Roles and Current Challenges of Peer Educators in delivering HIV/AIDS-related services: a case study in VietNam

Introduction

Vietnam has made significant progress in the fight against HIV/AIDS over the last three decades. In 2015, Vietnam was the first country in Asia to adopt the 90-90-90 target, i.e., 90% of people living with HIV (PLWH) knowing their HIV status, 90% of whom know their HIV-positive status accessing treatment, and 90% of patients having suppressed viral loads. In 2020, the target was expanded to 95-95-95, aiming to end the HIV epidemic by 2030 (Prime Minister, 2020). To achieve the target, the National HIV/AIDS Prevention and Control program must overcome several challenges. Notably, the AIDS epidemic is still concentrated in key populations, including men who have sex with men (MSMs), female sex workers (FSWs), and people who inject drugs (PWID). These groups not only have a higher chance of contracting HIV/AIDS but also face considerable stigma and discrimination and have limited healthcare access. Thus, achieving universal coverage of sufficient HIV prevention and treatment services among key populations would become more challenging than ever.

Vietnam has employed peer educators (PEs) for HIV/AIDS prevention and control activities among key populations since the early-1990s (Vu, Chung, Hoang, & Dondero, 2000). A large body of international (Berg, Page, & Øgård-Repål, 2021; He et al., 2020) and domestic literature (Cuong et al., 2016; Go et al., 2013; Sabin et al., 2019) has proven the effectiveness of peer-driven HIV/AIDs interventions. However, PEs have not been granted official positions within the health system. PEs have been recruited by the local health authorities (Khoat, West, Valdiserri, & Phan, 2003) or community-based organizations (CBOs) (Pham, Pham, & Le, 2022) to participate in project-based activities. In the former case, PEs work closely with the health staff from the commune health centers (CHCs) and district health centers (DHCs). In the latter case, CBOs work under the management of Non-Governmental Organizations (NGOs) or CDCs. It is worth noting that, a network of more than 11,000 CHCs forms the foundation of Vietnam’s primary healthcare. CHCs are responsible for implementing priority public health programs, organizing community-level preventive health services, examining and treating common diseases, etc. In addition to CHCs, DHCs provide more complex services and supervise their subordinate CHCs in service delivery. At the provincial level, the Department of HIV/AIDS Prevention and Control, a unit under the Provincial Centers for Disease Control (CDC) is responsible for implementing HIV/AIDS program.

Peer-driven activities were mainly supported by external funding, with minimal state budget payment channelled through the National HIV/AIDS Program (Ministry of Finance & Ministry of Health, 2012). However, since the National HIV/AIDS Program was the national target program in 2016 (Prime Minister, 2017), the former provincial HIV/AIDS Administration Center was incorporated into the CDC, currently operating as a department under the CDC, as explained above. This organizational structure alteration introduces additional challenges in retaining the PEs in HIV/AIDS control and prevention initiatives since advocating for state funding has become more competitive.

Consequently, the inevitable decreased donor funding together with the organizational structure change has caused a significant reduction in the PEs workforce, from about 8,000 PEs in 2013 to 1,000 PEs in 2018 (VAAC, 2018). The COVID-19 pandemic also struggled barriers to PEs in delivering HIV/AIDS services and, more severely, caused the dispersal of many CBOs (Nguyen, Nguyen, Khuat, Le, & Nguyen, 2022). To maintain and further expand the peer educator workforce to effectively reach the key populations, PEs’ roles must be well recognized. However, evidence of their current roles has still been limited. This study is the first nationwide study in Vietnam that aims to examine the roles and current challenges of PEs in the field of HIV/AIDS. Understanding the roles and challenges of PEs in delivering HIV/AIDS services will help local authorities and stakeholders recognize the roles of PEs appropriately and create a favorable environment for utilizing this workforce effectively.

Methods

Study Sites: Hanoi, Son La, Thai Nguyen, Thua Thien Hue, Lam Dong, Khanh Hoa, and Kien Giang were selected based on their ecological characteristics and representation of the HIV epidemic.

Study Design: Employing a mixed-method approach, including quantitative survey and qualitative interviews. The quantitative survey was conducted first; then qualitative interviews were conducted later to provide detailed information on PEs’ roles and challenges. The data collection period lasted from December 2021 to March 2022.

Results

Roles of peer educators in HIV/AIDS prevention and control

The survey shows the dynamic roles of PEs in HIV/AIDS prevention and control. Generally, there was a consensus reporting the PEs’ roles from both health staff and PEs (See Table 3).

Table 3. Results from the cross-sectional survey on the role of PE in HIV/ADS prevention and control.

Themes	Roles	Health staff N=63 (%)	PE N=147 (%)
Education and promotion	Providing health education materials for the at-risk population	57 (90.5)	124 (84.4)
	Educating and promoting behavior changes among the at-risk population	50 (79.4)	123 (83.7)
	Educating PLHW about ART treatment	47 (74.6)	124 (84.4)
	Giving instructions for using condoms/lubricant	57 (90.5)	135 (91.8)
HIV testing	Conducting HIV pre-test counseling	49 (77.8)	136 (92.5)
	Identifying and persuading the at-risk population to undergo HIV testing	60 (95.2)	145 (98.6)
Referral	Referring clients to HIV testing	56 (88.9)	141 (95.9)
	Referring PLWH to ART	48 (76.2)	116 (78.9)
Treatment support and home-based care	Providing support for ART, PEP, and PrEP treatment	19 (30.2)	72 (49.0)
	Providing home-based care for PLWH	22 (34.9)	56 (38.1)
Service organization and delivery	Dispensing needles and syringes	52 (82.5)	106 (72.1)
	Collecting used needle and syringes	46 (73.0)	100 (68.0)
	Dispensing condom/lubricant	63 (100.0)	142 (96.6)

Health staff highlighted that the distinct roles of PEs arise from their ability to effectively engage with the “hard-to-reach” population, while the health staff encounter numerous barriers in reaching these individuals.

“peers can effectively locate and easily access their customers. They are much better than us (health staff) in answering where and when to approach and whom to provide the services” (IDI, health staff 2)

“The advantage of PE is that they have the same living situation, interests, and habits, making reaching the hard-to-pick group easier … they can communicate and provide services such as referring customers to health facilities and HIV-self testing … They do not directly treat the patients, but they guide them and bring them to the health facilities … without customers, the healthcare system could do nothing …” (IDI, expert 1)

Qualitative interviews revealed additional roles not captured by the quantitative survey. Firstly, regarding health education and promotion, all HIV-specific topics, such as HIV prevention, stigma, ART literacy, co-infection control, etc., were mentioned in terms of “approach and education” in general. Non-HIV topics (i.e., healthy lifestyle, nutrition, and other common diseases) were recorded in several IDIs and FDGs:

“we teach them (PLWH) all kinds of subjects, HIV/AIDS and general health issues, like how to exercise, what is a healthy diet, what to do with back pain …” (FGD, PE, Thua Thien Hue)

“They have crucial roles in educating people, both PLWH and people with high-risk behaviors. The topics are diverse, from prevention of HIV and other STDs, how to disclose the HIV status, HIV stigma and discrimination, ART treatment, and treatment of other co-infections … sometimes and some topics, the target population only listens to their peers” (IDI, CDC 2)

Secondly, regarding HIV-specific care, key informants identified additional PEs’ roles in “identifying co-infections and side effects” (i.e., screening for co-infections and screening for treatment-related side effects) and “tracing patients who have missed their appointments.” Thirdly, regarding treatment support, key informants reported the roles of PEs in supporting PLWHs with treatment for other chronic conditions (e.g., tuberculosis) or methadone maintenance treatment (MMT) through motivating and reminding patients to collect their medication, and acting as “role models.” Fourthly, regarding service organization and delivery, key informants extrapolated the PEs’ roles in “accompanying patients to health facilities,” “supporting patients in administrative procedures,” and “delivering HIV self-test kits.” Last but not least, “collecting data on HIV epidemiological situation” was reported as one of the roles in the health system-oriented category.

Figure 1 presents the importance of PEs’ roles and their current practice. We presented the means of respondents’ answers. Although there were differing perspectives between health staff and PEs, they both agreed on the seven roles that were considered the most important and frequently performed: (1) Identifying and persuading at-risk populations to HIV testing services; (2) Referring at-risk groups to HIV testing services; (3) Counseling HIV pre-test; (4) Dispensing condom/lubricant; (5) Giving instructions for using condom/lubricants; (6) Educating PLHW about ART treatment; and (7) Referring PLWH to ART services.

Figure 1. Mapping the importance level of PEs’ roles ranking by health staff and PEs and the health staff’s assessment on demand for and current practice of each PEs’ roles.

Health staff generally placed a higher value on the importance of PEs’ roles compared to the value placed by PEs themselves. Only in the case of “providing HIV pre-test counseling” and “providing support for ART, PEP, and PrEP treatment,” PEs reported the importance of those roles higher than the health staff did. IDIs revealed that those roles might be under-recognized by healthcare providers since it is often believed that PEs are unable to be involved in treatment processes:

“peers could only do a good job in educating their peers, they can not provide treatment-related services” (IDI, health staff 5)

Discussion

To our best knowledge, this is the first study to collect data on a nationwide scale to synthesize the PEs’ roles in Vietnam. Their roles could be categorized into community-based and facilities-based activities. The prominent roles of PEs are identifying and referring customers to HIV testing services, communication, and education, and referring patients to treatment services. It is understandable since the word “educator” often relates to advocacy, counselling, distributing materials, making referrals to services, and support (Kerrigan, 1999).

The diverse roles of PEs in the HIV/AIDS program in Vietnam resemble those identified in a previous systematic review (Mwai et al., 2013; Ngcobo, Scheepers, Mbatha, Grobler, & Rossouw, 2022). However, this study acknowledges different roles of PEs reported in existing literature, such as linking and referring PLWH to specific services such as PreP or MMT, end-of-life care and funeral arrangement for PLWH, and conducting screening tests for drug abuse. This difference may originate from the characteristics of the healthcare system of different countries, the specific design of interventions involving PEs, characteristics of the HIV/AIDS epidemic, and cultural context.

While there is a general consensus among PEs and healthcare providers about PEs’ roles, there are still divergent viewpoints. For instance, some variations exist in the reported percentages of PEs providing HIV pre-test counseling and supporting ART, PEP, and PrEP treatment. Qualitative interviews suggest that these differences could be attributed to healthcare providers’ beliefs that PEs should not be involved in treatment processes. At the same time, PEs showed low confidence in performing these roles due to inadequate training. Thus, in the near future, to promote PEs’ roles in general and in delivering those HIV/AIDS treatment-related services, PEs’ roles need to be widely acknowledged among healthcare providers, and intensive training needs to be provided to help PEs effectively fulfil their roles.

Despite its profound effectiveness, the study shows that PEs’ roles in HIV/AIDS program in Vietnam seem to decrease. This observation is further supported by comparing the PEs’ roles reported in this study to those reported in the domestic literature published between 2003 and 2021. Indeed, some roles, including providing ART medication to patients who cannot go to health facilities; caring for women and children with HIV during hospitalization (Pham, 2009); referring patients with hepatitis B/C to relevant health facilities (Vu et al., 2019); referring patients to reproductive health services (Ngo, Ha, Rule, & Dang, 2013; Vu et al., 2019); and providing training and livelihood support (Nguyen et al., 2022; Pham, 2009), were no longer mentioned in this study. The remaining high demand for PEs in HIV/AIDS program is concerning as no replacement workforce is currently available.

The reduction in PEs’ roles could be explained in two ways. Firstly, there are many activities that PEs are still performing but have not been fully acknowledged, particularly in official reports. As explained by key informants, the current reporting requirements primarily emphasize quantitative indicators, including the number of people reached, at-risk cases tested, people tested, and those treated with ART rather than considering other activities that PEs performed. Secondly and more importantly, it is due to increasing challenges related to insufficient funding, inadequate training, lack of recognition, and stigma, as described in this study and other research (Khoat et al., 2003; Nguyen et al., 2022).

The lack of recognition was a profound challenge that linked to other difficulties. PEs’ roles and cost norms for peer-driven activities were only mentioned in Circular 163/2012/TTLT-BTC-BYT (2012-2015 period) (Ministry of Finance & Ministry of Health, 2012) and Circular 26/2018/TT-BTC (2016-2020 period) (Ministry of Finance, 2018). Since the national HIV/AIDS program was no longer the national target health program (Prime Minister, 2017), no updated guidance for peer-driven activities was promulgated, creating difficulties in allocating the state budget for those activities. Insufficient funding, coupled with decreasing international funding, created tremendous challenges in recruiting enough PEs to serve the increasingly hard-to-reach population, providing proper training for PEs to work effectively in the changing environment, and equipping them with adequate resources for their work. To address the challenges, some provincial CDCs have piloted signing social contracts with CBOs in selected peer-driven interventions (e.g., referral to HIV testing services, ART/PrEP treatment, and treatment support). By signing contracts with CBOs, provincial health authorities could grant PEs higher recognition. This study helps to provide local authorities with evidence of PEs’ roles to tailor the specific roles and responsibilities of PEs in those contracts. However, further investigation should be done to investigate the piloting results, the methods to measure PEs’ performance, and the payment mechanism to effectively and sustainably engage this workforce in HIV/AIDS interventions.

The study limitation lies in the study setting. We could only include seven provinces; thus, some activities of PEs, such as “training and livelihood support,” may not be vigorously carried out in these provinces. Besides, the cross-sectional survey only included a very small group of female-sex-worker- PEs. This may lead to underestimating some specific PEs’ roles related to FSW.

In conclusion, PEs have performed dynamic roles in HIV/AIDS prevention and control in Vietnam. Prominent roles are primarily related to identifying and referring customers to HIV testing services, performing communication and education activities, and referring patients to treatment. Despite its effectiveness, the decreasing roles of PEs seem not to meet the healthcare providers’ high demand. To maintain their roles, addressing the challenges of inadequate funding and training, lack of recognition, and remaining stigma issues is essential.