Review: Together We Can [TWC] Peer Education Programme

Background:
According to UNAIDS most recent report,

“although it [HIV] accounts for a relatively small share of the global epidemic, the Caribbean has been more heavily affected by HIV than any region outside sub-Saharan Africa,….. with the second highest level of adult HIV prevalence. …. Although sharp declines in HIV incidence were reported in some Caribbean countries earlier this decade, the latest evidence suggests that the regional rate of new HIV infections has stabilized.”

The Caribbean has a mixture of generalized epidemics (HIV prevalence is consistently over 1 per cent in pregnant women) and concentrated epidemics (HIV prevalence is consistently over 5 per cent in at least one defined sub-population and below 1 per cent in pregnant women in urban areas). Women account for approximately half of all infections in the Caribbean. HIV prevalence is especially elevated among adolescent and young women, who tend to have infection rates significantly higher than males their own age (United States Agency for International Development, 2008).

Purpose/objective:
The purpose of this evaluation was to work with a range of stakeholders to

i. Assess the effectiveness of the current TWC programme against its objectives, with a view to determining whether the intervention is making an impact on the targeted groups.
ii. Assess the relevance of TWC i.e. whether the methodology is responding to local epidemic situations, whether we are targeting the right people in the right way and at a scale to reduce HIV transmission. 
iii. Assess the efficacy of the programme, and whether internationally recognized peer education standards outlined in the International Federation’s document are being met, and make recommendations for improvement.
iv. Determine the most appropriate regional level monitoring mechanism to ensure that internationally recognized peer education standards are adhered to and maintained.
v. Make recommendations as to the way forward for HIV peer education programming in the Caribbean region.

Methodology:
The evaluation involved reviewing key documents and visits to Haiti, Jamaica and Trinidad to interview staff, volunteers and beneficiaries. In addition to this, in-depth telephone conversations took place with senior Red Cross staff or volunteers from Belize, Guyana and St. Lucia. Interviews also took place with the Director Generals of St. Lucia and Antigua and Barbuda and with a member of the Health and Care Advisory Board of the IFRC. All National Societies that fall under the Caribbean Regional Representation were contacted by e-mail.

Key findings and lessons learned:
- Peer education programmes need to set realistic behavior change goals that take into account challenges faced by the intended audience, including where peers reached are on the behavior change continuum. Overall, the TWC programme curriculum takes into account the needs of those who are sexually active and those who are not yet in a sexual relationship, through the promotion of both condom use and abstinence. However, it does not fully address some of the challenges of modern day life facing young people in the Caribbean, for example sexual relationships with an older person in return for money, goods, favors or protection.

- Overall, the effectiveness and impact of the TWC programme has been challenging to evaluate, with only Haiti and Guyana, currently supported by the American Red Cross, producing quantitative data to measure the overall effectiveness of the programme in relation to peers reached.

- In relation to peer educators, quantitative information from pre and post-tests of peer educator training in Haiti and Guyana, indicates that within those settings the programme has been effective, particularly in relation to knowledge and attitudes, although less effective in relation to self-efficacy. Additional time in the curriculum needs to be allocated to issues associated with negotiation, including “saying no”, delaying sexual activity, mutual fidelity, and condom use.

- Qualitative data gained from peer educators in Haiti emphasizes the positive impact that the programme has on peer educators. Although, not statistically significant, quantitative data related to peer educators in Belize would indicate that the programme is effective. No quantitative data is available from Jamaica, St. Lucia, or Trinidad and Tobago.

- In order to ascertain overall effectiveness of a peer education programme, it is important that the quality and scope of activities delivered by peer educators are routinely and robustly monitored and that a checklist is provided to assist with this. In some sites, it was ascertained that peer educators were not routinely monitored.

- The way in which some peer educators manage the implementation of the TWC curriculum, i.e. adopting a “pick and mix” approach to sessions implemented with peers reached will affect its overall effectiveness as it is a curriculum which is designed to be delivered in total.

- Although examples were given of how TWC had been used with a small number of vulnerable groups, in the main, National Societies do not target their TWC programmes according to vulnerability. In order to be more relevant National Societies need to address the HIV prevention needs of the most vulnerable and at-risk populations.

- TWC would appear to be less suited to some vulnerable populations. For example, members of vulnerable populations who have limited literacy skills (TWC relies on flipcharts and written materials) and those are who transient or have less structured lifestyles and are, therefore, unable to commit to a curriculum-based activity that requires attendance at all activities.

- The TWC curriculum would need to be adapted with specific population groups such as MSM, prisoners and sex workers to be relevant to their actual situations of risk and vulnerability.

- During the training of peer educators and activities with peers reached, the majority of the curriculum is conducted in mixed sex groups. Whilst effective teaching and learning involves open discussion and it is recognized that girls and boys need to learn to communicate with each other, they also need to be allowed the space to discuss gender issues and power dynamics in relationships in single sex groups.

- Overall, there is little in the curriculum, which would suggest a gender analysis has been implemented to ascertain how gender inequalities expose women and girls to the risk of HIV and how gender inequalities reinforce the subordination of women and girls.

- TWC is a comprehensive model of peer education, which identifies the roles and responsibilities at different levels within the programme. Internationally the programme has received several awards and has been acknowledged as an example of best practice.

- TWC is a curriculum-based intervention with between 14 and 22 activities according to site, which works well with in-school youth and youth in formal groups when delivered in its entirety.

- Studies have shown that youth peer education programmes have a positive impact on the peer educators themselves.  TWC peer educators demonstrated that they were the beneficiaries of the peer education process, with quantitative and qualitative data demonstrating that peer educators had made positive changes in their own knowledge, attitudes and behaviour.

- The skills learnt through the initial training and through the implementation process has provided youth with real life skills that they have been able to use. For example, it was reported that a young woman in Grenada, who is now teaching, had said that the programme had enabled her to make better life decisions, and a young woman in Jamaica, who had been a peer educator, reported that TWC had shaped her future career and that she is now an HIV consultant.

- Although, it is recognised that peer educators can add to the information provided in the Peer Educator Handbook and the Activity Kit, the information in these materials needs strengthening. The following need to be included: antiretroviral (ARV) treatment, including compliance, gender, HIV and AIDS and STI information, positive living, prevention of mother to child transmission, risk, (including, forced sex, intergenerational sex, multiple and concurrent partners and transactional sex), sexual and reproductive health and VCT. In addition, the curriculum does not provide guidance on how to work with 10 -14 year olds.

Recommendations:
In order to maximise the impact of peer education programmes, it is important that National Societies ensure that programmes:
• Are well targeted for vulnerability
• Provide consistent follow-up and support to peer educators
• Are implemented at a scale to have impact on the targeted population
• Utilize a life skills approach to HIV prevention.
As far as the way forward is concerned for HIV peer education programming in the Caribbean region, it is recommended that the focus of the programme remain with youth as this is an area in which National Societies have developed expertise and links. However, it would seem that TWC is at a juncture and is faced with a number of options:

Option 1: Develop a new peer education programme responding to most-at-risk populations:

Option 2: Continue using TWC
In the long-term, the continued use of the current model with existing target groups, i.e. working in the main with non-targeted and non-segmented in-school youth, youth in formal groups, including a small number of youth from vulnerable populations would not appear to be an option.

However, if National Societies want to continue using TWC as a peer education model, there would appear to be two alternatives, which could be phased in to the work of the National Society

1. Use TWC to work with key vulnerable populations: Such an approach could capitalize on the experience that National Societies have already developed in working with key vulnerable populations and could include working with:
o Young prisoners
o Youth in reform schools
o Street children living in institutions
o An MSM organisation
o NGOs whose focus is working with non-traditional TWC groups
This option should include a more in-depth assessment of the suitability of the current TWC model and curriculum for specific vulnerable populations, who should be involved during the assessment and adaptation processes. This option would require the adaptation of the curriculum with the target population to address their specific risk and vulnerability situation, in addition to training of youth peer educators from the target populations.

2. Segmenting the target population: Use the current model with an emphasis on
• Shifting the focus from generic in-school youth and youth in formal groups by segmenting the target populations according to which in-school youth or youth in formal groups are most vulnerable to acquiring HIV.

• Targeting youth in vulnerable locations, i.e. youth who live in locations that are violent, poor and in which sex for offers and sex work is common, or where there are high levels of youth migration. This approach would require research into youth sexual practices.