What is the Program?
The Peer Extend, Education and Resources (‘PEERs’) project at Mainline Needle Exchange trains peers to help people who use drugs navigate harm reduction, health and social services in Halifax and surrounding communities. Peers conduct outreach, primarily on foot, to distribute new supplies (e.g., smoking and injecting supplies) for safer drug use and safer sex, collect used drug use supplies and provide education and skills training on safer drug use practices. Peers also check on people’s wellness and provide referrals to various health and social support services within their community. The PEERs project is expanding its geographic reach and has broadened its scope to include “in-reach” to address risk and harms (e.g., stigma) associated with drug use in hospital and correctional settings.
Mainline is an organization founded on the meaningful involvement of people with lived and living experience of drug use and it strives to continuously build relationships with other organizations and institutions, including healthcare facilities, shelters, housing and legal support services and advocacy groups. Mainline has a “brick and mortar”’ hub in Halifax as well as two outreach vans that provide services throughout the Halifax area and the southwestern part of Nova Scotia. Mainline is a program of the Mi’kmaw Native Friendship Centre.
The PEERs project was initially funded by the Public Health Agency of Canada through the Harm Reduction Fund in 2018, and this funding was renewed in 2020.
Why Was the Program Developed?
A need was identified in Halifax, and elsewhere in Nova Scotia, to provide services to a growing community of people who use drugs and who are at risk for HIV, hepatitis C and other sexually transmitted and blood-borne infections (STBBIs), in addition to a need to address a rise in opioid-related deaths. In response, the PEERs project was developed in 2018 as a way to empower people who use drugs and to involve people with lived and living experience in the delivery of harm reduction services. The project started by providing community walkabouts to gather used drug use supplies, as well as navigation services and other supports. The aim of providing navigation services to people who use drugs in communities was to reduce the transmission of HIV, hepatitis C and other STBBIs. The project aims to connect people who use drugs with harm reduction services and other health (e.g., treatment, primary care services) and social services (e.g., housing, legal services) in their community.
Beginning in 2020, the project began providing in-reach services in hospitals, including advocacy and education for healthcare providers. The project had also planned to provide in-reach to correctional facilities, but this plan had to be adjusted to concentrate on activities outside of prisons as a result of the COVID-19 pandemic. In-reach services were planned for a variety of reasons: there was an identified service gap related to providing harm reduction services in these settings, there were high STBBI transmission rates in people who use drugs in correctional facilities, and there was a need for peer navigation support in hospitals, where people who use drugs often experience stigma and discrimination.
How Does the Program Work?
The PEERs project uses peer leads and peer navigators to deliver navigation services to people who use drugs in Halifax and elsewhere in Nova Scotia. Peers often have first-hand experience with stigma, as well as discrimination associated with drug use, and they can share their knowledge and experience with others to support them as they navigate services. The PEERs project builds on the power of people with lived or living experience to deliver relevant and effective programming.
The target population for the PEERs project is people who use drugs. This can include people who are street involved, who are homeless and/or are unstably housed, who face multiple barriers to accessing healthcare services or who are at risk of HIV and/or hepatitis C and other drug-related harms.
The PEERs project has both peer navigators and peer leads on each shift. Peer navigators are current or former clients of Mainline and have lived or living experience with drug use. Peer leads are individuals who have previously worked as peer navigators and who have demonstrated their ability to take on more responsibility. The work of the peer leads and navigators informs how programs are delivered at Mainline as they have knowledge of current drug use trends and where to meet the population.
Peer leads and navigators provide community outreach, primarily on foot. During outreach, peers distribute new supplies (e.g., smoking and injecting supplies) for safer drug use and safer sex, distribute educational materials (e.g., pamphlets, info cards), collect used drug use supplies, provide peer support and check on people’s wellness. Peer navigators also help people who use drugs in the community to navigate health and social services and direct people to Mainline and other community-based organizations. This includes referrals to services such as shelters, STBBI testing and treatment services and meal programs. Peer leads and navigators also provide STBBI prevention information and education and skills training on safer drug use practices. Peer leads are responsible for maintaining the project’s supplies and materials and keeping records, and they can make judgment calls about the work (e.g., cutting a shift short if necessary).
A program coordinator is involved in the overall coordination and implementation of the project. This includes providing and coordinating peer training, scheduling shifts for peer leads and navigators, reminding peers about their upcoming shifts, ensuring that peers know which areas to visit during shifts, ensuring that paperwork and program reports are complete, coordinating the payment of peers, and coordinating data collection for reporting and evaluation of the program. The program coordinator also provides support to peer leads and navigators (e.g., asking about any issues or questions that came up during shifts, providing feedback).
An important component of the PEERs project is partnerships with local health and social services. These partnerships enable peers to direct clients to these community-based services, including mobile outreach street health (MOSH), the North End Community Health Centre, all shelters in Halifax, primary care providers, opioid treatment programs, housing support organizations and STBBI treatment services. Peers also promote and connect individuals to other services that Mainline staff can provide (e.g., accompaniment to services, advocacy, tax filing help, and support with identification cards, housing and utility companies).
New peer navigators are recruited on a monthly basis. Peer navigators are existing clients of Mainline who express an interest in participating in the project. Mainline aims to involve at least 20 different peer navigators every month, as many clients want to participate. Peer leads are recruited from the pool of existing peer navigators to take on more responsibility within the project.
Training is provided to both peer leads and navigators. Peer leads receive training on overdose response, naloxone use and how to conduct safe needle searches. They also familiarize themselves with available educational materials such as pamphlets on safer smoking, safer injecting, infectious diseases, and STBBI testing and treatment. Additionally, peer leads are provided training related to their specific responsibilities, including training on how to complete the necessary paperwork following each shift, how to maintain program supplies and materials, and what community-based services are available to community members. Peer navigators are largely trained one-to-one by peer leads through knowledge sharing, mentoring and role modelling. Peer navigators are encouraged to leverage their personal experiences and knowledge to offer support and services to community members. Additional education is provided on an ongoing basis as topics arise.
Peer navigation shifts take place every Monday to Friday from 10:00 am to 1:00 pm. Peer leads work more often than peer navigators (usually every other day). Peer navigators and leads are paid an honorarium for their work. An honorarium was chosen as the method of compensation because it is a low-barrier option to pay peers. For example, it does not require a bank account or other documentation that may be required for employment. With a less onerous process for payment and documentation, more peers can be given the opportunity to participate in the project for shorter periods of time if that is their need or preference.
The expansion of the PEERs program allowed for additional in-reach services to be offered by peers and the project coordinator in both hospitals and correctional facilitates. Supports offered are similar to those provided in outreach settings (e.g., providing safer drug use supplies, information and skills training, referrals to health and social services) with specific services geared to each setting.
Peer leads and navigators visit hospitals when requested by a person who uses drugs and/or hospital staff, to provide supports while the person is in the emergency department or receiving inpatient care. Prior to the PEERs project, Mainline staff visited patients in hospitals to provide supports, but it was on an informal basis and they saw patients in a visitor capacity. One aim of this expanded in-reach service is to formalize the approach and build relationships with healthcare providers, so Mainline staff and peers can be called on as allied professionals to support patients. Another important aim is to provide education for healthcare providers. The intent is that in-reach services will include peer-to-provider connections to educate healthcare providers on harm reduction, the services Mainline provides, and ways to integrate harm reduction approaches into their work.
This peer in-reach complements other project activities led by the coordinator, including educational workshops targeted at hospital staff on topics such as the effects of stigma and discrimination on accessing health services, harm reduction philosophies and how to provide quality and respectful care to people who use drugs.
During the COVID-19 pandemic, adjustments had to be made to the approach (e.g., peers were not permitted to go into hospitals for training). Education efforts have thus far been completed by the program coordinator with the intention to involve peers when this becomes possible. The program coordinator meets with hospital staff to develop ongoing partnerships that include assistance with the development of harm reduction policies within the hospitals and efforts to distribute new drug use supplies through the emergency department.
Jails, prisons and the wider justice system
Through Mainline’s work with correctional facilities and organizations to support people who use drugs to navigate the legal system, in-reach provides more opportunities to share information and supports for people who use drugs who are incarcerated, recently released from jail or prison or navigating other parts of the legal system. Activities within prisons were put on hold because of the COVID-19 pandemic and peers instead focused on court support, which included peers providing information to community members at the courthouse for three hours every Monday. In addition, many individuals were released early because of the pandemic, and peers were able to provide supports to these individuals upon release, including connecting them to harm reduction supports and other services and programs.
Plans for prison in-reach work include “peer support days” where peers visit facilities and consult with those interested in learning more about safer drug use, the risks and harms associated with sharing drug use equipment and strategies for using more safely while they are incarcerated. Peers will also provide information about the supports available in the community that people can access when they are released.
- Peer navigators
- Peer leads
- Program coordinator
- Harm reduction supplies (safer injection and smoking supplies, naloxone kits, safer sex supplies, educational pamphlets and other materials)
- Community partnerships with health and social services (e.g., primary care, housing support, treatment services), including hospitals and correctional facilities
The project’s main challenge is responding to the high demand for peer navigator positions from its clients and the desire of many peers to work more than a few shifts per month. If additional resources were available, the intent would be to offer two peer shifts per day to accommodate the demand.
The PEERs project started in 2018. In 2018–2019, 32 peers were trained and in 2019–2020, 78 peers were trained. Peers reached 1,694 people in 2019–2020, most of whom were between 30 and 39 years old.
Harm reduction supplies distributed through the program in 2019–2020:
- Injecting equipment: 47,074
- Needle and syringes: 33,626
- Smoking equipment: 27,189
- Safer sex supplies: 2,564
Information or referrals provided in 2019–2020:
- Housing information or advocacy: 356
- Detox information or referral: 304
- Mobile outreach street health (MOSH) program: 102
- HIV/hepatitis C information and referral (e.g., treatment and related supports): 380
- Methadone information and referral: 280
- Legal information or advocacy: 439
The project has found that working as a peer navigator can provide benefits to the individual, such as safer drug use, improved stability, routine, pride and an opportunity to gain skills and confidence as educators and leaders in harm reduction. Peer navigators have shared that the project has had many positive impacts on them, such as improved social support networks, better employment potential, increased self-confidence and mental health, and the opportunity to be an agent of beneficial change within their community. Peer navigators benefit as much from the project as the people to whom they provide services.
- The most effective way to reach and have an impact on people who use drugs is to use a harm reduction approach and have people from that community lead the delivery of services.
- The training and educational sessions provided to peers are appreciated, as they provide opportunities for peers to gain additional skills, and although they are not mandatory, they are always well attended.
- Partnerships are incredibly valuable to the work as they help to leverage the skills and resources available in the community.
- Having solid relationships with a broad client base and a commitment to flexibility and “meeting people where they are at” have been critical to the program’s success.
Program Coordinator, Mainline Distribution & Disposal Program
Mainline Needle Exchange
5511 Cornwallis Street