August, 2016 - SUPPORT Summary of a systematic review | print this article |

Is peer education an effective method for HIV prevention in low- and middle-income countries?

Peer education uses individuals to convey specific information to members of a peer or target group with the aim of improving awareness or behaviours. Peer educators must share common key characteristics with those being targeted, but may either come from inside or outside the targeted group.

 

Key messages

  • Peer education may improve knowledge about HIV and about condom use in all target groups except amongst transport workers.
  • Peer education may reduce the sharing of drug injection equipment.
  • It is uncertain whether the use of peer education is associated with an increase in sexually transmitted infection rates in transport workers.
  • There is limited evidence regarding different approaches for recruiting, training, supervising, compensating and retaining peer educators.

Background

Peer educators receive training related to the issue about which they are asked to educate others. Such educational interventions are based on the assumption that peers exert a strong influence on individuals’ knowledge and behaviour. In certain instances, peers are seen as more acceptable than outside professionals, particularly if sensitive topics are being discussed. It has been argued that peer education empowers both the peer educator and the target group, and is more cost effective than interventions that rely on professional staff. Peer education can also help to gain better access to hard-to-reach populations. Such advantages make peer education a preferred tool in HIV-prevention interventions, and it is often used to spread knowledge about sexually transmitted infections, raise risk awareness, and promote safe sex strategies, particularly the use of condoms. 

This review on the impact of peer education on HIV/AIDS-related outcomes is one of a series of systematic reviews on behavioral interventions for HIV prevention in low- and middle-income countries.



About the systematic review underlying this summary

Review objectives: To assess the effect of peer-education interventions on HIV knowledge, sharing of drug injection equipment, condom use, and sexually transmitted infections in developing country settings.

Type of What the review authors searched for What the review authors found

Study designs & interventions

Peer education (the sharing of information by a peer in small groups or one-to-one).

30 studies were found including 3 randomised trials, 14 cross-sectional studies, 10 before-after studies, and 3 non-randomised trials.

Participants

No restrictions.

Youth (8 studies), commercial sex workers (12), injection drug users (4), transport workers (3), heterosexual adults (6), people in jail (2), and miners (1).

Settings

Developing countries (according to The World Bank).

Sub-Saharan Africa (13 studies), East and Southeast Asia (10), Central Asia (5), Latin America and the Caribbean (2 studies).

Outcomes

Behavioural, psychological, social, care, or biological outcomes related to HIV prevention.

HIV knowledge (26 studies), drug injection equipment sharing (6), condom use (29), sexually transmitted infections (11).

Date of most recent search: November 2006.
Limitations: This systematic review has important limitations. Only peer-reviewed journal articles were considered, and there were differences between studies with regard to outcome definition.

Medley A, Kennedy C, O’Reilly K, Sweat M. Effectiveness of peer education interventions for HIV prevention in developing countries: a systematic review and meta-analysis. AIDS Educ Prev 2009; 21:181-206.

Summary of findings

Thirty studies were conducted among different population subgroups including youth, commercial sex workers, drug injection users, transport workers, heterosexual adults, prisoners, and miners. The studies were conducted in sub Saharan Africa, Asia, Latin America, and the Caribbean. The studies reported outcomes on levels of HIV knowledge, condom use, drug injection equipment use, and sexually transmitted infections. 

Different implementation issues such as recruiting, training and supervision, compensation and the retention of peer-educators were reported in a subset of the studies. The described recruitment and training and supervision strategies were generally successful, and most programmes paid a small compensation fee to peer educators. Peer educator retention rates were reported to be low in most studies. However, this information appeared to be anecdotal and not collected systematically during process evaluations.

  • Peer education may improve knowledge about HIV and about condom use in all target groups except amongst transport workers. The certainty of this evidence is low.
  • Peer education may reduce the sharing of drug injection equipment. The certainty of this evidence is low.
  • It is uncertain whether the use of peer education is associated with an increase in sexually transmitted infections rates in transport workers. The certainty of this evidence is very low.
  • There is limited evidence regarding different approaches for recruiting, training and supervising, compensating and retaining peer educators.

Peer-education interventions

People:  Youth, commercial sex workers, injection drug users, transport workers, heterosexual adults, people in jail, miners.
Settings
:  Low- and middle-income countries.
Intervention
: Peer-education interventions.
Comparison
: No intervention.

Outcomes Impact Certainty of the evidence
(GRADE)

HIV knowledge

Across target groups:

- Knowledge about HIV increased:
OR 2.28; 95% CI 1.88 - 2.75

Stratified by target group:

- Knowledge about HIV increased (p<0.05) among all target groups except transport workers

Low

Injection drug equipment sharing

Sharing of drug injection equipment reduced:
OR 0.37; 95% CI 0.20 - 0.67

Low

Condom use 

Across target groups:

- Condom use increased:
OR 1.92; 95% CI 1.59 - 2.33 (all partners)

- Condom use increased:
OR 1.94; 95% CI 1.27 - 2.94 (regular partners)

- Condom use increased:
OR 2.23; 95% CI 1.70 - 3.09 (casual partners)

 

Stratified by target group:

- Condom use increased (p<0.05) among all target groups except youth and adolescents.

Low

Sexualy transmitted infections (STI)

Across target groups: uncertain whether STI rates increased:
OR 1.22; 95% CI 0.88 - 1.71

 

Stratified by target group:

- STI rates increased among transport workers (OR 1.95; 95% CI 1.45 - 2.62)

Very Low

OR: Odds Ratio; CI: confidence interval; p: p-value; GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
  • All the studies included were conducted in low- and middle-income countries. 
  • The study findings were not analysed in terms of the size of the effect, or the regions, economic situations, or socio‑political systems in which they were conducted.
  • In some countries, interventions targeting certain groups may be difficult to implement (see ‘Equity’ below).
EQUITY
  • All the studies focused on a specific group.
  • The review did not examine the effects of peer education interventions on specific ethnic, religious and sexual minorities.
  • The prevailing socio-political system of a country impacts on the visibility and accessibility of specific target groups such as ethnic, religious and sexual minorities, and illegal drug users. Such differences probably impact on the feasibility and effectiveness of interventions targeted to such groups.
ECONOMIC CONSIDERATIONS
  • The review did not provide information on absolute costs or cost-effectiveness.
  • Peer education is assumed to be more cost-effective than other interventions that rely on health professionals. However, very little information about cost-effectiveness was provided.
  • The impact of payments for peer educators on intervention effects is unknown.
  • Considerable financial and human resources may be required to sustain peer education programmes due to high rates of peer turnover, training and supervision requirements, and other potential costs.
  • It is unclear whether peer education interventions could lead to cost savings through reductions in levels of sexually transmitted infections.
MONITORING & EVALUATION
  • The certainty of the evidence for the effects of peer education interventions on behavioural outcomes is low.
  • The certainty of the evidence for the effects of peer education interventions on health outcomes is very low.

  • Any extension of peer education interventions to additional target groups (e.g. ethnic, religious and sexual minorities) should be monitored and evaluated.
  • Further evaluations of the effectiveness of peer education interventions on health outcomes are needed.
  • There is a need for process evaluations to understand how context might influence implementation.
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.supportsummaries.org/methods

Additional information

Related literature

Campbell C, Mzaidume Z. Grassroots participation, peer education, and HIV prevention by sex workers in South Africa. Am J Public Health 2001; 91:1978-86.

 

Campbell C, MacPhail C. Peer education, gender and the development of critical consciousness: Participatory HIV prevention by South African youth. Soc Sci Med 2002; 55:331-45.

 

Hutton G, Wyss K, N’Diekhor Y. Prioritization of prevention activities to combat the spread of HIV/AIDS in resource constrained settings: a cost-effectiveness analysis from Chad, Central Africa. Int J Health Plann Manage 2003; 18: 117-36.

 

Population Council. Peer Education and HIV/AIDS: Past Experience, Future Directions. 2002. Available at: www.popcouncil.org/pdfs/peer_ed.pdf

 

Strange V, Forrest S, Oakley A. Peer-led sex education - characteristics of peer educators and their perceptions of the impact on them of participation in a peer education programme. Health Educ Res 2002; 17:327-37.

 

This summary was prepared by

Peter Steinmann, Swiss Tropical and Public Health Institute, Switzerland.

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

Acknowledgements

This summary has been peer reviewed by: Caitlin Kennedy, Michael Sweat, Kevin O’Reilly, Chris Bonell, and Hanna Bergman.

This review should be cited as

Medley A, Kennedy C, O’Reilly K, Sweat M. Effectiveness of peer education interventions for HIV prevention in developing countries: a systematic review and meta-analysis. AIDS Educ Prev 2009; 21:181-206.

The summary should be cited as

Steinmann P. Is peer education an effective method for HIV prevention in low- and middle-income countries? A SUPPORT Summary of a systematic review. August 2016. www.supportsummaries.org

Keywords

evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, peer education, effectiveness, HIV.



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