Peers can be an important source of support for people with HIV as they manage their health and well-being. Offering peer support programs is one way that frontline organizations can engage peers in the delivery of services for people with HIV. This article summarizes a realist review that examined the factors impacting the effectiveness of HIV peer support programs.1
What is HIV peer support?
The review defined peer support as “the giving of assistance and encouragement by an individual considered equal.”1 Peers are characterized as individuals whose lived experience is similar to that of the person they are supporting. This similarity allows peers to offer support based on shared understanding and personal experience. Although the lived experience shared by peers and the people they support can be based on various characteristics, such as age or gender, in the review, HIV peer support referred to support provided by a person with HIV to another person with HIV.
With their personal experience of HIV, peers complement the support provided by a person’s healthcare team in maintaining health and well-being. Peer support can include providing education, counselling and health navigation, among other activities. Peer support is associated with beneficial outcomes for both the person receiving support and the peer providing support. Receiving peer support can positively impact the physical and mental health of people with HIV. Providing peer support can also positively impact the knowledge, skills and mental health of peers.
What is a realist review?
A realist review or synthesis is a type of literature review that aims to understand the context and mechanisms or conditions within which the intervention is delivered that impact the intervention outcomes.2 While a systematic review helps us to determine an intervention’s effectiveness, a realist review aims to help us understand what conditions and factors play a role in an intervention’s effectiveness. A realist review uses data from diverse sources (e.g., grey literature, commentaries) to understand an intervention, while a systematic review focuses on data from research studies and ranks those data (e.g., data from randomized controlled trials are prioritized).
A realist review starts with a theory identifying the intervention outcomes, and the context and mechanisms that may influence the achievement of these outcomes. A literature search is then done to identify evidence to test and further develop the proposed theory. The theory developed through the review can be used as a theoretical framework during program development and delivery to help understand the conditions that may impact whether a program achieves its intended outcomes.
What kind of evidence informed the development of the HIV peer support framework?
The authors developed a preliminary theoretical framework for HIV peer support by searching five websites for grey literature and existing peer support frameworks. The five websites were:
- British HIV Association (BHIVA)
- National Association of People with HIV Australia (NAPWHA)
- National HIV Nurse Association (NHIVNA)
Twenty-one documents from the website search were used to inform the preliminary framework. A document was included if it contained relevant information on a peer support intervention, intervention outcomes or mechanisms influencing peer support outcomes. The documents informing the preliminary framework included articles, guidelines, training manuals and webinars.
After developing the preliminary framework, the authors conducted a literature search for evidence to test and refine the framework. Fifty-two studies were included in the literature review. Characteristics of the included studies were as follows:
- They were published between 2005 and 2022.
- They involved people with HIV who were 18 years and older. Studies that focused on specific subgroups of people with HIV, such as people who were pregnant or in prison, were excluded.
- They involved a peer support intervention delivered by a person with HIV.
- Twenty-three studies were from the Americas, 15 studies from Africa, 10 studies from Asia, 3 studies from Europe and 1 study from Australia.
What conditions impact the effectiveness of HIV peer support programs?
The authors developed a theoretical framework for the delivery of HIV peer support programs that identifies:
- the types of support peers provide to people with HIV
- the outcomes, or benefits, of peer support for the people with HIV receiving support
- the mechanisms or conditions that impact whether a peer support program achieves these outcomes (mechanisms are divided into two categories: mechanisms related to program effectiveness and mechanisms related to program sustainability)
1. Types of peer support
The framework identifies five types of support that can be provided in a peer support program:
- Informational support involves peers providing support through education and by helping people with HIV understand health-related information.
- Instrumental support involves peers facilitating access to resources needed by people with HIV. Instrumental support can include medical support such as helping with referrals and transportation to appointments. It can also include support with day-to-day needs, such as help addressing food or housing insecurity or managing substance use.
- Emotional support involves peers providing support that positively impacts the emotional well-being of people with HIV.
- Affiliational support involves peers providing support that enables people with HIV to connect to social networks and reduce isolation.
- Appraisal support involves peers providing support that builds the capacity of people with HIV to make informed decisions about their health, self-care and daily life.
2. Outcomes of peer support for people with HIV receiving support
The framework identifies five main outcomes or benefits for those receiving support from a peer. These outcomes are categorized as:
- physiological, such as impact on CD4 counts or viral load
- psychological, such as impact on anxiety, depression and overall quality of life
- behavioural, such as impact on health management activities
- cognitive, such as impact on knowledge and confidence
- social, such as impact on community connections and engagement
3. Mechanisms that impact the effectiveness of peer support programs
The framework identifies eight mechanisms that can impact the ability of peer support programs to achieve the program outcomes included in the framework.
Five mechanisms relate to the conditions under which peers deliver support:
- Peers are provided with effective training so they have the knowledge and skills they need when providing support.
- Peers are able to deliver support that is tailored to the needs of the person they are supporting.
- Peers are able to provide a continuous line of support that takes place in both medical and community settings.
- Peers are able to act as a bridge between a person with HIV and their community and health services.
- Peers are able to convey needed information to the person they are supporting.
Three additional mechanisms relate to the relationship between a peer and the person they are supporting:
- The relationship provides mutual satisfaction to the peer and to the person receiving support. This means that providing support is fulfilling for the peer and receiving support is beneficial for the person with HIV.
- The relationship provides the person with HIV with a peer role model: the person with HIV feels encouraged and empowered through the example set by their peer.
- The relationship is characterized by acceptance and empathy: the person with HIV is able to speak to their peer supporter with openness and without fear of judgment.
4. Mechanisms that impact the sustainability of peer support programs
The framework identifies eight mechanisms that can impact the sustainability of peer support programs.
Two mechanisms relate to the ability of programs to retain peers:
- Benefits of providing peer support — Peer work can lead to feelings of achievement, belonging and community for peers, and it can help them to develop new skills. To ensure their continued participation in the program, it is important that peers feel they are benefiting from their work and are able to derive value and satisfaction from their peer role.
- Negative impact of providing peer support — Peer work can be a source of stress for peers, including emotional burnout and concerns about their privacy and confidentiality. Peer programs must provide supports that address these risks.
Two mechanisms relating to the perceptions of the people with HIV receiving support can also impact the sustainability of peer support programs:
- Concerns related to confidentiality — People receiving support may be concerned about the confidentiality of their personal information when participating in a peer support program. Peer programs must have policies and procedures in place to ensure the confidentiality of people receiving support.
- Benefits of receiving peer support — People receiving support can benefit from one or more of the potential outcomes of peer support identified by the framework. The achievement of program outcomes for people with HIV is key to the success of peer support programs and their continuation.
Finally, four mechanisms relating to the program design can impact the sustainability of peer programs:
- The availability of adequate financial resources will ensure that peers are properly compensated for their work and will enable the program to operate in the long term.
- Access to safe spaces helps to assure both peers and the people they are supporting that their privacy and confidentiality are being protected.
- Appropriate communication channels will help to ensure that peers are recognized and respected within healthcare settings and integrated into service delivery.
- Ongoing training for peers will help to support their personal and professional development.
What are the implications of the review for service providers?
The authors of this realist review developed a framework that identifies the types of support that can be delivered in an HIV peer support program, the benefits that the program can have for people with HIV receiving support and the conditions that may impact whether those benefits are achieved. Service providers can use the framework to help them understand the conditions under which a peer program may or may not succeed in supporting people with HIV. Key factors in the effectiveness of peer support programs include the following:
- Ensure peers are supported in their work. This includes providing peers with training and ongoing development opportunities, as well as effective supervision and feedback. Peers should also be appropriately compensated for their work.
- Design peer programs that allow peers to tailor the type of support they provide to meet the individual needs of the person they are supporting. Peers should also be able to act as a bridge to community and health services and convey needed information to the person they are supporting.
- Ensure the peer and the person they are supporting both find the peer support relationship beneficial and fulfilling. An example of this type of relationship is the person with HIV seeing their peer as a role model and a source of acceptance and empathy.
- Ensure there are practices, supports and safe spaces available to address areas of concern for both the peer and the person being supported. Privacy and confidentiality can be concerns for peers and the people they are supporting. Peers may also experience emotional burnout in their support role; supports should be available to address burnout and other potential negative emotional impacts of peer work.
- Integrate peers into the broader organizational team and establish communication channels that allow peers to work effectively within the team.
- Han S, Zhang Y, Yang X et al. The effectiveness and sustainability of peer support interventions for persons living with HIV: a realist synthesis. BMJ Global Health. 2023 Feb 1;8(2):e010966.
- Jagosh J. Realist synthesis for public health: Building an ontologically deep understanding of how programs work, for whom, and in which contexts. Annual Review of Public Health. 2019;40(1):361-72. Available from: https://www.annualreviews.org/doi/full/10.1146/annurev-publhealth-031816-044451
About the author(s)
Erica Lee is CATIE’s manager of website content and evaluation. Since earning her master of information studies, Erica has worked in the health library field, supporting the information needs of frontline service providers and service users. Before joining CATIE, Erica worked as the Librarian at the AIDS Committee of Toronto (ACT).