ORIGINAL ARTICLE ‘‘Positive Examples’’: A Bottom-Up Approach to Identifying Best Practices in HIV Care and Treatment Based on the Experiences of Peer Educators Marcia Veronika Dutcher, M.A., 1 Sheila Noely Phicil, M.P.H., 2 Sarah B. Goldenkranz, M.P.H., 3 Serena Rajabiun, M.A., M.P.H., 2 Julie Franks, Ph.D., 4 Brenda S. Loscher, Ph.D., 5 and Natabhona Marianne Mabachi, Ph.D. 6 Abstract Literature describing the roles and activities of peers working in HIV care is limited. Evaluations of the impact of peer-based behavior-change interventions reveal mixed results, due in part to varied program aims, structure, evaluation mechanisms, and training. Peers themselves are important resources to address these concerns and lay the groundwork for developing improved programs and evaluation strategies. This qualitative article de- scribes peer support in HIV care and treatment from the perspective of 23 HIV-positive peers across the United States. Peers reported that peer characteristics (HIV-status, common experiences, and self-care) enable them to engage clients. Peers also required flexibility to respond to client needs, and their activities spanned four types of social support: informational, emotional, instrumental, and affiliational. We recommend peer programs and evaluations accommodate the broad scope of peer work by acknowledging the need for flexibility and activities that are not always directly related to clients’ HIV care and treatment. Introduction F or over 30 years, a growing body of literature has de- scribed and systematically assessed the effectiveness of community-based peer services in assisting people with a variety of health needs. Evidence suggests that peers can positively impact patient access to care services, social sup- port, involvement in self-care activities and self-efficacy. Peers may also contribute to cost effectiveness. However, a recent meta-analysis of the impact of peer-based interventions on changing health-related behaviors in adults concluded that results have been mixed. 1 Diverse results of experimental peer interventions are challenging to interpret, in part because most published reports do not include a full description of peer activities’ reach and dose. 2 In addition, a full description of the skills and qualifications of peers would improve un- derstandings among funders, peers, and other project work- ers regarding the specific roles of peers as part of care and treatment programs. 3 Recent articles describing in detail the implementation of peer interventions to support HIV services represent an important advance toward understanding the factors that contribute to the effectiveness of peer-based support for health care. 4–7 An important and underutilized resource to address peer activities and identify consistent evaluation criteria is the col- lection of experienced peers currently working in the field of HIV care and treatment across the United States. A logical ‘‘bottom-up’’ approach, in which experienced peers describe the roles, activities, strategies, and elements they identify as important to their success, will help to better define peer roles. This approach may also be the first step in identifying best practices on which to model programs and structure evalua- tions. Although peer-based interventions vary, the underlying rationale for using peers is that peers share common charac- teristics with the target community 8 that enable them to offer support, encouragement, hope and mentorship to clients. 9 The 1 St. Louis Area Chapter American Red Cross, Health and Safety Services, St. Louis, Missouri. 2 Boston University School of Public Health, Health and Disability Working Group, Boston, Massachusetts. 3 Center for Health Training, Seattle, Washington. 4 ICAP Mailman School of Public Health, Columbia University, New York, New York. 5 Kansas City Free Health Clinic, Kansas City, Missouri. 6 University of Kansas Medical Center, Department of Family Medicine, Kansas City, Kansas. AIDS PATIENT CARE and STDs Volume 25, Number X, 2011 ª Mary Ann Liebert, Inc. DOI: 10.1089/apc.2010.0388 1