid Estimate of Adult Literacy in Medicine.

CONCLUSION

Future interventions that target minorities and older adults living with HIV should consider patients' learning needs, sex-specific and mental health needs, and delivery approaches, in order to increase uptake and improve disease management and health outcomes.

Socially-integrated transdisciplinary HIV prevention

Current ideas about HIV prevention include a mixture of primarily biomedical interventions, socio-mechanical interventions such as sterile syringe and condom distribution, and behavioral interventions. This article presents a framework for socially-integrated transdisciplinary HIV prevention that may improve current prevention efforts. It first describes one socially-integrated transdisciplinary intervention project, the Transmission Reduction Intervention Project. We focus on how social aspects of the intervention integrate its component parts across disciplines and processes at different levels of analysis. We then present socially-integrated perspectives about how to improve combination antiretroviral treatment (cART) processes at the population level in order to solve the problems of the treatment cascade and make "treatment as prevention" more effective. Finally, we discuss some remaining problems and issues in such a social transdisciplinary intervention in the hope that other researchers and public health agents will develop additional socially-integrated interventions for HIV and other diseases.

Health behavior change models for HIV prevention and AIDS care: practical recommendations for a multi-level approach

Despite increasing recent emphasis on the social and structural determinants of HIV-related behavior, empirical research and interventions lag behind, partly because of the complexity of social–structural approaches. This article provides a comprehensive and practical review of the diverse literature on multi-level approaches to HIV-related behavior change in the interest of contributing to the ongoing shift to more holistic theory, research, and practice. It has the following specific aims: (1) to provide a comprehensive list of relevant variables/factors related to behavior change at all points on the individual–structural spectrum, (2) to map out and compare the characteristics of important recent multi-level models, (3) to reflect on the challenges of operating with such complex theoretical tools, and (4) to identify next steps and make actionable recommendations. Using a multi-level approach implies incorporating increasing numbers of variables and increasingly context-specific mechanisms, overall producing greater intricacies. We conclude with recommendations on how best to respond to this complexity, which include: using formative research and interdisciplinary collaboration to select the most appropriate levels and variables in a given context; measuring social and institutional variables at the appropriate level to ensure meaningful assessments of multiple levels are made; and conceptualizing intervention and research with reference to theoretical models and mechanisms to facilitate transferability, sustainability, and scalability.