Peer driven or driven peers? A rapid review of peer involvement of people who use drugs in HIV and harm reduction services in low- and middle-income countries

Abstract

Introduction Peer involvement of people who use drugs within HIV and harm reduction services is widely promoted yet under-utilised. Alongside political and financial barriers is a limited understanding of the roles, impacts, contexts and mechanisms for peer involvement, particularly in low- and middle-income settings. We conducted a rapid review of available literature on this topic. Methods Within a community-academic partnership, we used a rapid review approach, framed by realist theory. We used a network search strategy, focused on core journals and reference lists of related reviews. Twenty-nine studies were included. We developed thematic summaries framed by a realist approach of exploring interventions, their mechanisms, outcomes and how they are shaped by contexts. Results Reported outcomes of peer involvement included reduced HIV incidence and prevalence; increased service access, acceptability and quality; changed risk behaviours; and reduced stigma and discrimination. Mechanisms via which these roles work were trust, personal commitment and empathy, using community knowledge and experience, as well as ‘bridge’ and ‘role model’ processes. Contexts of criminalisation, under-resourced health systems, and stigma and discrimination were found to shape these roles, their mechanisms and outcomes. Though contexts and mechanisms are little explored within the literature, we identified a common theme across contexts, mechanisms and outcomes. Peer outreach interventions work through trust, community knowledge and expertise, and ‘bridge’ mechanisms (M) to counter criminalisation and constraining clinic and service delivery environments (C), contributing towards changed drug-using behaviours, increased access, acceptability and quality of harm reduction services and decreased stigma and discrimination (O). Conclusion Peer involvement in HIV and harm reduction services in low- and middle-income settings is linked to positive health outcomes, shaped by contexts of criminalisation, stigma, and resource scarcity. However, peer involvement is under-theorised, particularly on how contexts shape mechanisms and ultimately outcomes. Efforts to study peer involvement need to develop theory and methods to evaluate the complex mechanisms and contexts that have influence. Finally, there is a need to expand the range of peer roles, to embrace the capacities and expertise of people who use drugs.

The Impact of Peer Support on Testing, Linkage to and Engagement in HIV Care for People Who Inject Drugs in Indonesia: Qualitative Perspectives From a Community-led Study

“…A key strength of our study was our community-led, participatory approach. By creating partnerships between researchers and the people whom the research is ultimately meant to impact, this study sought to combine the expertise of lived experience, advocacy and programming with academic social science research, in order to promote better use of research evidence and build research capacity in affected communities [39]. This approach allowed us to bring the insights and experiences of peers into all aspects of the research process, while allowing community researchers learn with academic professionals and develop the con dence and critical skills to design, manage and carry out research.…”

Adequate funding of comprehensive community‐based programs for key populations needed now more than ever to reach and sustain HIV targets

“…These models are described in several global guideline documents relevant to key populations [ 24 , 25 , 26 , 27 ]. Frequently, DSD models for key populations involve peers, often as educators, counsellors, mobilizers, navigators or simply as network members to leverage expert community knowledge, build trust and increase the uptake of community‐based services [ 28 , 29 , 30 , 31 ]. For example, sites run by key populations, such as drop‐in centres (DICs) and community clinics, provide important treatment alternatives.…”

“…While structural interventions seek to address the upstream factors that cause inequities, service integration and person‐centred care acknowledge these inequities and develop service packages addressing their downstream impact [ 46 ]. For example, programs among key populations have successfully integrated HIV‐related services with mental healthcare [ 47 ], gender‐affirming care [ 48 ], harm reduction [ 29 ], STI and viral hepatitis diagnosis and treatment [ 49 , 50 , 51 ], tuberculosis [ 52 ], sexual and reproductive health [ 53 ] and services that address gender‐based violence [ 54 ]. As one specific example, through EpiC Kenya, 220 key population clients who were initially reached with services to address violence (e.g.…”

Understanding the Perspectives of Women Who Use Intravenous Drugs and are Experiencing Homelessness in an Urban Centre in Canada: An Analysis of Ethnographic Data

“…As well, repeated positive interactions with familiar healthcare providers may be required to build the trust and rapport that has been damaged by the current healthcare system ( Motavalli et al, 2021 ). Trust has been found to be an important mediating factor for healthcare access among WUID and may be facilitated through use of nurses who demonstrate compassion and non-judgemental care and whose presence is consistent and thus familiar, along with the integration of peers and other people who use drugs into healthcare services ( Chang et al, 2021 ; McNeil & Small, 2014 ). Further, WUID should be directly involved in their care decisions and pathways, reflecting a philosophy of nothing about us without us ( Canadian HIV/AIDS Legal Network, 2006 ) ( Table 2 ).…”