September, 2010 - SUPPORT Summary of a systematic review | print this article |

Is peer education an effective method for HIV prevention in low- and middle-income countries?

Peer education uses individuals to convey specific information, awareness or behaviours to members of a peer or target group. Peer educators must share common key characteristics with those being targeted, but may either come from inside or outside it. This transmission of information to others is used to inform and influence the decisions taken – and thus the health behaviours – within the targeted communities. Prior to an intervention, peer educators are given appropriate training. Peer education is a widely used strategy to disseminate information on sexually transmitted infections (STIs), in low- and middle-income (LMIC) countries. It has been argued that peer education empowers both the peer educator and the target group, and is more cost effective than interventions that rely on professional staff.

Key messages


  • Peer education may improve knowledge about HIV and about condom use in all target groups except amongst transport workers
  • Peer education may reduce the sharing of drug injection equipment
  • We are very uncertain whether the use of peer education is associated with an increase in STI infections rates in transport workers
  • There is limited evidence regarding different approaches for recruiting, training and supervising, compensating and retain-ing peer educators


Peer education uses individuals who share key characteristics with members of a target group to convey specific information, awareness or behaviours. Peer educators receive training related to the issue about which the are asked to educate others. Such educational interventions are based on the assumption that peers exert a strong influence on individual knowledge and behaviour. In certain instances, peers are seen as more ‘acceptable’ than outside professionals, particularly if sensitive topics are being discussed. Peer education can also help to gain better access to hard-to-reach populations. Such advantages make peer education a preferred tool in HIV-prevention interventions, and it is often used to spread knowledge about STIs, raise risk awareness, and promote safe sex strategies, particularly the use of condoms.

This review on the impact of peer education on HIV/AIDS-related outcomes is one of a series of systematic reviews on behavioral interventions for HIV prevention in LMICs.

About the systematic review underlying this summary

Review Objectives: To assess the effect of peer-education interventions on HIV knowledge, sharing of drug injection equipment, condom use, and STI infection in developing country settings.
/What the review authors searched forWhat the review authors found
Interventions Peer education (the sharing of information by a peer in small groups or one-to-one)

30 studies including:

  • 3 randomised controlled trials
  • 14 cross-sectional studies
  • 10 before-and-after studies
  • 3 non-randomised controlled trials
Participants No restrictions

8 studies among youth
12 studies among commercial sex workers
4 studies among injection drug users
3 studies among transport workers
6 studies among heterosexual adults
2 studies among people in jail
1 study among miners

Settings Developing country (according to The World Bank)

13 studies from sub-Saharan Africa
10 studies from East and Southeast Asia
5 studies from Central Asia
2 studies from Latin America and the Caribbean


Behavioural, psychological, social, care, or biological outcome(s) related to HIV pre-vention

26 studies assessed HIV knowledge1
6 studies assessed drug injection equipment sharing2
29 studies assessed condom use3
11 studies assessed STI infection4

Date of most recent search: November 2006
Limitations: This systematic review has important limitations.5 
1.Only peer-reviewed journal articles were considered. 
2.There were differences between studies with regard to outcome definition. 
The average effect size was calculated if articles reported different measures for the same outcome (e.g. condom use). In such instances, a stratified analysis was undertaken (e.g. condom use by partner type and target popula-tion). However, this approach did not address the fact that the time window in which measurements were taken might also be important and might therefore mask important differences.

1 The outcome “HIV knowledge” included variables measuring correct and incorrect information about modes of HIV transmission and prevention.

2 The outcome “injection drug equipment sharing” included reported episodes of shared needles/syringes, rinse water, and/or cookers.

3 The outcome “condom use” referred to the proportion of respondents who either (a) did or did not use condoms or (b) did or did not have unprotected sex.

4 The outcome “STI infection” included STI incidence, current prevalence, and lifetime prevalence, and was measured through self-reporting, chart reviews, and clinical diagnoses.

5 In addition to the listed limitations identified using the GRADE process, the following items should be considered:

- A numerical score measuring rigour was developed for the review. However, equal weighting was given to, on one hand, a study which had used pre- and post-test measures and a random selection of subjects for its assessment and, on the other, a study that had used control groups and random allocation. The latter group, we contend, was more important. In the meta-analysis, estimates from studies of varying rigour appeared to have been pooled and the rigour score did not seem to have been applied.- It would have been better to define the inclusion criteria and to undertake a meta-analysis of the findings from the included studies, possibly using a sensitivity analysis with more/less strict inclusion criteria.

Medley A, Kennedy C, O’Reilly K, Sweat M. Effectiveness of peer education interventions for HIV prevention in developing countries: a systematic review and meta-analysis. AIDS Educ Prev 2009;21:181-206.

Summary of findings

Thirty studies were conducted among different population subgroups including youth, commercial sex workers, drug injection users, transport workers, heterosexual adults, prisoners, and miners. The studies were conducted in sub Saharan Africa, and studies were also reported in Asia, Latin America, and the Caribbean. Three of the studies included were randomised controlled trials (3 studies reported outcomes on levels of HIV knowledge, and 3 on condom use). The others were mostly cross-sectional and uncontrolled before and after studies. HIV knowledge, drug injection equipment use, condom use, and STI infection were considered as outcomes.

Different implementation issues such as recruiting, training and supervision, compensation and the retention of peer-educators were reported in a subset of the studies. The described recruitment and training and supervision strategies were generally successful, and most programmes paid a small compensation fee to peer educators. Peer educator retention rates were reported to be low in most studies. However, this information appeared to be anecdotal and not collected systematically during process evaluations.

  • Peer education may improve knowledge about condom use and HIV in all target groups except amongst transport workers
  • Peer education may reduce the sharing of drug injection equipment
  • We are very uncertain whether the use of peer education is associated with an increase in STI infections rates in transport workers
  • There is limited evidence regarding different approaches for recruiting, training and supervising, compensating and retaining peer educators
Outcomes Impact No of Participants
Quality of the evidence
HIV knowledge

Across target groups:

- Knowledge about HIV increased:

OR 2.28; 95% CI 1.88, 2.75

Stratified by target group:

- Significantly increased (p<0.05) among all target groups, except transport workers

(18 of 26 studies)

Injection drug equipment sharing

Sharing of drug injection equipment reduced:

OR 0.37; 95% CI 0.20, 0.67

(4 of 6 studies)


Condom use


Across target groups:

- Condom use increased:

OR 1.92; 95% CI 1.59, 2.33 (all partners)

- Condom use increased:

OR 1.94; 95% CI 1.27, 2.94 (regular partners)

- Condom use increased:

OR 2.23; 95% CI 1.70, 3.09 (casual partners)

Stratified by target group:

- Condom use significantly increased (p<0.05) among all target groups except youth and adolescents

(19 of 29 studies)

STI infection

Across target groups: uncertain whether STI infection rates increased:

OR 1.22; 95% CI 0.88, 1.71 (p>0.05)

Stratified by target group:

- STI infection rates significantly increased (p<0.05) among transport workers

(OR 1.95; 95% CI 1.45, 2.62)

(7 of 11 studies)

p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

  • All the studies included were conducted in LMICs.
  • The study findings were not analysed in terms of the size of the effect, or the regions, economic situations, or socio political systems in which they were conducted
  • In some countries, interventions targeting certain groups may be difficult to implement (see ‘Equity’ section below).
  • All the studies focused on a specific group.
  • The review did not examine the effects of peer education interventions on specific ethnic, religious and sexual minorities.
  • The prevailing socio-political system of a country impacts on the visibility and accessibility of specific target groups such as ethnic, religious and sexual minorities, illegal drug users, etc. Such differences probably impact on the feasibility and effectiveness of interventions targeted to such groups.
  • The review did not provide information on absolute costs or cost-effectiveness.
  • Peer education is assumed to be more cost-effective than other interventions. However, very little information about cost-effectiveness was provided.
  • The effect of payments for peer educators on intervention effects is unknown.
  • Considerable financial and human resources are required to sustain peer education programmes due to high rates of peer turnover, supervision requirements etc.
  • It is unclear whether peer education interventions could lead to cost savings through reductions in levels of STI infections.
  • The quality of evidence on the effects of peer education interventions on behavioural outcomes is low.
  • The quality of evidence on the effects of peer education interventions on biological outcomes is very low.
  • In high-income countries it is not possible to assume that peer education interventions that are effective in particular settings will work in others.
  • Any extension of peer education interventions to additional target groups (e.g. ethnic, religious and sexual minorities) should be monitored and evaluated.
  • Further evaluations of the effectiveness of biological outcomes are needed.
  • There is a need for process evaluations of how context influences implementation.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low- and middle-income countries. For additional details about how these judgements were made see:

Additional information

Related literature

Campbell C, Mzaidume Z. Grassroots participation, peer education, and HIV pre-vention by sex workers in South Africa. American Journal of Public Health 2001, 91(12): 1978-1986.

Campbell C, MacPhail C. Peer education, gender and the development of critical consciousness: Participatory HIV prevention by South African youth. Social Science and Medicine 2002; 55(2):331-345.

Hutton G, Wyss K, N’Diekhor Y. Prioritization of prevention activities to combat the spread of HIV/AIDS in resource constrained settings: a cost-effectiveness analysis from Chad, Central Africa. International Journal of Health Planning and Management2003; 18(2): 117-36.

Population Council. Peer Education and HIV/AIDS: Past Experience, Future Directions. 2002. Available at:

Strange V, Forrest S, Oakley A. Peer-led sex education - characteristics of peer educators and their perceptions of the impact on them of participation in a peer education programme. Health Educ Res 2002; 17(3):327-37.


This summary was prepared by

Peter Steinmann, Swiss Tropical and Public Health Institute, Switzerland


Conflict of interest

None declared. For details, see:



This summary has been peer reviewed by: Caitlin Kennedy, US; Michael Sweat, US;

Kevin O’Reilly, Switzerland; Chris Bonell, UK


This summary should be cited as

Steinmann P. Is peer education effective for HIV prevention in low- and middle-income countries (LMICs)? A SUPPORT Summary of a systematic review. Sep-tember 2010.