Harlem Hospital peers at the center of a multidisciplinary HIV care team
Harlem Hospital’s Infectious Diseases Division is a pioneer in the use of peers— specially trained members of the community who are living with HIV/AIDS – to support others who are learning to cope with the daily challenges of the disease. In 1998 the Division launched a randomized controlled trial of an innovative, peer-based intervention to help clients stay in care and improve their adherence to antiretroviral therapy (ART) regimens.
About the Harlem Hospital peer program today
The trial's successful implementation led to the continuation of the Harlem program. Today four peers, with a caseload of 10-15 clients each, form an integral part of the network of care, focusing on underserved populations targeted by the Ryan White CARE Act. These peers establish a one-on-one relationship with their clients and collaborate closely with health care professionals to improve the quality of health care that clients receive.
They meet with clients in any location that is convenient, including public places, the hospital center, self-help group meetings, and even clients’ homes. “The most important thing you do as a peer is to connect with the client and build trust,” explains Jackie Howell, who has worked as a peer in Harlem Hospital for seven years. “Unless you build trust, the client is not going to speak to you or believe what you say.”
Depending on clients' needs, a peer may brainstorm ideas for adapting a treatment regimen to the client’s daily schedule, provide emotional support and a listening ear, navigate the health care network, work with case managers to refer clients to needed services, accompany them to appointments, or help them to learn more about the HIV virus. They may also co-facilitate support groups or participate in monthly meetings of the Harlem Hospital Community Advisory Board.
A team approach to HIV care
Through biweekly case management meetings, a multidisciplinary team of peers, social workers, case managers, program managers, doctors and other care providers review the entire spectrum of client care to identify areas for improvement. By working as a liaison between care providers and clients, peers often help clients to understand and accept their doctors’ medical advice, overcome mistrust of the medical system, and offer providers additional insights into a client’s situation.
“One of the things we did as peers was to get connected with the doctors,” explained Howell. “The doctors at Harlem Hospital were very respectful of the peers, and that helped our program improve.” Finding and training the “natural helper” Filling the role of peer in an HIV care network requires careful recruitment, says Julie Franks, PhD, who served as evaluator for the study. “In addition to being familiar with the community and adherent to ART, we look for a ‘natural helper’, someone with a non-judgmental attitude towards people’s lifestyle and preferences and an ability to listen,” according to Franks. “They have to be able to use their experience and their listening skills and empathy to say, ‘You know, I went through the same thing.’”
Potential peers attend a rigorous training program. The training programs run for several weeks, with half- or full-day sessions that total about 50 hours. The intensive curricula combine adult learning theory, best practices from Harlem Hospital and other peer programs, and the needs of the local community. Topics range from the basics of HIV care and treatment and communications skills to specific challenges like substance use and mental health concerns. The highly interactive training and includes experienced peers who share their knowledge with participants.
Members of the original training team collaborated in the foundation of PACT (Peer Advanced Competency Training program), a national education and capacity-building center for peer programs. Since 2006 PACT has provided comprehensive training, based on the Harlem Hospital model, for HIV peers working throughout the New York City area.
Challenges of the peer role
The nontraditional nature of the peer role presents unique challenges. “This is not a typical professional relationship,” explains Paul Colson, PhD, PACT Program Director. “We’re asking people to reach out in a personal way to help somebody. Exactly how that plays out can be tricky. That’s why we give some guidance around what kind of health-promoting behaviors we want peers to help clients develop: things like building a good relationship with providers, creating a social support network, identifying personal barriers to keeping appointments or adhering to medication, and focusing on self care.”
Because HIV-positive peers share many of the same challenges as the clients in the communities they serve, the peer supervisory role is crucial to the success of the Harlem Hospital program. According to Colson, peers thrive under supportive work conditions that provide structure, flexibility and a problem-solving approach to supervision. The program supervisor meets with each peer weekly to review activities, discuss peer-client interactions and assess client response, and discuss any stresses affecting the peer. PACT offers a full day of supervisor training to organizations like Harlem Hospital to provide supervisors with the tools they need to support peers effectively.
Through these close interactions with peers, the supervisor often identifies areas for additional training, such as recognizing clinical depression or identifying symptoms of mental illness. The Harlem Hospital staff then organizes peer training devoted to these topics. The health educator staff also encourages peers to take advantage of the many public health training opportunities available in New York City and helps to coordinate registration, transportation, and follow-up activities around these professional development opportunities.
Rewards of a successful peer program
Serving as a role model to others can help peers strengthen their own resolve to adhere to treatment regimens. Many peers derive deep personal satisfaction from helping others through a difficult time, and the support, skills, and self-confidence that they develop by working in the program contribute to improved self-esteem.
Through the support and encouragement of their peer partners, the number of clients staying in care and taking their medications has improved. “Imagine a client who didn’t want to know anything about HIV, about getting off drugs, about taking care of themselves, and in the end wanting to do all these things,” observes Howell. “That’s the success we achieved in the peer program.”
