Here we present results from a process evaluation of a peer-led HIV prevention intervention. The Risk Avoidance Partnership, conducted from 2001 to 2005, trained active drug users to be peer health advocates (PHAs) to provide harm reduction materials and information to their peers. Results indicate that PHAs actively conducted harm reduction outreach both when partnered with staff and on their own time. Although PHAs conducted most of their outreach in public locations, they also provided drug users with harm reduction materials at critical moments in places where HIV risky behaviors were likely to occur. PHAs were credible and trusted sources of information to their drug-using peers who sought PHAs out for HIV prevention materials. Process evaluations of successful HIV prevention interventions are necessary to understand how and why such interventions work for further intervention refinement.

The Risk Avoidance Partnership (RAP) Project conducted in Hartford, Connecticut, tested a program to train active drug injectors and crack cocaine users as “Peer Health Advocates” (PHAs) to deliver a modular HIV, hepatitis, and STI prevention intervention to hard-to-reach drug users in their networks and others in the city. The intervention was designed to diffuse health promotion and risk reduction interventions by supporting PHAs to model prevention practices and deliver risk and harm reduction materials and information. We compared change in behaviors and attitudes between baseline and 6-month follow-up of 112 primarily African American and Latino PHAs, 223 of their drug-network Contact Referrals, and 118 other study recruits (total n=523). Results indicated significant HIV risk reduction among all study participants, associated with significant health advocacy action conducted by PHAs, and a relationship between exposure to the RAP peer-delivered intervention and risk reduction among all study groups. Findings suggest that active drug users' engagement in peer health advocacy can set in motion a feedback and diffusion process that supports both the continued work of the PHAs and the adoption of harm reduction and mimicking of health advocacy by their peers.

Efforts have expanded to create AIDS prevention programs for drug users that consider the social context and interpersonal relationships within which risky practices take place. The Risk Avoidance Partnership (RAP) project is designed to train active drug users as "Peer/Public Health Advocates" (PHAs) to bring a structured, peer-led intervention into the sites where they and their drug-using social networks use illicit drugs. The RAP Peer Health Advocacy training curriculum and peer-led intervention promote harm reduction among drug users and support drug-user organization to reduce infectious disease and other harm in the context of injection drug use, crack cocaine use, and sexual activity. Initial findings suggest that RAP PHAs perceive a significant positive role change in themselves while conducting health advocacy work, and willingly and successfully carry the peerled intervention into locations of high-risk drug activity to deliver it to their peers even in the absence of project staff support.

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Peer delivered, social oriented HIV prevention intervention designs are increasingly popular for addressing broader contexts of health risk beyond a focus on individual factors. Such interventions have the potential to affect multiple social levels of risk and change, including at the individual, network, and community levels, and reflect social ecological principles of interaction across social levels over time. The iterative and feedback dynamic generated by this multi-level effect increases the likelihood for sustained health improvement initiated by those trained to deliver the peer intervention. The Risk Avoidance Partnership (RAP), conducted with heroin and cocaine/crack users in Hartford, Connecticut, exemplified this intervention design and illustrated the multi-level effect on drug users' risk and harm reduction at the individual level, the social network level, and the larger community level. Implications of the RAP program for designing effective prevention programs and for analyzing long-term change to reduce HIV transmission among high-risk groups are discussed from this ecological and multi-level intervention perspective.