Youth-to-Youth–Peer Workers in HIV/AIDS Youth Programs: A Peer Development Guide

Involving youth peers in the development and provision of HIV prevention and care programs for adolescents requires that non-peer adult staff play a vital role in ensuring the safety and personal growth of youth staff. With the proper environment, training (of peer and non-peer staff), and communication and organizational systems, youth and adult staff can be equal partners in the design and delivery of successful HIV services targeting young people.

Bay Area Young Positives, Health Initiatives for Youth, and Walden House – three programs based in San Francisco – and YouthCare, a Seattle-based program, utilize the support of peer staff in many different ways. This section discusses lessons learned among each of these programs based on their experiences working with and supporting peer staff. Additionally, each program offers practical tips about supporting youth in the workplace that can be implemented in a broad variety of programs targeting young people.

There are many ways to support young people at an agency whose primary purpose is to provide peer support. The following section provides a guide to facilitating peer staff development and support. Four areas are discussed: (1) supervision, (2) clinical support, (3) training, and (4) making the transition from client or program participant to staff member.

1. Supervision: Set Up Regular Supervision Meetings with Your Employee. The supervision meeting allows the supervisor the opportunity to discuss employee projects and progress in meeting goals as well as to assist the employee in problem solving. Regularly scheduled meetings provide consistency and feedback so employees will know what is expected of them. In turn, this will give them a sense of stability and allow them to feel safe in their job. Positive feedback is important since an employee who hears only negative feedback may become demoralized. A supervisor may express appropriate interest in employees’ lives outside of the agency. This can create a more personal approach to supervising. In addition to allowing time and space for staff to discuss matters and receive feedback, it is also important as a supervisor to be receptive of the same process. Employees should know that it is important for them to give constructive feedback to their supervisor.

        Successful youth programming requires time and resources. Support and supervision of peer staff is an extremely
        time-intensive enterprise and should include the following tenets:

• A support system that promotes growth. Pair new peer staff with other staff to help foster this process. Match the young person up with a mentor within the agency or a community partner.

• Skills assessment and staff development plan. Develop tools to properly assess the staff’s strengths and weaknesses. Coordinate individual development plans for peer staff based on their needs and career objectives.

• Allow for mistakes as learning tools. Create a safe space to promote risk taking and experimentation within the workplace. Consistent supervision and coaching will allow peer staff to grow in a structured environment with constructive feedback and support.

• Establish boundaries and ensure accountability. An employee handbook should outline a standard set of ground rules for all staff to sustain the best possible professional environment. Adapt the policies to meet the needs of younger staff, such as offering a flexible, yet consistent, plan that promotes wellness.

2. Clinical Support. Clinical support is a type of support group for peer workers that is provided by a licensed professional consultant. The consultant provides support to the staff on personal issues that may arise while working with their peers. Issues for consideration may include how peer workers are affected by the results of their counseling and how they can do their job more effectively when supporting their peers. Minimally, meeting once a week for 90 minutes is suggested. The goal of this meeting should be to allow peer workers to discuss personal issues that arise related to the work they are doing. Subject matter can vary from how peer workers may be attracted to the person they are counseling to the peers not liking the client. Difficult subject matter should be discussed in these meetings in a non-judgmental style. These meetings should entail a discussion of any issue that may help the peer employee to better perform his/her job tasks, such as how to establish boundaries with peers.

3. Training. Providing training is a necessary part of developing young people. Training activities will reflect the needs of the young person and the agency. It is important to assess knowledge and skills of the person hired in areas such as phone skills, typing, faxing, copying, and basic computer operation. Training staff in these areas can increase productivity. Some types of training that may be offered include:

• Peer Counselor Training. Topics may include active listening, transference and counter-transference, difficult behaviors, crisis and suicide intervention and prevention, and chart noting and/or data entry.

• Facilitation Training. This includes many of the same topics covered in Peer Counselor Training, but may require more emphasis on active listening and working. Facilitation gives an opportunity for a young person to gain valuable skills to use when presenting to a group or facilitating his/her own group.

• Advocacy Training. Speaking at public events and/or political events.

• Treatment and Health Issues. This may range from the latest drug treatment therapies to basic knowledge of HIV/AIDS.

• Diversity Training. Serving and working with diverse staff and clients is challenging and may require specific exercises and discussions to exchange ideas and establish guidelines around individual and group identity issues.

• Peers Training Peers. Once peers are trained, they can in turn train others. This is an excellent way of leading and empowering young people.

4. The Transition from Client to Staff Member. The transition from client to staff member occurs when a person who is receiving support services by an agency is ready to give support to their peers. This process is a transition from "provided to provider," and requires a close look when considering adding peer support at an agency. This transition is inevitable at an agency that provides peer support. Utilizing youth workers may require hiring from the population being served. With this process comes transition.

There are many points to keep in mind when this transition occurs. The first step is recognizing that the peer does not need the support of the agency and is ready to provide services. With this transition, they will lose some of the services provided to them in the past. As they transition, new boundaries will have to be established for the peer in their new role as provider. There is a natural hierarchy between the one who receives support and the one who gives support. The person who gives support has to keep in mind that there are boundaries that need to be created to give ethical and professional support. The re-defining of these boundaries should be addressed during clinical consultation, during which time the peer workers will also gain valuable support from their new peer group, "the staff."

When a peer staff person is promoted into management, he/she will encounter many different obstacles. New boundaries have to be established with the staff he/she was once a part of and are now supervising. There will be more tasks and responsibilities, and he/she may have the ability to hire and fire employees.

Many agencies reach a point where their programs have gotten too big for current staff to handle, or their members or clients have demonstrated a need that current agency staff are unable to fill. At this point, it is necessary to evaluate the need for a new position. This process involves three basic steps.

Step One: Define Service Gaps. The first step consists of defining the gaps in the services the agency is providing, such as: (1) Is there a counselor available when clients most need one? (2) Are referrals to emergency housing being handled adequately? (3) Do female clients or members have enough support in the agency?

Step Two: Evaluate Existing Positions. Once the gaps in services have been identified, the second part of the process involves evaluating existing positions and job descriptions. The purpose of this is to see if it is appropriate for any staff person to expand his or her position to include new duties. An example would be an agency employing two peer counselors to plan events and counsel clients that have experienced a huge drop-off in the number of young women attending events and/or accessing services. One way to address this issue might be to put one of the peer counselors in charge of creating and implementing an assessment and outreach plan to reach young women. Once the decision is made to create a new position, a job description must be created.

Step Three: Define Job Parameters and Qualifications. Creating a job description is a two-part process that includes defining the parameters of the job and developing the specific qualifications an applicant must have to apply for the position. Defining the parameters of the job works well as a brainstorming process. Including staff in this process will help to ensure staff support of the new position. Several questions will need to be addressed. How does this position fit into the agency? Who will work closely with this position? Who will supervise this position? Will this be a supervisory position? What kind of training will this person need about the specifics of his or her job, as well as the standard training for the agency?

Once written, it is important to distribute the job announcement to populations harboring the skills and characteristics defined in the job description. In addition to non-profit publications, youth agencies, community-based agencies that have youth or childcare programs, high schools, local colleges, and community newspapers are appropriate targets for distribution. And, of course, the job description must be published in the recruiting agency’s own newsletter, on its web site, and in other agency publications. Perhaps the most essential recruiting tool is word of mouth.

Once the position has been thoughtfully developed, the main task at hand is to advertise the opening to a pool of eager and qualified young candidates. The following guidelines may be used in the process of recruiting for a peer position.

• Circulate Position Opening Where Youth Will See It! Recruiting youth to apply for a position is often challenging due to their inability to access traditional means of employment opportunity resources, such as newspapers, employment centers, and the Internet. In order to inform youth of a position opening, utilize resources that young people access, such as youth centers and other youth-related programs, youth magazines and publications, coffee shops, and other settings where youth are commonly found.

• Position Description Must Have Youth Appeal! Age and culturally appropriate marketing is the key to attracting a broad pool of candidates. Youth typically respond to catchy flyers and posters more commonly than to dense, small point face agency position descriptions. Convert the original position description into a flyer, with large bold font, highlighting the relevant information, including hourly wage, position title, key responsibilities, and job requirements. This is a practical way to get a young candidate’s attention.

• Word of Mouth is a Sure Bet! One of the best ways to disseminate information about a position opening is via word of mouth. Phone other people within your network of providers and urge them to inform youth staff working with them and/or participants of their programs about the available staff position. Arrange to deliver a brief announcement at another agency’s staff meeting or youth group to spread the word about a position opening. Personal referrals often validate the candidates’ qualifications simply due to the fact that individuals within your peer network have endorsed them. But remember never to rule out a candidate because he/she does not have a personal reference that you know.

A traditional and effective means of coordinating an application process is to request that all candidates submit a resume highlighting their experience and a one-page cover letter outlining why they are interested in the position. This information should, of course, be included in your job announcement with a deadline for application submission. Alternative application processes can definitely be used, particularly with youth who may not have a resume or access to a computer. However, all applicants should be expected to provide you with some form of documentation that highlights their qualifications and experience.

Identifying a core set of criteria for selecting candidates is essential to the ultimate outcome of the hiring process. Following are some useful candidate selection tips:

• The criteria used for candidate selection should be directly related to the position’s key responsibilities and requirements. In identifying criteria, the following questions may be helpful:

1. What skills will the individual need to best carry out the given responsibilities of the job?

2. What kind and how much relevant work and/or field experience will the individual need in order to succeed?

3. What special skills and/or unique perspectives and experiences should the final candidate possess?

4. How old should the individual be?

5. Who will the individual be working with both inside and outside of the agency (staff vs. clients)?

6. What, if any, outside responsibilities does the candidate have that may interfere with the job?

7. What type of a work schedule will be required of the individual?

8. Will the individual need to have strong trouble-shooting skills?

9. Should the individual have past experience working within a team environment?

• Upon answering the above questions, a clear set of criteria for the position will need to be prioritized based on key responsibilities.

• It may be useful to rank individuals around a consistent set of criteria (from 1-3). This scoring system can be used to select an initial set of candidates to interview. Candidates who score threes on all of the criteria will be considered for an interview and candidates who score zeroes most likely will not be considered. Common criteria to rank a candidate’s qualification are work and/or life experience, education and training, related skills, and cultural competency. These numerical scores should only be used as guidelines and do not necessarily reflect a final decision.

• Never hire a candidate based solely on one criterion, but rather on a balance of all requirements of the position.

• Never hire a candidate based solely on specific demographic characteristics, such as ethnicity, age, gender, HIV status, or sexual background. Diversity in the workplace will enhance your programs; however, the above characteristics should never override an individual’s overall qualifications for a job, but rather they should complement them.

• One to two staff members should take the lead on coordinating the selection process while drawing input from other staff working within the program. No more than five people should be in charge of selecting the initial candidates to be interviewed. However, more staff can be involved in identifying the core criteria for the position.

• How many candidates should be interviewed for the position? This depends on how much time the recruiting agency has and the size of the selection pool. Between three and eight candidates is typical for interview selection.

As an example, in Figure 1 above, Candidates A and D would be invited back for an interview. It would seem logical to consider Candidates E and F as well, but again, the numbers should be used as a tool to guide the decision process and not necessarily an indication of a final choice.

Once the interview candidates have been selected, the next step will be to coordinate the interview process. This process can be divided into three basic tasks: (1) designing the perfect interview, (2) interview logistics coordination, and (3) the interview.

1. Designing the Perfect Interview. A lot of thought and consideration should be devoted towards the development of the interview structure.

• Establish a specific set of outcomes for the interview to guide the development of questions.

• The responses to the questions should reflect both the criteria of the position and the desired outcomes of the interview.

• A standard interview lasts anywhere between one half hour to 45 minutes. At least 10 minutes should be given to the candidate to ask questions about the position.

• Be creative with questions. There is a limited amount of time to capture a large amount of information.

Following are examples of interview questions:

• Motivation: Give me some examples of job or volunteer experiences that were satisfying and rewarding to you. In what situations did you find yourself working the hardest?

• Goal Setting: What do you hope to gain personally from this position? If you could write your own job description, what would it include? If you were to work here, what types of development and training opportunities would you like?

• Planning and Organization: How do you determine your daily priorities? How do you coordinate your priorities with those of others?

• Problem Solving: Describe a significant problem you faced within the last six months. How did you handle it?

• Flexibility and Tolerance of Ambiguity: Describe a situation you have worked in where there were rapidly changing priorities. How did you adapt? How did you feel about it?

• Creativity: Give me examples of when you have solved problems in new ways.

• Initiative: What projects have you initiated on your own during the past year?

• Interpersonal Issues: With what types of people do you work best? Who do you have the most difficulty working with? What kinds of people frustrate you the most?

• Position Fits: What aspects of this job do you find most attractive? What special skills or qualifications do you possess that make you the best candidate for this job?

• Cultural Competence: What experience(s) have you had working in an environment with many different kinds of people varying in age, gender, race, sexual orientation, and ethnicity?

• Self-Confidence: What things do you do better than most people? What are you proudest of? What natural abilities do you have?

Be sure to ask the same set of questions to all of the candidates. To do otherwise is unfair and against the law.

2. Interview Logistics Coordination. Guidelines for coordinating interviews with candidates:

• Establish a realistic timeline. Interview processes, particularly for youth, often take more time and energy to coordinate.

• Interview no more than four to five candidates in one day. Interviews are often tiring, and the judgment of a candidate shouldn’t be swayed because interviewers are burned out during the interview.

• Always notify the candidates about the decision shortly after the interview. People often coordinate a first and second round of interviews to narrow down the selection process.

3. The Interview. The following tips should help facilitate a successful interview with a young person:

• Establish a comfortable, youth-friendly environment for the candidate. Make them feel safe. This environment should be maintained not only for all youth candidates, but other youth staff, program clients, and members.

• Open the interview by describing the position in further detail–give an overview of the program’s history and mission.

• Be clear about the position and make sure the candidate understands as well. Ask him/her to tell you what they believe to be the major job responsibilities.

• Interview the candidates with one to two co-workers. Allow 15 minutes after each interview to process thoughts and/or concerns.

• Take notes during all interviews. In the process of making a final decision these documented references will be useful.

• Communicate the hiring timeline to the candidates.

• Be as objective as possible. Base decisions on skills and experiences, not personality (although, a gut feeling about the individual is very important).

• Have the candidates provide personal references.

• Be sure to rehearse introductions and interview questions with the panel of interviewers prior to the actual event. Always be prepared.

Always be sure to incorporate the input of other staff in your decision making process. Two to three people should be given the lead to coordinate the hiring process in accordance with your agency’s administrative policy. Additional staff persons are often included in second round interviews.

Once hired, there are several issues to consider in welcoming the new peer to the work environment. To ensure peer staff understand the program’s organizational structure, working environment, policies, procedures, and benefits, all new staff should receive a formal orientation session conducted by a designated staff member. New employees should receive an introduction to program policies and practices, an explanation of applicable benefit programs, instruction in completing necessary employment and benefit forms, an employment handbook, a copy of their job description, the program’s organizational chart, and a copy of the program’s mission statement. New staff should sign an acknowledgment that they have received the employee handbook.

On their first day of work, the new employee’s supervisor should acquaint the employee with coworkers and explain job content and duties, performance requirements and standards, working conditions, and pertinent rules and policies.

A successful program should have all policies and guidelines (detailed in the employee’s orientation) documented in a comprehensive employment handbook. Good handbooks are user-friendly, clearly-defined and should include, but not be limited to, the policies outlined in Table 2.

In order to preserve the integrity of programs and services, as well as to maintain a safe work environment for peer staff, an agency should strictly maintain a comprehensive confidentiality policy. Below is an example of what should be included.

During the course of employment with an agency, employees may learn certain facts about coworkers, volunteers, and participants that are of a highly personal and confidential nature. Examples of such information are:

• physical and mental health condition

• medical treatment

• finances

• living arrangements

• employment status

• work performance

• sexual orientation

• drug use and/or abuse history

• relations with loved ones

• criminal history

Employees may not disclose any information as described in the above paragraph to anyone not employed by the agency without the specific consent of the person or people involved.

In communicating personal and confidential information about coworkers, volunteers, and participants, staff should make every effort to be aware of and sensitive to the confidence and trust placed with them in receiving that information.

If, at any time, employees are uncertain of whether or not information is confidential, it is their responsibility to review the information with the person or people to whom it directly relates, and/or seek clarification and guidance from the agency’s Executive Director.

Walden House’s Young Adult HIV (YAH) Project serves multi-diagnosed young adults and adolescents between the ages of 13 and 25 years old. These young people are in residential treatment for substance abuse disorders and are either living with, or at high risk for acquiring HIV. Many have co-occurring psychiatric diagnoses. For those individuals not already living with HIV disease, histories of drug abuse, unsafe sex and, in some cases, criminal activity and street survival tactics put them at great risk for contracting the HIV virus.

The young people receiving services often deny that they need help or need to change their behaviors. They often resent authority figures or clinicians who insist otherwise. Walden House is continually examining how better to reach these young people and what clinical approaches are most effective. One strategy that YAH has explored is the utilization of peer staff (or youth workers) as a means for reaching the youth community and establishing meaningful linkages to the larger service delivery system.

The main objectives of the YAH project peer staff component are to provide individualized counseling and support to young people living with the virus and to educate high-risk youth not already identified as HIV-positive about HIV/AIDS, its relation to other high-risk activities, and risk-reduction methods.

For the peer workers employed at Walden House, training is provided on counseling and intervention techniques, HIV/AIDS (including pre- and post-test counseling), substance abuse, and assorted behavioral health issues. As new training is offered, the peer workers continue to refine their skills. The 150 different HIV/AIDS organizations in San Francisco provide a wonderful pool of expertise for both staff training and client education.

The efficacy of the YAH adult-youth partnership relies not just on training peers, but on sustaining them through effective supervision and practical and emotional support. Providing support in the form of supervision is important when employing peers. In the YAH project, the youth worker and his/her adult supervisor designate a specific time for supervision. This usually consists of about an hour a week of uninterrupted discussion in which both individuals can check in and offer feedback to one another. Specific clients and their issues are considered, as is the evolving relationship between adult supervisors and peer staff.

For adult and youth workers, inter-agency collaboration and coordination is critically important. YAH works closely with many other programs that serve youth in San Francisco. YAH peer staff attend a regular inter-agency collaborative case conference where agency offerings and specific clients are discussed. The meetings serve to educate staff about the programming at other agencies with similar target populations, as well as to promote the best available care for each client. These discussions and the many other ongoing collaborative ventures in which peer staff are involved help build a cooperative, peer-laden human services network that maximizes the breadth and quality of services for young clients.

The peer staff uses health education presentations by service providers and HIV-positive young people as a means of spurring clients’ interest in finding out about their own serostatus. Under the auspices of the YAH program, these guest speakers – most of whom are young themselves – come into the Walden House facilities (the only residential treatment program for adolescents in San Francisco) and talk to the clients about HIV and related high-risk behaviors. The clients receive basic education on anatomy and sexually transmitted diseases for which they are at risk. They are taught diagnostic and prevention methods. Because many of the guest speakers are living with HIV, much of the discussion focuses on what it is like to cope with this disease on a day-to-day basis. When they hear the individual stories, clients start to realize how similar they are to the guests in front of them. Having a diverse group of young people educating the Walden House residents about their lives removes some of the "invulnerability" elements from the clients’ thinking.

For many young clients, this is the first time that they have had open and accurate communication about sexuality. The use of peer workers in this setting eases much of the anxiety and discomfort young people may experience when discussing these issues. The adolescents are encouraged to familiarize themselves with their bodies and take an active role in their health care.

Walden House also employs young people to do HIV pre- and post-test counseling with adolescents and ensure the completion of the testing process. Many of these adolescents have never been educated about HIV. For a significant portion of this population, their only experience with HIV testing has been a blood draw while in custody. These adolescents received no education or counseling, simply a phone number to call for their lab results. Many young people approach YAH peer staff with the same tale of never having made that phone call.

A lack of familiarity with HIV/AIDS, coupled with being at high risk for exposure to the virus, makes the testing process extremely stressful for these clients. YAH’s peer workers serve as a resource for these clients. They are trained to perform risk assessment and pre- and post-test counseling. The period between the blood draw and informing the client of the result is one marked by increases in stress, acting out, etc. During this one-to-two week period, clients look to the program for the support that will sustain them. The peer counselors make themselves easily accessible to the clients.

The staff also facilitates community support. The youth worker helps the adolescent to create a strong support system comprised of clinical staff, as well as family and friends, before embarking on the testing process. While some clients prefer to endure the waiting period on their own, peer staff explain how much easier it can be with the help of fellow residents and staff. Following these discussions, most young people choose to enlist the full resources of the program. This may mean daily sessions with the peer staff, but seeing each client through is the ultimate reward.

Walden House utilizes testing sites at different clinics that cater to young people and provide additional counseling for the client. In many cities, one would be hard-pressed to find even one "adolescent-friendly" clinic. San Francisco residents are lucky because they have a choice of several.

Finally, after receiving the test results, peer staff continue to support the client and explore the implications of the test result. If necessary, staff can provide support with the process of disclosure and help the client access any necessary medical care. Since employing peer workers to facilitate the testing process, Walden House has noticed a greater demand for testing as well as a greater openness towards and awareness of HIV within the adolescent community.

The YAH project provides support and assistance to help youth re-enter society successfully. To give the clients a sense of what it is like to interact socially while sober, monthly outings with the young people are planned. These outings involve dinner, bowling, the movies, etc. We often ask the young people to choose an activity and the youth workers lead these outings. This is also an opportunity for the young clients to learn more about having fun without mood-altering substances. For many of them, this is a new experience. If a client has been shooting dope from adolescence onward, many activities in the "straight" world are new, and their emotional development sadly reflects this. The development of social skills is crucial to the prevention of relapse, and the assistance of peer staff has been invaluable in this area.

These youth will need support with job skills, schooling, money management, and other important life skills. Young adults who graduate from Walden House are often faced with the task of finding a job or returning to school. These are adult responsibilities with which they often have had little experience. Few of these young people have ever learned to manage their own money or maintain a budget. Peer staff help clients devise budgets and continually check in with them to make sure that the budget is being properly maintained. The peer workers at Walden House are responsible for helping young clients create resumes and conduct job searches. These workers can be instrumental in supporting these young people and helping them to develop these life skills, thus facilitating the process of reentry into society as independent adults.

Walden House utilizes numerous peer staff for its young adult HIV program. Peer staff are responsible for various project tasks and employ different methods to accomplish them.

• Health Education. Make recommendations/connections with other agencies/individuals to meet the needs of young clients.

• HIV Testing. Facilitate discussion around uncomfortable topics and support clients through the process from initial risk assessment to post-test counseling.

• Recreational Outlets. Show clients how real (and fun) life can be without drugs through regular social outings.

• Case Management. Peer staff coordinate programming to meet the individual needs of each client (e.g., housing, health care, long-term options).

• Logistical Support. Includes supportive services such as transportation to appointments.

• Development of Life Skills. Help cultivate the life skills (e.g., resumes, job skills, school) of clients who have grown up outside the mainstream, but now need the skills to reintegrate themselves into society.

• Outreach. Familiarize agency staff with the target population, and familiarize the target population with available services.

• Advocacy. Serve as a liaison between young clients and non-peer staff (voice the needs of young people).

• Decision Making. Active participation in all decision making regarding clients.

• Peer empowerment. Presence of peer staff as positive role models serves to empower youth and peer staff at other agencies.

• Community-wide Case Conferences. Conduct meetings of various local service providers who serve similar populations and clients to discuss how to better serve these groups or individuals.

• Brown Bag Lunches. Facilitate casual information sharing meetings of local youth service providers to discuss the challenges and successes of peer workers.

• Participation in Outside Events. Attend the National AIDS Update Conference, Unity Jam, and many other conferences, festivals and gatherings to network and publicize the program and highlight peer-based programming.

• Role Modeling. Serve as role models through the choices peer staff make both personally and professionally.

• Emotional Support. Provide accessible, non-judgmental care and support.

• Client Treatment Plans. Development of treatment plans that reflect the realities and needs of the target population.

• Facilitation of Client Communication. Reduce age and culture-bound obstacles to communication.

YouthCare is a non-profit community-based organization in Seattle, Washington, which has been providing comprehensive services to runaway, homeless, and sexual minority youth since its inception in 1974. As research began to show that peers often make the most appropriate messengers of HIV prevention messages, YouthCare began to hire young people from populations of street-involved, homeless, and sexual minority youth. YouthCare has an eight-year history of hiring clients for peer internship positions. YouthCare defines a peer as someone who identifies with the same population as the population they are trying to reach. (Consequently, non-peer staff is a person in a paid professional capacity that has had ample separation from the target populations that YouthCare serves.)

In Seattle, YouthCare’s Prevention, Intervention and Education Project (Project PIE) and Seattle’s Positive Youth (SPY) are the only programs that focus solely on young people infected with and affected by HIV. In 1995 and 1996, YouthCare was able to send several young people to meetings of the National Alliance of HIV Positive Youths (NAPY) in Washington, DC. These meetings of young people from around the country served as an inspiration for the youth from Seattle. One youth came back from the conference excited to start a support group by and for young people with HIV. YouthCare researched many models to design its program. Many of the young people with HIV who were enrolled in case management with Project PIE, participated in designing the Seattle’s Positive Youth (SPY) programming and are largely responsible for its success — reaching young people with HIV. SPY began as a support and social group for young people living with HIV in 1996. At the time this guide was written, YouthCare employed two half-time peer interns for SPY.

YouthCare decided to use an internship model for the hiring of all peer positions. Staff members believed that this lent an "educational" air to the program, and also set clear start and end dates for the position. YouthCare’s previous experience found that it was most useful to have a time-limited internship because it allowed more youth to be hired. It also allowed for easier hiring practices for the agency where "professional" positions came with many hiring requirements and reduced potential obstacles for young people who have been involved in the juvenile justice or foster care systems. Using the term "internship" also allows for a creative hiring process. One example is to be more creative in posting positions, such as places where young people congregate, and by using posters and word of mouth, rather than the more traditional newspapers. (Note: The only regret program staff express with this model is that they are unable to provide insurance, vacation, and sick leave benefits for the interns. To compensate for this, YouthCare tries to pay young people at a higher rate than they could get at other entry-level positions.)

Hiring clients has its benefits and its challenges for both peer and non-peer staff. It has been an asset to programs and services to have individuals that access the services provide those services. Internships are six months in length, and youth can apply for a maximum of two terms in the same position. Internships applicants must submit a cover letter and resume. YouthCare staff members who do not participate in the hiring process often help youth with their resumes and cover letters. For some, this may be their first time applying for a position or job. The staff believes that all people benefit and improve each time they go through an interview process. Therefore, every six months interviews are held. Interview committees are comprised of youth and staff (peer and non-peer).

Upon being hired, peer staff meet with a supervisor to discuss job expectations. This discussion can include timeliness, calling in when running late, and representing the agency in public. Interns also receive training on facilitation, HIV/STD information, paperwork, basic counseling skills, boundary setting, outreach safety, and ongoing in-service training offered by the agency.

Supervisors also discuss how working in these jobs will affect their own relationship to the YouthCare service system. It is the belief of staff members that it is more important to get needed services than to try and provide them to someone else. In some cases a peer may choose to get support from another organization. It has been YouthCare's experience, however, that HIV-positive clients choose to maintain their relationship with their Project P.I.E. case manager because they are not able to receive the level of support they feel is needed from other HIV service agencies. There is ongoing communication between the peer, their case manager and the supervisor to continually assess how the combination of roles is working.

The non-peer staff roles are often multiple. The supervisor for SPY is also the supervisor for Project PIE. It is most important to set up clear boundaries, talk openly about roles, prioritize the clients needs, make sure everyone knows which issues should be taken to the supervisor and which issues should be taken to the Case Manager.

There are several potential challenges when hiring from a client group. If a client is hired as a peer, it changes his/her role. YouthCare staff members discuss how confusing the multiple roles (case manager/supervisor – client/staff) can be. An example of this is that a peer may facilitate an HIV support group in which one of their friends is participating. In this case, the paid peer is the group facilitator first and friend second. The friend could become frustrated that the peer is treating them as a group member and not as the person they hang out with on the weekends. Another example is that they may have spent the day with their case manager at the doctor dealing with personal medical issues, and then have to facilitate a social group with the same case manager that evening. In this case, the roles are that of facilitator/co-facilitator, not case manager/client. It has been YouthCare's experience that "honesty is the best policy." YouthCare recommends that people talk openly about roles, and make sure both peer and non-peer staff members are getting support or consultation to deal with these issues. At YouthCare it often said, "If it’s difficult to deal with, then you’re probably in the right place."

Not getting hired for a peer position can also be difficult for a young person. Many youth can feel rejected if they are not hired. This might be especially difficult if one of the people that didn’t hire the youth is their case manager. Some clients have refused case management services or have not wanted to participate in programs after being rejected for a peer position. Case managers have supported clients through this process by starting dialogue early on about what it will be like to be hired or not hired. The SPY supervisor always meets individually with those who were not offered a job to discuss their feelings.

It has been YouthCare’s experience that the benefits of hiring peers greatly outweigh the costs. For agencies that serve disenfranchised youth and choose to use clients as staff, the benefits are as follows.

• Providing job-training skills to young people that have little or no prior job experience makes peers more employable after they leave your organization.

• As a community-based organization, clients from the target population are actively involved in giving back to their own communities through the provision of resources and services that would otherwise be delivered by someone from outside their cultural, ethnic or situational group. Many people believe that clients respond best to people with whom they identify as being most like, or have experiences most like their own.

• The organization gives back to the community in a very non-traditional way through the creation of jobs and the increase of job skills. This goal allows communities with few means to have more access to resources.

For organizations considering utilization of an internship program, or hiring young people from the target population, consideration should be given to the costs associated with hiring peers. Supervising peer programs also is a time-intensive task. Because many peers start these positions with little job experience and limited experience facilitating or organizing groups, they often need a mentor or supervisor to provide them with necessary skills. At the beginning of the internship it is not uncommon for the supervisor to work equal or more hours to the number of hours worked by the peers. As the internship progresses, the need for that level of supervision often decreases.

• Be clear about expectations concerning "professionalism," i.e. level of communication desired, what happens when someone isn’t showing up on time, what representing the agency in public means, etc. No one performs well if they do not have clear expectations from their supervisor.

• Know that supervising young people may take extra time at the beginning of an internship, and be prepared to take time when issues arise.

• Having a dedicated staff person supervising the peers is a good idea for consistency and acknowledges that supervising peer staff is a significant part of the job.

• Learn to be comfortable talking about issues of power and staff roles. It will surely become an issue.

• Be willing to have discussions with youth about the difficulties they may experience being peer staff.

• Bring up issues and concerns about power and staff roles.

• Learn how to manage being a "peer" by balancing work expectations with the expectations of friends who might not take your authoritative position seriously.

• Peers know best how to reach their friends and other youth. Don’t let adult staff forget that.

• Social service providers often make really good recommendations for peers for future jobs.

• Try to give the non-peer staff a little credit when you can. Remember that the goal is to have a balance between providing sensitive services and being an "agent of change" among the larger society.

• Having HIV and working in HIV services provision can be challenging. Remember to get your support first. Be honest about where you are physically and emotionally. It is difficult to help others unless your needs are met first.

Section 4: Street and Agency Outreach with Peer Support: Boston HAPPENS and Teen Outreach Primary Services (GBAPP/TOPS)

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