Changing drug users' risk environments: peer health advocates as multi-level community change agents

Peer delivered, social oriented HIV prevention intervention designs are increasingly popular for addressing broader contexts of health risk beyond a focus on individual factors. Such interventions have the potential to affect multiple social levels of risk and change, including at the individual, network, and community levels, and reflect social ecological principles of interaction across social levels over time. The iterative and feedback dynamic generated by this multi-level effect increases the likelihood for sustained health improvement initiated by those trained to deliver the peer intervention. The Risk Avoidance Partnership (RAP), conducted with heroin and cocaine/crack users in Hartford, Connecticut, exemplified this intervention design and illustrated the multi-level effect on drug users' risk and harm reduction at the individual level, the social network level, and the larger community level. Implications of the RAP program for designing effective prevention programs and for analyzing long-term change to reduce HIV transmission among high-risk groups are discussed from this ecological and multi-level intervention perspective.