toronto i-ii 12:45 pm

Toronto I-II 12:45 pmPeer-based interventions in the prevention, engagement and treatment cascade: Opportunities and challenges

Jane SimoniProfessor of Psychology and clinical psychologist in the development and evaluation of health promotion interventions

Discussion Panel: Mike Hamilton, Gareth Henry Haoua Inoua, Tara Jewal, Percy Lezard, Sean LeBlanc, Duncan MacLachlan,

Moderator: Francisco Ibáñez-Carrasco

Opportunities and challenges for peer-based interventions in the HIV prevention, engagement and treatment cascade

Jane M. Simoni, Ph.D.University of Washington

Ontario HIV Treatment Network: 2013 Research ConferenceToronto, Ontario November 18, 2013

Overview Research reviews of peer

interventions Project PAL: What we tried and what

we learned Benefits and challenges to

implementing and sustaining peer-based interventions

Notes from the field: Recommendations for implementation

PEER SupportGlobal tradition of non-professional,

community-based health care workers– Practical knowledge of local needs and preferences– Shared culture facilitates engagement and trust

Diversity of roles reflected in diversity of titles– Community health worker, buddy, promotor,

accompagnateur, advocate, lay worker, peer Policy statements promote use of peers to achieve public health goals, especially among marginalized or disadvantaged populations

What Defines a Peer? Essential Elements

Peers share with the target group key personal characteristics, circumstances, or experiences (i.e., “peerness”)

The contributions/benefits of peers’ work derive largely from their status as peers

Peers lack professional training or accreditation/status in the scope of their work

Peers function intentionally according to standard protocols, rather then operating solely as part of a naturally occurring social network Simoni et al., 2011

Literature Review: Is peer support

beneficial?

Are peer interventions for HIV efficacious? A systematic review

Simoni et al., 2011, AIDS and Behavior

Methods– Searched PubMed and PsychInfo– Search terms: HIV, peer*, intervention(s)– Scanned references and consulted colleagues – Articles published before November 1, 2010– Written in English

Included articles that:– Peers were the only or a main interventions– Addressed HIV-related health concern as main

outcome– Used statistical methods of evaluation– Was a primary report of the results

518 studies were identified330 excluded during abstract review

71 excluded during data extraction process117 met criteria

28 were RCTs54 quasi-experimental35 cross-sectionalMostly in the US (n=51) but newer studies represent developing world (n=54)

Targeted outcomes - n (%)

Examples:– unprotected anal intercourse and condom use – perceived risk, perceived importance, beliefs, intention– needle sharing, cleaning needles, methamphetamine use– HIV tests, CD4 counts, tests for STIs, and viral load – electronically monitored adherence, condom sales

Format of peer interventions68 formal meetings or structured groups40 outreach activities24 formal one-on-one 15 popular opinion leader

Populations – n (%)

Efficacy of peer interventions was assessed by summing the number of studies with a supportive result for at least one of the variables in the specified domain (a very liberal estimate).

Overall interventions were efficacious, although the likelihood of a supportive result varied according to outcome domain: Peer interventions appear to be most successful with attitudinal and HIV knowledge outcomes, less so with substance use, risky sex, and biological outcomes.

Outcomes that did not rely on self-report (biomarkers/other) were seldom used and much less likely to offer evidence of success

Is study design rigor a moderator of intervention efficacy?5 out of 6 domains did not differ in efficacy by study designThe exception was biological outcomes– More rigorous designs were LESS likely to demonstrate support for the

peer intervention under study

Moderators of outcome domains

Study location– Studies in the U.S. were more effective at changing attitudes

and cognitions than studies in developing countries

Intervention modality– Studies that used outreach were more effective at

changing substance use than studies without outreach

Population studied– Studies intervening with non-PLWHA were more effective

at changing sexual behavior than studies targeting PLWHA

– Studies intervening with non-MSM were more effective at changing attitudes/cognitions than studies targeting MSM

Conclusions from Simoni et al., 2011

“[F]indings suggest that we can have some confidence in peer interventions, yet more data are needed demonstrating an effect in the most rigorous study designs and with outcomes that are not potentially affected by respondent bias.”

Female Sex Workers: A Systematic Review

Kerrigan et al. (2013). AIDS and Behavior.Review & meta-analysis in low/middle income countries (1990–2010)6,664 citations, 10 met inclusion criteriaHIV – n=2 observational with protective combined effect (OR: 0.84, 95% CI: 0.71–0.99)

STI infection– n=1 longitudinal showed ê gonorrhoea/chlamydia (OR: 0.51, 95% CI: 0.26–0.99)– Observational studies showed ê gonorrhoea (OR: 0.65, 95% CI: 0.47–0.90), but

non-significant on chlamydia and syphilisCondom use– n=1 RCT showed improvements with clients (ß: 0.3447, p = 0.002)– n=1 longitudinal showed improvements with regular clients (OR: 1.9, 95% CI:

1.1–3.3), but no change with new clients– Observational studies showed improvements with new clients (OR: 3.04, 95 % CI:

1.29–7.17), regular clients (OR: 2.20, 95 % CI: 1.41–3.42), and all clients (OR: 5.87, 95 % CI: 2.88–11.94), but not regular non-paying partners

Conclusion: “Overall, community empowerment-based HIV prevention was associated with significant improvements across HIV outcomes and settings.”

Peer-led interventions to reduce HIV risk of youth: A review

Maticka-Tyndale et al. (2009) Evaluation and program planning

Review and synthesis

n=24 peer-led programs in low/middle income countries

HIV/AIDS risk reduction targeting youth in their communities

Peer-led interventions to reduce HIV risk of youth: A review

Maticka-Tyndale et al. (2009) Evaluation and program planning

Findings

Majority show positive change in knowledge and condom useEffects on other sexual behaviors and STIs were equivocal

Effectiveness of Peer Education Interventions for HIV Prevention in Developing Countries

Medley et al. (2009) AIDS Education and Prevention

Review and meta-analysis– n=30 peer ed interventions in low/middle income

countries– January 1990 and November 2006

Significant Findings– HIV knowledge (OR: 2.28; 95% CI: 1.88, 2.75)– IDU equipment sharing (OR: 0.37; 95% CI: 0.20, 0.67)– condom use (OR: 1.92; 95% CI: 1.59, 2.33)– Non-significant on STIs (OR: 1.22; 95% CI:0.88, 1.71)

Conclusion– “Meta-analysis indicates that peer education programs in

developing countries are moderately effective at improving behavioral outcomes but show no significant impact on biological outcomes. Further research is needed…”

Effectiveness of peer interventions for youthTolli (2012). Health Education Research

Systematic review– Peer education interventions for youth in European Union– n=17 publications, involving only 5 studies– January 1999 and May 2010

Conclusion– A few statistically significant and non-significant changes – “[O]verall, compared to standard practice or no

intervention, there is no clear evidence of the effectiveness of peer education concerning HIV prevention, adolescent pregnancy prevention and sexual health promotion for young people in the member countries of the European Union. Further research is needed…”

Project PALPromoting Adherence for

Life

Project PAL Promoting Adherence for Life

$1.8 million 5-year NIMH-funded R01Full randomized clinical trial based on pilot in the Bronx (Project HAART)2 X 2 factorial design, with randomization to:–Buddy–Pager–Buddy & Pager–Standard of Care

Recruitment and EligibilityRecruitment (2003-06)– Madison HIV Primary Care Clinic

Harborview Medical Center, Seattle– Nurse specialist– Provider referrals

Eligibility– At least 18 y.o.– Starting or switching antiretroviral medications– English-speaking– No significant cognitive impairment or active

psychosis

Nurse Recruiting

Computer-Assisted Self-Interviews

Patients completed CASI interviews at the clinic

Interviewing & Reimbursement Schedule

CASI interviews: $60 at baseline, $20 at 2 weeks, $35 at 3, 6, and 9 monthsTelephone interviews at 2 and 4 months ($0)$35 bonus for returning the EDM cap and completing all 5 interviews$15 for each buddy mtgPatients could earn up to $240

Conceptual Framework

Affirmational

Emotional

Informational

Satisfaction with Social

Support Received

Adherence

Depression

Regimen Knowledge

Self - Efficacy

Main MeasuresPerceived social support (both general and adherence-specific)Self-efficacy to adhereDepression (CES-D)Knowledge of HAART7-day self-report of missed doses (100% vs less)Electronic drug monitoring (MEMS)HIV-1 RNA VL and CD4 Count

3-Month Buddy InterventionComponents

Bi-monthly Buddy MeetingsDiscuss adherenceProblem-solve around life issues related to adherenceAdopt a harm reduction approach to substance use

Weekly Phone callsMore in-depth individualized supportChance to broach more sensitive issuesBetter suited for participants with confidentiality concerns

Who were our buddies?Other HIV+ patients from the clinic who

were…• Adherent to a HAART

regimen• Willing to participate in

initial training and ongoing supervision

• Socially skilled• Able to commit for 6

months• Referred by staff or self

Buddy TrainingContent of training–Setting boundaries–Barriers to accepting help–Strategies for adhering–Referring for medical issues–Assessing and referring for

psychological distress–Assessing and providing social

supportOngoing bi-monthly group supervision

Pager Intervention3-month intervention periodPatients in the pager arm received daily individualized text pages reminding them which med & how many to take (i.e., “informational support”)

Messages customized to protect patients’ confidentialityEducational and entertainment message alsoBased on prior data showing the efficacy of alarms in adherence and high prevalence of “forgetting” doses

Standard of Care: HAART ProtocolCLINICIAN– Talk about starting medications

COUNSELOR– Talk about the meds & why it is important to take them regularly,

possible side effects, drugs interactionsNUTRITIONIST– Talk about the meds and their food requirements and how to use

food to help control any of the side effects.SOCIAL WORKER– Talk about things that could impact how you take your meds,

including housing, finances, etc.CLINICIAN– Again, talk about your readiness to start meds and answer any

remaining questions. If you are ready, prescriptions will be written.

PHARMACIST– Answer any questions about your medications and confirm your

knowledge and acceptance. Pick up 2-week supply of meds.

Flow of Participants223 enrolled

SOC (n= 56) Buddy only (n= 58) Pager only (n= 56) Buddy & Pager (n= 53)

2 week(n= 52)

2 week(n=56)

2 week(n= 54)

2 week(n= 51)

2 month phone(n= 48)


2 month(n= 47)

2 month(n= 44)

3 month(n= 51)

3 month(n= 49)

3 month(n= 54)

3 month(n= 51)





6 month(n= 48; 2 pending)








Results

Baseline Socio-demographics

Demographic Variable (N = 224) n (%)

Gender Male Female Transgender

169 (75%)53 (24%)

2 (1%)

Race/ethnicity African-American Hispanic Caucasian Other

67 (30%)25 (11%)

105 (47%)27 (12%)

Education < High school degree High school degree / GED Some college / AA ≥ College graduate (BA/BS)

47 (21%)64 (29%)93 (42%)

19 (9%)

Employment Status Full or part-time Unemployed

43 (19%)180 (81%)

Age (in years)Years since HIV diagnosis

M (SD)

40.0 (8.2)8.5 (6.7)

Overall Adherence

2 weeks 3 months 6 months 9 months

BL Post F/U F/U

Missed doses % % % % 0 74 66 62 60

1-2 18 20 21 21

3+ 8 14 17 19

How many doses of your HIV medication did you miss in the last 7 days?

Socio-demographic Correlates

of AdherenceAt 3 months, employed participants were more likely to report 100% adherence than unemployed participants (85.4% vs. 70.6%), χ2(1) = 3.70, p = .05

At 3 months, African Americans were less likely than other participants to report 100% adherence (53.2% vs. 71.6%), χ2(1) = 6.39, p = .01

(Adherence not correlated with gender, income, education, relationship status.)

Does Intervention Improve Adherence?

Self-Report Those receiving buddy support were more

likely to have not missed doses in the week prior to post-intervention assessment. Odds ratio = 2.1, p = .02

No effect for either buddy or pager intervention at 6 or 9-month follow-up

Trends in Self-Report Adherence- Buddy- No Buddy

- Pager- No Pager

Shaded regions = 95% CI

Changes in Self-Report Adherence

Intervention Effects – EDM Adherence

Those receiving buddy support had a trend towards taking more doses in the week prior to post-intervention assessment. Estimate = 8.9%, p = .11

Trends in EDM Adherence

- Buddy- No Buddy

- Pager- No Pager

Shaded regions = 95% CI

Changes in EDM Adherence

Biological Markers A priori findings

No significant effect of intervention on Change in CD4 count Achieving undetectable viral load

Were participants engaged in the interventions?

Pager support Range: 0 to 96.5% Mean: 41.1% (SD= 31.1%)

Buddy support Range: 0 to 6 meetings attended Mean: 2.8 meetings (SD= 2.2)

Biological Markers – Post hoc

Among pager participants, higher pager response rate was associated with: Greater CD4 count at 3, 6, 9 months.

↑10% pager response → ↑12-23 CD4 (p’s < .05)

Lower viral load 3 and 9 months ↑10% pager response → ↓0.1 Log10VL

(p’s < .05)

Biological Markers – Post hoc

Among buddy participants, greater attendance of peer support meetings was associated with… A trend towards lower Viral Load at 3 and 6

months. ↑1 meeting → ↓0.1 – 0.2 log10VL (p’s

< .10)

Significantly lower Viral Load at 9 months ↑1 meeting → ↓0.2 log10VL (p < .01)

Conclusions1. Medication adherence starts off high and

erodes over time for most patients.2. An RCT testing buddy & pager adherence

promotion strategies demonstrated some success during the first 3 months.– Specifically, those receiving buddy support (vs.

those who did not) had greater likelihood of reporting 100% adherence in the 7 days prior to the 3-month post-intervention interview.

– Electronic drug monitoring revealed a trend towards improved adherence for those receiving vs. not receiving buddy support.

CDC Recognition

Both Peer Support and Pager Support classified as interventions with “Good Evidence” by CDC and will be available online for distance learning implementationsTwo of the few evidence-based HIV medication adherence interventions identified in CDC’s systematic review of the literature from 1996 to 2009

Peer Support to Promote Medication Adherence Among People Living with

HIV/AIDS: The Benefits to Peers

Patricia Marino, PhDJane M. Simoni, PhD

Louise Bordeaux Silverstein, PhD

Social Work in Health Care, Vol. 45(1) 2007

As part of the pilot Project HAART in the Bronx, NY, we conducted qualitative interviews with nine HIV-positive peers who had participated in an intervention designed to provide support to other HIV-positive individuals as one means of promoting antiretroviral therapy adherence. Analyses of the peers’ common dialogue about their involvement in the study revealed four main themes . . .

I. Social AcceptanceBeing with those who are going through the same thing (89%)I heard everyone was going through what I was going through and people felt the same way I didFeeling accepted within an otherwise isolating disease (56%)I know for sure I am not alone nowFeeling safe in the program (67%)Whatever you said in that room stayed in that room

II. Reciprocal SupportSupport from peers (78%)You found something here they could not find no place elseReceiving support on many levels (89%)Verbally we were able to talk about things they could not tell other people be it their husbands, moms, pops or childrenBy helping other people I got something in return (100%)I found that they were there to listen to me. We helped each otherHelping other people through example (89%)I was doing something for other people

III. Personal Growth and EmpowermentFeeling entitled enough to talk about disease (67%)Most people do not ask questions. I do not know whether we feel intimidated or we feel we are not going to know what they are talking about. The program made me feel like that is not true.Being part of project HARRT gave me strength (67%)It gave me confidence to look into more things because of the positive experienceChange in outlook (78%)I am a totally different person now

IV. Resistance and Other ChallengesObstacles to accepting support (100%)Certain people were just in denial and nothing you can say is going to change thatCertain people you cannot help (56%)There was times when you could help certain people and certain people you cannot helpNo control over loss (56%)It knocked me for a loop because it did not enter my mind that I would lose somebody

Conclusions: Benefits and Challenges of

Peer Support

Benefits of Peer SupportTo clients:– Can provide a specific type of support– Can target “hard-to-reach” populations– Good for those who fear stigma– Can take a harm reduction approach– Some beneficial effects on HIV outcomes

demonstrated

To peers themselves:– Peers can benefit (helper-therapy principle)– Empowerment– Training and possible employment– Sustained health outcomes

Negatives of Peer SupportTo clients:– Peers overstepping – dispensing medical advice– Harm to clients through peers’ inexperience or lack

of skills– Boundary violations (peers vs. friends/lovers)– Breaches of confidentiality– Legal liability

To peers themselves:– Peers experience personal failure/loss when clients

do not progress– Peers’ own health challenges– Risk for relapse

RecommendationsBroaden opportunities for peers Strengthen trainingConduct process evaluations Examine systematically peer activities Rigorously evaluate program outcomesDisseminate and sustain successful programs

Future Notes from the Field: What might be useful for

clinical practice?

Peer SelectionKey Criteria

– Social and communication skills– Compassion, empathy, non-judgmental

attitude towards others’ lifestyles– Acceptable to and respected by target group– Willingness to commit to training and a

minimal length of participation– Experience with ART (not necessarily

successful – struggles can lead to empathy and solutions)

– Stable recovery from substance dependency

Training of Peers - 1Methods

– Skills-based training– Adult learning principles– Mix presentation of information, practice

of skills, constructive feedback on skills– Trusting environment for disclosing and

reflecting on experiences relevant to peer work

– Refreshers, updates, advanced workshops

Training of Peers - 2Topics

– Communication skillsActive listeningConflict resolution

– Peer roles on multidisciplinary teams– Disclosure– Defining and enforcing boundaries– Transference/countertransference– Self-care – Back-to-work issues

HIV Peer Training ResourcesHRSA-funded HIV Peer Educator Training Sites (California, Missouri, New York) – curricula and information available at http://www.hdwg.org/peer_center/Family Health International/YouthNet Youth Peer Education Toolkit Training of Trainers Manual

http://www.hdwg.org/peer_center/

Recruitment StrategiesElicit recommendations from– Target client population

Announce search for peer candidates at Community Advisory Boards (CABs) and other patient organizationsAsk community leaders and activists to suggest candidates

– Experienced peersPeers can identify former clients, fellow patients, fellow members of AA, NA, or support groups

– Medical and other providersAsk a member of the client population to confirm providers’ recommendations of patients and clients

Advertise for self-referrals– CAB and other patient organizations– Central community gathering places– Explain desired characteristics and requirements

Key Elements of Peer Support in Adherence Interventions – 1

Trusting relationships– Emotional support: help clients process

emotional reactions to HIV status, illness, medication, disclosure

– Social support: cultivate social networks and norms supportive of adherence and related behavior changes

– Model adherence, healthy behaviors, good communication with providers

Education and mentoring– Personalize education with examples from

peers’ own history– Provide practical advice for integrating

adherence into daily life– Recognize and celebrate progress towards

adherence

Key Elements of Peer Support in Adherence Interventions – 2

Patient Navigation and Advocacy– Identify health and social service needs,

facilitate referrals– Accompany client to medical and other

appointments– Identify resources for resolving issues

important to clients, e.g. insurance, benefits, immigration status

Formats for Peer SupportOne-on-one support– Frequent (weekly) contact, in person, phone, or e-mail

facilitates the development of trusting relationships– With support from supervisor, may take place off-site in

location where a client feels safe– Discussion of adherence may come after peer-client

relationship is established over several weeksGroup support– Support groups led by trained peers help normalize HIV

status, overcome isolation, foster norms supportive of adherence, present peer as role model

– Educational sessions present information tailored to clients in culturally appropriate styles

Multidisciplinary teams– Peers complement professionals’ services– Clarify and reinforce information from providers– Bring unique insights and information to team

Supervising PeersCollaborate with peers to develop specific job skills, responsibilities, and expectations that correspond to their unique qualificationsUse ‘teach back’ techniques to ensure that peers fully understand their roleCustomize recording forms to document all aspects of peer activities and for ease of useProvide individual or group ‘supportive supervision’ to reflect on peer’s emotional reactions to client interactions and develop skills and expertise Encourage peers to develop their own support network through support groups for peers, ongoing workshops, or opportunities to socialize with fellow peers

Resources for Peer Supervisors‘Peer Support for HIV Treatment Adherence: A Manual

for Program Managers and Supervisors of Peer Workers.’ Mannheimer et al, 2003. Available at www.peerNYC.orgCoping with Hope: HIV Treatment Decisions/Adherence. A multidisciplinary Mental Health Services Curriculum,’ USDHHS Center for Mental Health Services et al, 2000. Available at www.aidsetc.orgTraining in multidisciplinary team development, including peers, through Cicatelli Associates, Inc., www.cicatelli.org ‘Integrating Peers into Multidisciplinary Teams: A Toolkit for Peer Advocates’ and ‘Supervisors’ Guide’. Cicatelli Associates Inc., 2007

http://www.peernyc.org/

http://www.aidsetc.org/

http://www.cicatelli.org/

CompensationRecommended if programs are to be sustainable – Free time to the project means less earning time

Compensatory optionsAt minimum provide meals and expenses Monetary or non-salary incentives

– T-shirts, bicycles, access to loans, free medical care, and/or the status of being a peer educator.

Opportunities for recognition Increased responsibilities and decision-making authority Opportunities for personal and professional growth

– Compensation must be relative to avoid creating social distance between the peer and the intended audience

Compensation is needed to improve job satisfaction, retention rates, and program sustainability

Retention StrategiesSkills assessment and staff development plan – Conduct periodic individual and group support sessions

with peer educators to address stress, burnout, and other psychological aspects as well as to share successes and ideas

Provide peer volunteers with ongoing educational sessions and opportunities to "socialize" with other volunteers Involve peer educators in decision-making and giving them broader responsibilities related to program design, implementation, and evaluation

AcknowledgementsCo-investigators– Thomas (Mac) Hooten, Marc Gourevitch, Bu Huang, Cynthia

Pearson, Pamela Frick Schwartz, Karina WaltersConsultants– Laurie Bauman, Seth Kalichman, Gary Marks,

Research assistants at Yeshiva University– Mary Alm, Oshra Cohen, Nina Cooperman, Patricia Marino,

Sara Mott, Michelle L. Monaco, E. Cathrine StrugstadResearch assistants at UW– Alison Wilhelm, Mary Plummer, David Pantalone, Heidi

Montoya, Dellanira Valencia-Garica, David Huh, Keren Lehavot, Sam Yard, Kim Nelson, Bryan Kutner

Staff and undergraduate studentsParticpants!!

UW LAB

Ontario HIV Treatment Network

Thank you and I wish you well in your work!

Thank you

End of presentation

Jane [email protected]

For copies of this presentation or to join the adherence listserv

mailto:[email protected]

What’s next?10:15 a.m.Break/Networking/Poster

Sessions(Foyer)

10:15 a.m.Visual Story Galleries(Foyer, Richmond, University, Adelaide)

toronto i-ii 12:45 pm

Documents

community health advisors

communitybased care

lay health care workers

nations health care

peer policy statements

primary care

public health goals

peer support beneficial