The federal Ending the HIV Epidemic (EHE) initiative is built on four pillars: diagnosis, treatment, prevention, and response. States can play a key role in EHE efforts by strengthening public health prevention, monitoring infection data, and providing treatment infrastructure and services to individuals living with human immunodeficiency virus (HIV). Peer workers, who have proven effective at engaging people living with HIV in care and maintaining viral suppression, present states with an opportunity to further strengthen investments in the EHE.
Engaging people with HIV in treatment is imperative to achieving the EHE goal of increasing viral suppression among diagnosed individuals to 90 percent by 2030. To support this goal, several states, including New York, Florida, and Wisconsin, are implementing models that facilitate connection to treatment using HIV peer workers. This non-licensed workforce of people with lived experience with HIV can bring knowledge of the unique challenges that come with managing HIV and also help states supplement the existing healthcare workforce that serves people living with HIV.
Workforce
Recruitment
States may experience challenges in recruiting HIV peer workers, as potential recruits must be comfortable sharing and leveraging their lived experience with HIV and the stigma associated with the disease remains significant. Wisconsin learned through listening sessions formed by community members who live with HIV that individuals who could comfortably discuss their HIV status were more likely to establish an effective therapeutic relationship with clients. Fostering this open dialogue is particularly important for HIV peer workers, who help clients engage or reengage in HIV care by connecting them to appropriate community resources and helping them schedule and attend appointments. Having lived experience is a primary qualifier for this workforce across state programs, and this experience often comes with knowledge on how to navigate social and economic challenges that peer workers can leverage in their work. For example, HIV peer workers with experience navigating resources like transportation and housing supports are able to better facilitate those connections for their participants.
Retention
HIV peer workers may have trauma history related to their HIV status and the surrounding stigma and can be at risk of secondary trauma given the nature of the work. Wisconsin’s team has experienced burnout among staff that were new to the HIV field, despite efforts to mitigate re-traumatization. As a result, Wisconsin has supported its HIV peer workforce with ready access to mental health counseling services. New York’s HIV peer worker programmatic requirements address re-traumatization and burnout, recognizing the importance of practicing self-care to prevent burnout, and are encouraged to seek support from supervisors when needed. States can consider what additional supports they can provide to ensure the health and wellbeing of HIV peer workers and empower them to continue providing the unique and integral services they offer.
Funding
New York, Florida, and Wisconsin each rely on a combination of funding sources to support and sustain their HIV peer worker programs. States can leverage multiple federal resources to support these programs, including Ryan White HIV/AIDS program funds from the Health Resources and Services Administration (HRSA), which totaled nearly $99 million for the EHE initiative in 2021. Additionally, states are using Centers for Disease Control (CDC) grants for HIV peer worker services. Florida operates four HIV peer worker programs through the county health departments in Alachua, Duval, Orange, and Palm Beach through CDC Prevention Cooperative Agreement grant funds. The state also supports five additional community-based HIV Peer Navigator programs through the CDC High Impact Prevention Grant.
New York State’s Department of Health AIDS Institute considers improving HIV care outcomes as its highest priority in its current state priorities action plan and has dedicated funding to support this. The AIDS Institute operates with state general fund appropriations as well as Ryan White funding, and supports the state’s HIV peer worker program using a combination of these resources. Allocated funding goes towards training and continuing education requirements, as well as maintaining the academic center that awards peer worker certification and oversees applications. The AIDS Institute also encourages entities that are funded to provide HIV prevention and care services to employ HIV peer workers using state and federal funds.
Wisconsin uses rebates and savings from medication purchasing to support its program. Leveraging savings from HRSA’s 340B drug pricing program through purchasing medications for the state’s AIDS Drug Assistance Program, Wisconsin funds a grant with Diverse and Resilient, the local nonprofit organization that employs the HIV peer workers in the state.
Core Competencies
States can develop distinct core competencies that HIV peer workers must demonstrate in order to deliver services. The chart below highlights themes across Florida, New York, and Wisconsin’s HIV peer worker programs’ core competencies. While there is consistency across state requirements, each program requires a unique set of core competencies that emphasize client connection as a necessary function of the client-peer relationship. For example, Wisconsin’s HIV peer navigators are encouraged to share harm reduction information and resources with clients, while New York peers may refer clients to syringe exchange and other harm reduction services. The shared experience between a peer and a client can support access to services, including treatment for substance use disorder (SUD) and harm reduction services.
| Core Competency Themes | NY | FL | WI |
| Lived experience with HIV/AIDS, including effective disease management and self-care strategies | X | X | X |
| Relates to clients via shared lived experience, despite the differences that may exist between them; ability to strategically and comfortably share personal experience and HIV status | X | ||
| Demonstrates strong and effective communication skills; communicates using a person-centered approach | X | X | X |
| Ability to self-advocate, advocate for others, and advocate for access to services | X | X | |
| Understands own personal and cultural identity and how these influence personal attitudes, reactions, and assumptions; develops awareness of and manages own personal biases and triggers | X | X | |
| Ability to address health literacy needs | X | ||
| Ability to embrace and communicate a self-affirming empowering attitude | X | X | |
| Trauma informed, person-centered approach | X | X | |
| Upholds agency confidentiality policies and procedures | X | X | |
| Recognizes own vulnerabilities and emotional responses to work-related matters; employs self-care strategies to promote wellness and prevent burnout | X | ||
| Recognizes knowledge limits and seeks supervisor assistance, opportunities to increase knowledge and peer support skills | X |
Program management
As non-licensed staff, HIV peer workers do not need to meet accreditation-based clinical supervision requirements under most state models. Instead, HIV peer workers work with other program staff to ensure that specific program protocols and processes are met through operational direction and oversight. In Wisconsin, a licensed physician, nurse practitioner, or physician assistant with HIV clinical care experience must provide medical oversight of the HIV peer workers, but HIV peer workers do not operate under their supervision. HIV peer navigators must meet one-on-one with their program manager at least once a week; these meetings allow for discrete conversations concerning job performance, questions, or issues that arise, as well as opportunity for regular feedback, informal check-ins, and casework development. Florida’s HIV program supervisors regularly assess each peer’s performance and recommend opportunities to improve, as well as request feedback from clients about HIV peer workers’ performance. The Florida Department of Health offers responsive technical assistance to HIV peer worker supervisors who are receiving poor feedback. New York State HIV peer workers must pass an exam and must complete a 500-hour supervised practicum with an agency providing relevant services, during which the supervisor gives regular feedback and completes an evaluation. HIV peer workers are assessed based on the core competencies enumerated in the table above, and ten HIV-specific core competencies. HIV peer worker supervisors are not required to be licensed, certified, or hold an advanced degree, but they are provided with HIV peer worker supervisor training and guidance resources.
Key steps for states
Support HIV peer workers through programmatic oversight. The nature of peer work can create unique challenges and successes. For programs in which HIV peer workers are not operating under the licensure of another professional, states can provide program-driven protocols and programmatic oversight in order to support the professional needs of this workforce.
Acknowledgements
This fact sheet was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award under the National Organizations of State and Local Officials (NOSLO) cooperative agreement totaling $836,859.00. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov. The authors would like to thank HRSA project officer Diba Rab and her colleagues for their guidance and helpful feedback, as well as policy leaders from Florida, New York, and Wisconsin for their time and insight.
