Can We Talk?
In Texas, HIV peer counseling takes up where prevention education leaves off

By Lizabeth Kelley, LPN, and Todd Logan, LMSW

One year after its launch, the HIV peer education program in the Texas state prisons was so successful that the inmate educators often were stopped in the halls by other inmates who had more questions or wanted advice. Clearly, inmates needed something beyond the education sessions. Today they have it: peer counseling.

In early 1999, the Texas Department of Criminal Justice partnered with AIDS Foundation Houston to initiate peer education in five prisons. In this program, teams of inmates took part in a 40-hour curriculum taught by AFH to learn how to deliver a four-part HIV education program to other inmates. After six months, the training program was found to have made statistically significant improvements in both knowledge and behavior.

TDCJ then created a full-time position for an HIV peer education coordinator to establish similar programs in all of the state’s facilities and institutionalized the program by creating a job code for HIV peer educators.

Expanding the Concept
Soon afterward, in the summer of 2000, the AFH director approached the Training and Public Education Branch at the state health department’s Bureau of HIV and STD Prevention. AFH’s idea: modify existing prevention counseling curricula to train offenders in basic counseling skills and concepts. After such training, inmates could provide HIV prevention counseling to supplement the efforts of the peer educators.

TPEB staff who had helped to develop the original training program for prevention counselors quickly jumped to the task. They started by meeting with people from TDCJ, AFH, the University of Texas Medical Branch and an independent evaluation firm, Sage Associates, to explore the needs and goals of peer HIV prevention counseling and establish a plan of action. Major issues for early planning included:
• Expanding the focus from HIV prevention to include other relevant behaviorally preventable infectious diseases (such as hepatitis, especially HCV, and other sexually transmitted diseases)
• Establishing criteria for trainee participant selection
• Determining how to discuss risk reduction behaviors considered infractions by TDCJ without seeming to condone those behaviors
• Defining the rights, responsibilities and supervision of peer prevention counselors
• Coordinating the logistics of testing and giving test results
• Clarifying boundaries needed to maintain confidentiality
• Negotiating a timeline and location for program rollout

Putting It to the Test
Ultimately, TPEB agreed to design a training program and pilot it at Gatesville Women’s Prison. Gatesville was selected because of its proximity to Department of Health headquarters in Austin, support from the warden and staff, and its strong and consistent team of HIV peer educators. The unit coordinator/substance abuse education program director was enthusiastic about the program, willing to supervise the counseling and quickly identified easily observable meeting areas that could be used for peer prevention counseling.

Gatesville personnel selected women to participate on the basis of their status as gatekeepers in the community, a clean record of behavior, a demonstrated investment in the project and sufficient time left to serve on their sentence to warrant investment of training resources. Roughly half of the women selected for peer counseling had already been trained as peer educators.

Meanwhile, TPEB staff collected resources and designed a skills-building curriculum to meet the challenges and needs of incarcerated counselors dealing with incarcerated clients. Paramount was the foundation of security, confidentiality, confidence building and respect for both the participants and the women they would counsel.

Before the five-day class, trainees were sent the TPEB self-paced Prevention Counseling Pre-Course used throughout Texas to provide a technical foundation for novice prevention counselors. TDCJ medical authorities included instructions for the trainees to discuss risk reduction in terms of "free-world" behaviors to avoid implication that the counselors condoned activities prohibited by TDCJ (e.g., condom use). The pre-course was otherwise unmodified.

Enthusiastic Students
TPEB staff arrived on a rainy Sunday, Sept. 24, to set up the room and prepare for Monday’s first day of class. Unexpectedly, they found the 14 participants patiently sitting in the classroom, waiting to begin. This moment set the tone and established three prevailing themes that would define the workshop:
• Trainees were unfailingly welcoming, willing and enthusiastic.
• The unplanned and unexpected were often serendipitous. In this case, TPEB staff used the unexpected presence of the women to review the pre-course material—and happily discovered the women able to quote whole passages from memory.
• Communication between TDCJ staff and the trainers would be a continual challenge.

TPEB staff were impressed with the energy and determination the participants brought to the training. Both trainers agreed that working with the women was one of the top training experiences they’ve ever had.

"They had such heart and dedication," says one. "They would go to their ‘dorms’ and make up their own role-plays to practice the concepts covered in the classroom. No one else has ever done that in training."

"And the days were long," the other trainer adds, "starting at seven and lasting until almost five. We were exhausted and they had to be, too. But still they took every assignment we gave them and added to it. I was struck by their hopefulness. They were willing to be embarrassed and awkward because they knew if they could master these skills they could really make a difference."

By the end of the five days of skills-building activities the women had:
• Adapted the technical pre-course material into their own language
• Mastered basic counseling skills and concepts
• Confronted their own issues of risk and risk reduction
• Discovered and developed a confidence in their ability to support behavior change
• Practiced counseling and been counseled several times
• Created a plan for continuing support of one another as they continued to develop as counselors
• Forged a bond with one another that continues today

Unexpected Challenges
After the counseling program began, some unexpected challenges arose that proved to be learning experiences. Although the counselors were ready and the counseling logistics were worked out, inmates were slow to take advantage of formal peer prevention counseling.

Planners had envisioned that the counseling would take up where peer education left off, providing individual support as requested. In fact, the impetus for peer counseling training came from peer educators who described a multitude of questions and informal consultations after class, in hallways and while on work details.

However, inmates—and some staff—had difficulty distinguishing between peer counseling and peer education. Those who recognized the need for additional support after the education sessions often thought the peer prevention counselors were exclusively for those already infected with HIV.

Despite these problems, though, none of the trainers or participants were discouraged. The trainers are ready to take their experience into other correctional facilities. The women of Gatesville continue to provide informal counseling to one another and to their families through letters and visits. Gatesville officials report that none of the women who went through the program have had a single infraction of any kind since the training.

Even if no formal counseling were ever done, TPEB staff agree that the changes they saw in the women they trained were worth the investment. The women would agree. As one participant said, "You know, at the end of the day, you go home, the volunteers go home, even the suits go home. And then, all we have is each other." The peer prevention counselor training made that support for each other more valuable.

— About the Authors:  Lizabeth Kelley, LPN, is curricula research and development manager and Todd Logan, LMSW, is a training specialist with the Texas Department of Health, HIV/STD Health Resources Division, Training & Public Education Branch, based in Austin. E-mail them at beth.kelley@tdh.state.tx.us or todd.logan@tdh.state.tx.us.

[This article first appeared in the Summer 2002 issue of CorrectCare.]