Peer Navigation Services

Introduction

Peers show what is possible

While the type of HIV services available has changed since the early days of the HIV epidemic in Canada, programs like Peer Navigation Services in Vancouver show us that peers are often an important part of effective initiatives.

Peer Navigation Services is a partnership between the Positive Living Society of British Columbia (PLBC), the John Ruedy Immunodeficiency Clinic (IDC) at St. Paul’s Hospital and the Vancouver STOP Project. Peer navigators offer the expertise of professionally trained peers to people newly diagnosed with HIV and those who may have been living with HIV for a long time but who are currently not accessing healthcare. The peers use their lived experience with HIV to support the client in understanding that they can live long, fulfilled and healthy lives with HIV. Peer navigators also support clients to improve their ability to manage their own health and care.

Peer Navigation Services is a unique partnership between a clinic and the community. The program maintains two offices and offers peer navigation in two distinct settings: one in a hospital and one in a community organization (PLBC). Peer navigators working out of the community office typically work on outreach. At the clinic, peer navigators work alongside healthcare professionals, bringing their knowledge and training into the hospital/clinic setting.

Working from their office adjacent to the waiting room at the IDC, the peer navigators are able to connect with people living with HIV at a time when they are often most vulnerable and overwhelmed. The outreach peer navigators work closely with a clinical outreach team (the STOP Outreach Team, which is made up of nurses, social workers and other outreach workers) to connect with people living with HIV in the community who may not have adequate social and medical supports to benefit from HIV treatment.

These peers help to stabilize all clients, regardless of where they meet them, by connecting them to supports and helping them to navigate the world of HIV care and treatment, which can be complex. They show that using lived experience to help others is key to making a difference.

What is the Program?

In 2011, the Positive Living Society of British Columbia (PLBC), the John Ruedy Immunodeficiency Clinic (IDC) at St. Paul’s Hospital and the Vancouver STOP Project developed and launched Peer Navigation Services for people living with HIV. Specifically, peer navigators provide ongoing support and education to people living with HIV to help clients develop the ability to better manage their own health and care.

Peer navigation is an example of a successful community–clinic partnership. The skilled peer navigators form the core of this partnership, working closely with an interdisciplinary clinical care team to offer extensive HIV support, care and access to treatment for people living with HIV, especially those who face significant barriers to care. This clinical team includes nurses, social workers, physicians, pharmacists and dietitians.

The program includes peer navigators who offer information, education and connection to services in a clinic and/or on outreach. Although all of the navigators serve people living with HIV, the clinic and outreach groups operate from different perspectives within the continuum of care model.

Peer navigators meet with people living with HIV in the clinic or in the community and work to build trusting relationships, helping them (1) to understand that it is possible to live well with HIV by managing their own illness and (2) to live physically and emotionally healthy lives by accessing a variety of services and activities.

Peer Navigation Services aims to:

• delay the progression of HIV among clients
• promote the value of HIV care and treatment
• improve the transition between HIV diagnosis and entry into care

Through these three aims, the program also works to reduce the onward transmission of HIV by delaying advanced HIV disease, promoting HIV care and treatment and improving the transition between HIV diagnosis and entry into care.

Both clinic and outreach peer navigators accomplish these goals by sharing their personal journeys with clients. They also provide education on living with HIV and help clients to navigate the variety of clinical and community agencies available. Navigators make the process through which their clients learn about HIV and how to manage their health easier. They offer treatment education to help clients understand, become ready for and, when the time is right, start and adhere to treatment. Peer navigators also support clients to make lifestyle changes that the clients want to make and help ensure people living with HIV do not fall through the cracks of the healthcare system.

The peer navigators are trained in peer counselling and health issues related to HIV/AIDS including sexually transmitted infections, self-care, the progression of HIV disease and harm reduction strategies. Peer navigators are continuously offered training to develop their skills and to share their knowledge with their clients.

In December 2013, Peer Navigation Services became the only HIV peer-to-peer program in Canada to receive Leading Practice status by Accreditation Canada. Accreditation Canada awards  Leading Practice status to programs that are examples of high-quality leadership and service delivery, and which demonstrate that they are innovative and creative; client-centred; evaluated and achieved intended results; sustainable; and adaptable by other organizations.

A presentation that offers an overview of Peer Navigation Services is available online.

Why Was the Program Developed?

The Peer Navigation Services program was the result of several factors:

• an identified community need
• a history of peer work at the Positive Living Society of British Columbia (PLBC)
• the years of collaboration between PLBC and the John Ruedy Immunodeficiency Clinic (IDC)
• the unique funding of the Vancouver STOP Project

Addressing a community need

Peer navigation was originally conceived in 2007 as a workshop for gay men to help them manage their own health and care. This was originally funded by the AIDS Community Action Program. The Peer Navigation Services program was developed in response to two key community needs. First, some people who were newly diagnosed with HIV were not connecting with care and support services immediately after diagnosis, in part because of negative experiences receiving their HIV diagnosis, such as during pre- or post-test counselling. These experiences often caused people to avoid care, treatment and support. In other cases, people were not offered support immediately after diagnosis and they did not know how to access services.

Second, some people living with HIV (who knew their HIV status) in Vancouver who were street entrenched or who had come to mistrust and avoid the healthcare system were not engaged in care at all.

A comprehensive peer-to-peer program, like Peer Navigation Services, that immediately engaged people newly diagnosed with HIV to offer support and that connected people who were not engaged to care was urgently needed to respond to these challenges.

History of peer work at the Positive Living Society of British Columbia

PLBC has a long history of providing peer-focused information to people newly diagnosed with HIV. They have been educating their membership and communities since 1986 about HIV/AIDS and the key role that peers play in HIV/AIDS care, treatment and support. For example, PLBC developed the first HIV information brochures for people living with HIV, by people living with HIV, in British Columbia. They have also developed and carried out a number of peer-led workshops and one-on-one education programs for people living with HIV. Feedback from their members over their years has provided valuable insights, which they have used to adapt and improve their work.

Given the strong history of peer work at PLBC, this organization was well suited to develop a complex, peer-led, community–clinical partnership program that aimed to support marginalized people living with HIV and people who are newly diagnosed with HIV.

The Positive Living Society of British Columbia and the John Ruedy Immunodeficiency Clinic: a long history working together

The IDC–PLBC partnership that is a part of Peer Navigation Services is not new: the IDC has been an important partner of PLBC for some time. The IDC is a low-barrier, comprehensive healthcare clinic for people living with HIV/AIDS based at St. Paul’s Hospital. The clinic provides extensive supports, offering everything from medical care to housing referrals to psychosocial support. The clinic’s patients have access to family physicians with training to provide care to people living with HIV, registered nurses, social workers, pharmacists and a dietitian.

However, in the past, the IDC had not offered many peer-based services unless PLBC was involved, such as a support group co-facilitated by the IDC and PLBC. Over the past few years, one staff person at PLBC, who would go on to develop and coordinate Peer Navigation Services, had been working with a social worker at the IDC to facilitate a support group at the clinic. PLBC also participated on the IDC’s patient advisory group.

This work laid the foundation for Peer Navigation Services because the valuable and unique role that peers play in the care of people living with HIV particularly was becoming clearer. The PLBC–IDC partnership enabled the two organizations to explore differences between clinic and community practices to figure out how peers could be integrated into a clinical context.

Developing Peer Navigation Services in partnership with the Vancouver STOP Project

PLBC spent many years developing the skills and partnerships necessary to coordinate a program like Peer Navigation Services. The program began to take a more concrete shape when Vancouver STOP Project funds became available. Using their existing relationship as a foundation, PLBC and the IDC joined forces with the Vancouver STOP Project to develop and deliver this program.

How Does the Program Work?

Location

Peer Navigation Services operates out of two separate offices, one of which is clinic based and the other of which is outreach based.

In the clinic, the peer navigators’ office is located in the main reception area of the John Ruedy Immunodeficiency Clinic (IDC) at St. Paul’s Hospital, among researchers, physicians, social workers and HIV specialists. The office is inviting and friendly. The reception area displays resources designed to educate clients and inspire hope in a healthy future.

The outreach peer navigators work from an office located at the Positive Living Society of British Columbia (PLBC). Their primary work is accompanying clients to appointments or meeting them in coffee shops. They coordinate their activities with the program coordinator and the STOP Outreach Team. For more information on the STOP Outreach Team, please see the case study.

Hiring peer navigators

Creating a diverse team

Before it recruited and interviewed candidates, PLBC conducted informal community consultations to determine the mix of peer navigators it should recruit. They wanted to know which communities, age groups and experiences peer navigators should represent. At the time the program was developed, the “right mix” of people living with HIV in Vancouver was as follows: a woman from a middle-class background, a young gay man, an older gay man, people in recovery from addiction, a person with First Nations ancestry and a person who was fluent in Mandarin and/or Cantonese.

Recruiting peer navigators

PLBC took the lead on recruiting peers first by posting recruitment posters in local HIV community agencies. Interested candidates were invited to contact the community agency for pre-screening, which helped determine their appropriateness for the program. To be eligible to participate in an interview for one of the positions, candidates had to have been living with HIV for at least three years and demonstrate a healthy integration of HIV into their daily life. Further, a person who disclosed that they were in recovery from an addiction had to have been substance-free for at least three years, to reduce the impact of potential triggers. All candidates had to be willing to publicly disclose their HIV status and, when appropriate, disclose their history of addiction. Finally, candidates had to demonstrate strong self-management skills and to explain how they had developed a positive and hopeful outlook about HIV. Emotional intelligence, empathy and logical thinking were also valued.  

Interviewing potential candidates

Candidates who were recommended were interviewed by PLBC in one of two ways. Candidates interested in a full-time peer navigator position were formally interviewed by a panel. Candidates interested in a part-time position were interviewed using a more informal discussion-style interview. This approach was used because many candidates interested in the part-time positions had limited experience with resumes and interviews. To reduce their barriers to the hiring process, PLBC used a narrative counselling approach to the interview, in which casual conversation was encouraged and the interviewer used dialogue to draw out the information needed to make a hiring decision. In all cases, candidates were assured that no matter how challenging their past experiences had been, their chances of being hired would not be affected by their personal history.

Not all interviewed candidates could be hired. Those not selected were offered one-on-one support to encourage them to develop ongoing strategies to support re-entry into the workforce.

Training peer navigators

Peer navigators undergo extensive training, which includes the provision of information on HIV treatment, prevention and management and other topics related to supporting clients’ abilities to manage their own health and care and the peer navigator’s own self-care.

Peer navigators pass on to their clients much of what they learn in their training sessions. Therefore, training is offered in plain language and delivered via easy-to-use diagrams and other tools. The goal is for peer navigators to pass on information in such a way that clients will learn and retain it, develop self-management skills and make informed choices about their lives and healthcare.

Training includes the following topics (for more detailed information on this training, please contact PLBC [see Contact Information]):

Overview of the Peer Navigators Services project: Information on the history of the program and peer-based work at PLBC is shared, along with the goals and objectives of the project. The expectations of the peer navigators are also shared.

Working in an interdisciplinary team: Given that this program represents a unique clinic–community partnership, peer navigators are offered information on what it means to work within this environment. A site tour of the clinic is provided, clinical staff provide information on the services that they offer and the structure of the clinic, and peers learn about the importance of confidentiality in a clinical setting.

What it means to be a peer: Peer navigators are trained in competencies related to MIPA (meaningful involvement of people living with HIV) and are provided with strategies to determine each person’s readiness to be a peer and information on boundaries and triggers.

Outreach-specific training: Outreach-based peer navigators are then offered specific outreach training, including information on working with the STOP Outreach Team, information on HIV testing events and information on maintaining confidentiality for clients in an outreach context. During this training they also develop competencies in HIV testing.

HIV competencies: A significant amount of the training provided to peer navigators focuses on HIV/AIDS-related competencies. This information is divided into two sections: “Learning about it” (the content) and “Living with it” (the process). These two sections are the foundation for the “HIV basics” that are provided by the peer navigators to their clients.

“Learning About it” includes the most up-to-date information on HIV, including HIV prevention strategies and the latest in HIV care and treatment. “Living with it” offers peer navigators the opportunity to discuss what the information in the module means to someone’s everyday life.

HIV-related training includes seeing HIV as an episodic disability, preventing disease progression, the life cycle of the virus, HIV treatment and blood work, side effects of HIV and antiretroviral therapy, factors that influence premature aging, the transmission equation, disclosure, the value of self-care for HIV-positive people and the concept of patient-centred care.

Ongoing training

In addition to the structured training discussed above, peer navigators receive additional training to support and enhance their skills on an as-needed basis. This includes:

• computer skills (offered by another PLBC program)
• shadowing other peer navigators
• reflective listening skills (taught by a psychologist)
• developing appreciative inquiry/strength-based conversations
• transference and counter-transference
• being with someone when they receive catastrophic news (taught by a BC Centre for Disease Control nurse)
• harm reduction for addictions (taught by a Vancouver Coastal Health harm reduction nurse)
• HIV testing options
• trans-theoretical model of behaviour change
• brief and loss
• understanding the communication process

Finally, PLBC holds monthly lunch-and-learn sessions and quarterly dinner forums on topics related to HIV and health. These learning opportunities are provided by physicians in the community and funded by pharmaceutical companies. All peer navigators are required to attend.

All full-time employees also receive annual educational funding to enhance their work-related skills.

For more information on the training of the peer navigators, please see Program Materials.

Clients accessing Peer Navigator Services

Potential clients of Peer Navigation Services must be newly diagnosed with HIV or living with HIV and require support to re-engage in care.

There are many ways to access Peer Navigation Services. People are typically first engaged with the program through a referral. Referrals come from a variety of sources, including members of the STOP Outreach Team, who meet people on the street or in other community agencies; the IDC staff, who meet possible clients in their general clinical practice; PLBC agency walk-ins, which includes people who are looking to access support services; and community agencies that are familiar with the Peer Navigation Services mandate.

In the beginning, all referrals went directly to the program coordinator who manages the peers. The program coordinator could effectively determine which peer navigator would be the best fit for the new person. Over time, however, peers have become known in the IDC and on outreach, and as a result referrals sometimes now include a request for a particular peer. When this happens, the program coordinator is still notified because this person helps manage the workloads of the peers. Whether a request for a specific peer navigator is made or not, the program coordinator considers key personality traits and life experiences that may relate to those of the potential client when matching a peer navigator with a client.         

At the clinic, a referral through the program coordinator may not be necessary. The connection between the peer navigator and the client can be made very quickly because an IDC staff person can walk a patient to the peer navigators’ office or, with the patients’ consent, invite a peer navigator into the person’s medical appointment.

Connecting with clinic peer navigators

When a new client enters the IDC, they go through an intake process (usually an interview) with an IDC nurse or social worker. Typically, a clinic peer navigator is introduced into the process immediately following this intake, which is an important step in building trust and ensuring continuity of care with the client. The peer navigator is able to offer their lived experience right from the start. This is sometimes a new client’s first time meeting a person living with HIV. Once a new patient meets the peer navigator, they can choose whether or not to participate in this service on an ongoing basis. If they do participate, they will meet one on one with the peer navigator, typically shortly (within 1–2 days) after engaging with the program.

Peers will then develop ongoing relationships with clients, providing a range of services. Weekly, biweekly or monthly appointments can be made, but clients mostly drop in. The IDC in general and Peer Navigations  Services in particular are set up to be low barrier, so clients do not require an appointment to see their peer navigator.

The peer navigator on duty in the clinic will hang out in their office with the door open and in the IDC waiting area to provide a supportive and non-threatening presence for people coming into and leaving the clinic. By making themselves accessible, the peers help to identify specific resources, bridge gaps for people in the busy clinic and engage patients who struggle with the way the medical system operates, including things like wait times and referrals.

Connecting with outreach peer navigators

Unlike clients who connect with clinic peer navigators, who are engaged in some form of care at the IDC, people who connect with outreach peer navigators are usually not engaged in care at all. People who connect with outreach peer navigators are usually identified by the STOP Outreach Team or by other service providers working in the community. Generally, outreach clients fall within one of three broad categories:

• Clients who have been recently diagnosed with HIV have a moderate to good ability to manage their own health and care and are generally stable. These individuals do not have access to the IDC peer navigators because they are not diagnosed at the IDC or are not patients of the IDC.
• Clients who are newly diagnosed with HIV experience challenges managing their own health and care. These are usually related to addiction, mental health conditions or unstable housing. Individuals in this category may not be accessing any kind of healthcare.
• Clients who have been living with HIV for some time (and are aware of their status) experience challenges managing their own health and care. These challenges are usually related to addiction, mental health conditions or unstable housing. Individuals in this category may not be accessing any kind of healthcare.

When a potential client is identified, the service provider, usually an outreach nurse, will explain to them the value of the program. If the client agrees to meet with a peer navigator, a referral is made to the coordinator. The coordinator and the nurse will determine which peer navigator is the best fit and whether or not a nurse will accompany the peer navigator on the first visit with the client. As this is a highly vulnerable time for most newly diagnosed people, regardless of their stability, approaches that are tailored for each individual are required.

The peer navigator will contact the client, explain their role and allow time for the client to talk. If the first contact is by phone or text message, they will choose a mutually safe place and time to meet, and their relationship builds from there.

The work of the peer navigators

A peer navigator supports a person living with HIV to engage actively in their own healthcare decision-making to improve their emotional and physical health and address and potentially stall HIV disease progression. To accomplish this, clinic-based and outreach-based peer navigators provide similar services. Both provide essential engagement and linkage-to-care service to clients, and both build clients’ trust in health and social services. Both teams also ease the process through which their clients gain HIV knowledge and self-management skills. They help ensure people living with HIV, regardless of their unique circumstances, do not fall through the cracks in the healthcare system.

Peer navigators use a therapeutic relationship model. This means engaging clients where they are currently at and at a pace with which clients are comfortable. Peer navigators help clients navigate the often-intimidating world of HIV treatment and services by providing a range of support services aimed at developing clients’ emotional and physical self-management strategies.

While there is no typical relationship between a peer navigator and a client, the following outlines the services that peer navigators often offer to clients.

Provide emotional support: While peer navigators are not trained as counsellors, they do provide emotional support to clients. However, if a client requires more intensive counselling to address significant mental health issues, they will be referred to an IDC social worker or community psychologist.

Share basic information on HIV and AIDS: Peer navigators are trained to offer HIV education, including information on HIV treatment, care and transmission, to their clients informally through their one-on-one conversations and sometimes using the training materials developed for the peer navigators program. These materials are designed to reduce clients’ misunderstandings about HIV by helping them to learn about the new realities of HIV infection, HIV disease progression, and the transmission and prevention of other sexually transmitted infections.

Build on clients’ own skills in self-management: Using supportive education, peer navigators address individuals’ self-management skills for their emotional and physical health. They talk to clients about clients’ own strategies to stay healthy. They also provide information on and support around disclosure strategies (including information on legal rights and obligations), harm reduction strategies, and the value of HIV antiretroviral treatment to prevent transmission of HIV to others.

Prepare clients for antiretroviral therapy: Peer navigators talk to clients about the benefits of antiretroviral therapy, inform them how antiretrovirals work, teach them basic information about blood work and offer treatment information so that clients can make informed decisions about when and if to start and stay on HIV treatment. This is a very important part of the work of the peer navigators, as it increases the ability of clients to understand treatment and thus client readiness to start treatment.

Support behaviour change: Peers support the behaviour change that clients are interested in making so they can improve stability in their own lives. Specifically, change in drug use behaviours is supported through harm reduction education, referral to addiction counselling and mental health support, as well as efforts to upgrade housing and create safe spaces for clients through the creation/strengthening of social networks (friends, family, support groups, community-based organizations), among many other things.

Accompany clients: Outreach peer navigators also support their clients by accompanying them to medical and other appointments and addiction meetings. This is an important tool for people who have less stability in their lives.

Once peer navigators have shared the basic information about HIV and self-management, a client is supported to stay connected to care through additional health programs that address their physical, emotional, social and spiritual needs. These include consultations with dietitians, healing retreats, treatment information sessions, peer support groups and formalized HIV social network programs, among other things.

Additional elements of peer navigation in the clinic

As members of the healthcare team at the IDC, clinic peer navigators are critical to the IDC’s ability to build its clients’ trust in the healthcare system of St. Paul’s Hospital. Through their work, the peer navigators support people to stay engaged in care at the IDC.

IDC-based peer navigators work in a very different setting than their outreach-based counterparts. The clinic-based peer navigators are able to offer some additional services, as described below.

Support people with HIV who have been admitted to hospital: Clinic-based peer navigators support clients not only of the IDC but also of 10-C, the in-patient HIV ward at St. Paul’s Hospital. People who have HIV-related opportunistic infections, malignancies, infections related to injection drug use or complications of chronic liver disease (e.g., hepatitis B and C) or who are experiencing adverse effects related to antiretroviral therapy are admitted to this ward. If clients are discharged from 10-C to an outside clinic for the first time, an outreach peer navigator will take over to make sure the client stays within the continuum of care in the new site.

Provide appointment support: To support ongoing linkage to care, peer navigators will remind clients about their appointments. They also speak to clients about the physician–patient relationship, the language used by physicians and what patient-centred care means, and they help clients to prepare for their doctors’ appointments by developing a list of the questions they might have about their health. They also explain the process of accessing drugs, how requisition forms work and how to understand and cope with long wait-room times when they happen. They also attend appointments with the client when asked and debrief the client after the appointment.

Facilitating and supporting self-management discussion groups

Peer navigators also facilitate self-management groups at PLBC and at the IDC. These discussion groups function as a support group, providing opportunities for clients to build their support networks. These groups also help clients to further build their skills in self-managing their HIV-related health. In addition, they serve as a transition support as clients move from an ongoing need for a peer navigator’s services to stability without this support, while remaining engaged in the HIV community. Peer navigators can accompany clients for the first few meetings if the clients find attending a group challenging.

Establishing the peer – healthcare provider relationship

PLBC and the IDC identified key stakeholders in each organization early to ensure that the collaboration between their staff and the peer navigators would be successful. These stakeholders were tasked with working together to establish the vision and goals for the project and helping to secure ongoing support from other staff.

PLBC and IDC provided ongoing support to their respective organizations for the changes that occurred when peer work was introduced into their clinical environment. For example, some peers may have a dual role as both clients of the clinic and colleagues of the clinical staff, which can present some challenges for both the peers and clinicians during the adjustment period.

The introduction of the peer navigators required both the peers and the healthcare providers to be willing to learn from each other and talk about their approaches to providing services to clients. This involved a steep learning curve for both parties. The initial barriers were reduced as the program established itself and as the positive effects of the program on clients became clear.

Through the work of the peer navigators, clients were kept engaged in care and their health outcomes visibly improved; this evidence helped both the peer navigators and clinicians to see the value of the program. Within a few months of the introduction of the program, most of the healthcare practitioners involved and the peer navigators themselves came to value the peer navigators’ expertise and see this role as a vital complement to the other clinical services provided at the IDC and through the STOP Outreach Team.  

Ensuring confidentiality

The clients’ right to confidentiality is one of the most important values of the Peer Navigation Services program. Peer navigators are offered training in concepts of confidentiality and sign confidentiality agreements for both PLBC and the Vancouver STOP Project. For a copy of this confidentiality policy, please see Program Materials.

Required Resources

Human resources

1 full-time equivalent (FTE) peer navigation coordinator, 2.5 FTE clinic peer navigators, 1 FTE outreach peer navigator, 2 part-time outreach peer navigators (15 hours/week), 3 part-time outreach peer navigators (5 hours/week)

Desirable attributes for navigators

While not every peer navigator has all of the skills listed below, it is important for peer navigators to bring a mixture of the following skills and experience to their role:

• willingness to share their HIV status with the public
• proven ability to be proactive and creatively engage new people
• strong problem-solving and decision-making skills
• knowledge of relevant community agencies, community events and services
• knowledge about HIV, including HIV testing and treatment
• excellent interpersonal and communication skills
• team player who is able to work well in a group and independently
• upbeat, optimistic, friendly and authentic
• leadership qualities
• strong organizational and time-management skills
• street outreach experience
• group facilitation training

Some peer navigators also have completed or are working towards a 2-year social services diploma, which complements their training well.

Challenges

Bridging the gap between clinics and community organizations can be a challenge: While medical clinics and community-based organizations have similar goals for the health and well-being of HIV-positive people, their organizational values, philosophies and culture are often different. Bridging the gap between these two types of necessary services can be difficult for both the medical and peer-based communities. The two parties responsible for Peer Navigators Services (IDC and PLBC) addressed this difficulty by being willing to undergo change through a process of negotiation.

Lived experience can be undervalued: In formal healthcare contexts, lived experience can be undervalued, particularly in relation to educational experience. At times, both the peer navigators themselves and the medical staff undervalued peer knowledge. This issue was addressed through a slow process of negotiation and change among the two groups. In addition, the demonstrated positive outcomes of the program helped all parties recognize the value of peer knowledge.

Role clarity on interdisciplinary teams: Role clarity was a key challenge of the collaboration of peer navigators with healthcare providers. At times, different staff duplicated efforts, partially because clients required different services at different times. This could be addressed through more comprehensive definitions of the roles and responsibilities of each team and position.

Outreach can pose dangers: Outreach peers work with some people who face significant marginalization. Peer navigators have been caught up in mental health housing lockdowns by SWAT teams and witnessed active drug use. These experiences may place peers in danger and may act as triggers for their own challenges. Peer navigators report incidents to the coordinator and together they establish supports to deal with the situation. In some cases, it has been decided that the peer navigators will no longer work in a particular situation. The peer navigators are not blamed when this happens; rather, they are supported to feel good about keeping themselves safe.

Peer–client boundaries: The therapeutic relationship between peer navigator and client is a key component of the program. Given the intensity of the client–peer relationship, clients sometimes redirect feelings that they have for other people in their lives onto the peer navigator. Peer navigators are trained to recognize the signs of this and counselled to reorient the client to the boundaries of their professional relationship. In addition, given the connections between clients and peer navigators, peers may also, rarely, blur their professional and personal boundaries by developing their own personal feelings for the client. The coordinator watches for signs of this and will discuss it with the peer navigator, possibly in consultation with the contracted psychologist.

Evaluation

Qualitative and quantitative data were collected to ensure that the Peer Navigation Services project was addressing the needs of the communities that it serves as well as helping to achieve the goals of the Vancouver STOP Project.

As with other Vancouver STOP Project pilots, a logic model was created for the peer navigators program, which involved creating a diagram outlining the program’s inputs, activities, outputs and expected outcomes. This logic model helped PLBC and IDC develop the program and evaluate it. For a copy of the peer navigators program’s logic model, please see Program Materials.

Outputs measured to help determine the success of the program included the following: the number of peer navigators hired and trained, the number of clients served (and characteristics of these clients), the number of groups held and the number of clients linked to care at the IDC or 10-C. This information was collected by the Vancouver STOP Project at six-month intervals.

The following short-term outcomes were also identified:

• for peer navigators: increased knowledge to provide HIV self-management support, increased self-confidence to provide HIV self-management support
• for clients: increased knowledge of HIV, increased self-confidence to manage their HIV-related health, satisfaction with peer navigator service, decreased viral load, increased CD4 count
• for the partnership: satisfaction among the STOP Outreach Team, IDC, 10-C and PLBC staff regarding the coordination of the program and collaboration among the members of the peer navigation team

The peer navigator team collected this information, in consultation with the Vancouver STOP Project, via a survey filled out by clients at the IDC and returned to a drop-box in the waiting room, a focus group and individual interviews with clients. For a detailed analysis of these outcomes, please see the interim evaluation report on peer navigators in Program Materials.

Importantly, Peer Navigation Services also assessed its success by reflecting on its effect on linkage to care for clients. Anecdotally, the program has greatly reduced the time it may take an individual to connect with care after an HIV diagnosis, from years to weeks.

For more information on the evidence that supports health navigation in HIV care more broadly, please consult Health Navigation: A Review of the Evidence.

Lessons Learned

Peer navigators bridge the gap between client and clinician: At times, communication between clients and clinicians can be challenging. Peer navigators successfully bridge this gap, because they are trained to “speak the language” of both parties.

The partners must have a strong peer-based programming history: PLBC has a long history of providing peer-based programming. Given this, they were well suited to develop a complex, peer-led, community–clinical partnership program that aimed to support particularly marginalized people living with HIV. The IDC, the clinical partner in this project, also has an extensive history providing comprehensive care to people living with HIV. This was also an important component of this project’s overall success. For more information on the IDC, please see the IDC case study.

There’s no cookie cutter approach: The success of Peer Navigation Services is due, in part, to the fact that the project was uniquely tailored to a specific community and HIV-related health services. Although PLBC receives many inquiries about how to develop peer-based initiatives, there is no cookie cutter approach. Each organization must take the resources that already exist and shape the program to meet the particular needs of the peers and the community.

Program Materials

• Peer navigation logic model
• Peer navigation training course syllabus
• Peer navigation code of ethics
• Peer navigation training material example: peer readiness action plan worksheet
• Peer navigation ethical guidelines in professional relationships
• Peer navigation brochure
• Peer navigation flyer for physicians
• Peer navigation flyer for waiting room
• Interim evaluation report on peer navigators

Contact Information

Peer Navigation Services:

John Ruedy Immunodeficiency Clinic
St. Paul’s Hospital
608–1081 Burrard Street, Vancouver, BC  V6Z 1Y6, Canada
Tel: 604-806-8477

Peer Navigation Services Coordinator:

Glen Bradford
Positive Living Society of British Columbia
1107 Seymour Street, Vancouver, BC  V6B 5S8, Canada
Tel: 604-908-7710

What is the STOP HIV AIDS Project?

Seek and Treat for Optimal Prevention of HIV/AIDS (STOP) was a $48 million dollar, four-year (2010–2013) pilot project funded by the government of British Columbia. This project aimed to increase the quality of life of people living with HIV and to reduce the number of new HIV infections by taking a proactive public health approach to finding people living with HIV, linking them to HIV care and treatment programs and supporting them to stay in care. STOP aimed to improve the experience of people living with HIV or AIDS in every health and social service interaction and significantly improve linkage and engagement across the full continuum of HIV prevention, testing and diagnosis, treatment, and care and support.

As a pilot project, STOP was rolled out in Vancouver and Prince George. It was made up of numerous interconnected and discrete clinic-based, hospital-based, community-based and policy-focused programs implemented through the collaboration of an impressive number of stakeholders.

In 2011, PLCB received funding and support from the Vancouver STOP Project to develop and implement the Peer Navigation Services program, including hiring a peer navigator coordinator, two full-time clinic peer navigators, one full-time outreach peer navigator and four part-time peer navigators working in outreach and the clinic. The Vancouver STOP Project funds also provided space at the IDC for an office and allowed the IDC social worker to mentor the peer navigators. The Vancouver STOP Project also supported the relationship between PLBC and the IDC.