The CHAT intervention integrated peer education, risk reduction and communication skills. Peer Mentors, compared to women in the comparison condition, reduced a greater number of their risky sexual behaviors over time. Peer Mentors were less likely to have two or more sexual partners at the 6-month follow-up. One possible explanation is that Peer Mentors engaged in numerous activities to communicate information about the rates of HIV and STIs in their communities, such as the candy activity, which influenced their personal behavior to be consistent with their peer outreach conversations. Cognitive dissonance theory suggests that individuals who publicly promote risk reduction would be more likely to engage in risk reduction as compared to individuals who do not publicly advocate. Public commitment to HIV/STI prevention may have led to reductions in number of sex partners and increases in condom use among Peer Mentors.
Significant changes in condom use were observed among Peer Mentors. Peer Mentors were less likely to have unprotected vaginal or anal sex, regardless of type of partner. CHAT intervention messages focused on a variety of condoms such as latex condoms, polyurethane, female condoms, and flavored condoms, and condoms were distributed to participants. Awareness of the diversity of condoms available, as well as easy access to condoms, may have persuaded participants to try a condom that they had not used previously and talk to partners and other network members about condom use.
In addition to increasing condom use during specific sexual acts, Peer Mentors were less likely to have unprotected sex with both main and non-main partners. Over 80% of participants in both groups reported having a main sex partner. The intervention group was almost 60% less likely to have unprotected sex with a main partner at the18-month follow up. Consistent condom use with a main partner is challenging since use of condoms may suggest infidelity or lack of trust. In a qualitative study of heterosexual couples at high risk for HIV, Corbett and colleagues (38
) found that many couples feel that not using condoms are signs of trust and intimacy as well as “placing their love for their partner and other emotional needs over concerns about their health
”. The present study findings suggest that training women to have conversations with numerous individuals in their social networks may enable them to practice these communication skills with sex partners in comfortable, natural settings and practice safe sex.
In addition to communication skills to talk with both main and non-main partners, participants were taught to solve problems regarding common complaints about condom use such as reduced pleasure or loss of erection. While the skills training was used for peer outreach, some Peer Mentors also used this information to persuade their own partners to use condoms. Participants were encouraged to use their participation in a Peer Mentor program as a reason to use condoms, such as stating “Remember that program I told you I was in, they gave us this bag of condoms and asked us to try them out. Can we use one so I can do my homework?” Training women in these communication skills options may have empowered women to persuade their partner to use condoms.
Many of the index participants were non-injection drug users. While there was a trend of reduction of cocaine and heroin use, as well as crack use, significance was not reached. Drug use was integrated into the intervention material. However, since information on sexual risk reduction was more salient, Peer Mentors have focused on their own sex behaviors rather than considering how drug use impacted their own HIV/STIs risk behavior. Future interventions should focus on both types of risks because any successful change in one type of behavior may not make a huge difference if the individual is still practicing other risky behaviors. Focus on both types of risk in social network-based interventions is also an effective way to diffuse risk reduction information to sex partners and other network members who use drugs.
Overall, women in both conditions reported high rates of communication with family, friends, and partners about HIV/STIs. Peer Mentors, as compared to those in the comparison group, were more likely to talk to their family members and this trend remained stable over time. In the intervention sessions, many participants noted the importance of sharing this information with their children. In addition, index participants in the intervention group were more likely to talk with their friends about HIV and STIs. Talking to individuals who were not partners may have been viewed as less problematic, especially for women Previous research has shown that higher levels of communication are associated with perceived norms about safer behaviors (39
). Continued conversations with family members or friends may have reinforced the role of Peer Mentor and led to development of safer sex norms and ultimately safer behaviors. More research is needed on the quality and frequency of these conversations about HIV.
There are limitations of the study that should be noted. First, sampling selection bias may be present since participants volunteered to be Peer Mentors. Through participation in the intervention, participants may have underreported their risk behaviors due to social desirability bias. As a result, the sample may have appeared to be less risky than intended, which means behavior change may be a challenge. There may have been some contamination as a result of some index participants in the intervention group promoting risk reduction with index participants in the comparison group. This dynamic may have reduced the differences between the two conditions.
Many HIV/STI prevention interventions have demonstrated behavior changes at 6 month or less follow-up assessments (40
). Our study found that a Peer Education intervention is effective at reducing individual risk behaviors, including reductions in unprotected anal sex, unprotected vaginal sex, and unprotected sex with main or non-main partners over the 18-month follow-up period.
By taking on the role of Peer Mentor, women lowered their own risk for HIV and STIs. While all of the index participants were women, over half of the network participants were men. Thus, Peer Mentor interventions for women are also an avenue to reach men. In addition, through dissemination of risk reduction resources and information in a social network, norms about risk reduction may prevail.
Community-based organizations should consider implementation of peer education interventions whose reach goes beyond the people who attend their programs. Peer education interventions capitalize on naturally occurring social influence process and can sustain behaviors for an extended period of time as they influence dynamics of the social environment, such as norms, in addition to the individual.