Psychosocial and Health-Related Behavioral Outcomes of a Work Readiness HIV Peer Worker Training Program

{"Background": "People living with HIV (PLHIV) face significant social and economic challenges including poverty, discrimination, unstable housing, and unemployment. Despite medical advancements transforming HIV from a terminal to a chronic illness, the employment rate among PLHIV in 2019 was estimated at 48.6% compared to 63.1% in the general population. Peer workers\u2014individuals with lived experience who work in healthcare or social service settings\u2014play an important role in HIV prevention and treatment, yet outcomes related to HIV peer worker training have not been well studied. Employment is recognized as a critical social determinant of health, associated with improved HIV continuum of care outcomes including medication adherence, retention in care, and quality of life. This study aimed to assess whether participation in a work readiness peer worker training and internship program produced significant changes in psychosocial outcomes (depression, internalized HIV stigma, self-esteem) and health-related behavioral outcomes (medication adherence, patient self-advocacy, safer sex communication apprehension).", "Methods": "This retrospective secondary data analysis evaluated a New York City-based peer worker training program (PREP) conducted from September 2014 through December 2018 across nine cohorts. The training was an eight-week program held three days per week (10am-4pm) focusing on work readiness skills, HIV service skills, and self-management. Eligible participants had to be HIV-positive, medically adherent, stably housed, and in recovery from drugs and alcohol for at least nine months. After training, participants could apply for a six-month paid peer internship (10-20 hours/week at $15/hour). Surveys were administered at three time points: baseline (first day of training), training completion (final day), and internship completion (sixth month). A total of 259 individuals completed baseline surveys; 137 completed baseline and training follow-up; 55 completed all three time points. Measures included: depression (PHQ-9 for cohorts 3-9, BDI for cohorts 1-2), internalized HIV stigma (ISAT, 10-item scale, range 5-50), self-esteem (Rosenberg Self-Esteem Scale, range 1-40), HIV medication adherence (ACTG adherence questionnaire, normed 0-100), safer sex communication apprehension (5-item subscale, range 5-30), and patient self-advocacy (12-item scale, range 5-60). Paired t-tests were used to assess individual-level score changes between time points. Chi-square and ANOVA tests assessed baseline group differences.", "Key Results": "At baseline, participants had a mean age of 44.6 years; 56.37% identified as male, 37.45% female, and 6.18% as transgender; 83.14% had at least a high school education; 94.51% were persons of color (61.57% Black/African American); 83.81% had undetectable viral loads; 50.6% had been living with HIV for over 15 years; and 59.8% had last worked within the past 5 years. For the full training completion group (n=137), paired t-tests showed significant score decreases in depression (PHQ-9) and internalized HIV stigma, and significant score increases in self-esteem, patient advocacy, and medication adherence between baseline and training completion (p<0.05). No significant change was found for the Beck's Depression Inventory or safer sex communication apprehension. When stratified by program participation, non-internship participants showed no significant changes in health-related behavioral outcomes, while internship participants showed significant increases in patient advocacy and medication adherence and significant decreases in safer sex communication apprehension (p<0.05). Among internship participants (n=55) across all three time points: depression (PHQ-9) and internalized HIV stigma significantly decreased between baseline and training completion and between baseline and internship completion (but not between training and internship completion); self-esteem significantly increased only between baseline and internship completion; medication adherence significantly increased between baseline and training completion only; patient self-advocacy significantly increased between baseline and training completion and between baseline and internship completion; safer sex communication apprehension significantly decreased between baseline and training completion and between baseline and internship completion.", "Clinical Implications": "This study demonstrates that peer worker training programs can serve dual purposes: preparing PLHIV for employment while simultaneously improving psychosocial and health outcomes. The significant reductions in depression and internalized HIV stigma, coupled with improvements in self-esteem, medication adherence, and patient self-advocacy, suggest that structured work readiness programs may be effective structural interventions for addressing social determinants of health among PLHIV. The finding that medication adherence improved despite already high baseline levels (average 88.9%) is notable, as employed PLHIV have been shown to have 27% higher odds of achieving medication adherence compared to unemployed PLHIV. The maintenance of improvements through the six-month internship suggests sustained benefits. Given that fewer than a dozen evaluated work readiness programs for PLHIV have been published since HAART became available, this study addresses a critical gap in the literature. The authors recommend expanding peer income disregard policies (such as New York State's OTDA policy allowing peers to earn wages while maintaining benefits) to other states, and creating similar allowances for SSI recipients. Future research should employ longitudinal designs with comparison groups to better understand long-term outcomes including paid employment and quality of life."}