Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial

Attitudes and beliefs regarding depression, HIV/AIDS, and HIV risk-related sexual behaviors among clinically depressed African American adolescent females

Individuals' attitudes and beliefs toward behaviors are key indicators of behavioral performance. The purposes of this study were to elucidate attitudes and beliefs about depression, HIV/AIDS, and HIV risk-related sexual behaviors among clinically depressed African American adolescent females and to develop an understanding of their context for HIV risk. For this descriptive qualitative inquiry, semistructured interviews and surveys were employed (N = 24). The narratives reveal that behavioral sequelae of depression (i.e., loneliness) can produce risk for HIV. These findings may guide psychiatric nurse educators, scientists, and practitioners to modify HIV risk among clinically depressed African American adolescent females.

Developing a prevention synthesis and translation system to promote science-based approaches to teen pregnancy, HIV and STI prevention

The Interactive Systems Framework for Dissemination and Implementation (ISF) is a multi-system framework that can guide research-to-practice efforts by building and supporting the work of three interacting systems: the Prevention Delivery, Support, and Synthesis and Translation Systems. The Synthesis and Translation system is vital to bridging science and practice, yet how to develop it and train support system partners to use it is under-researched. This article bridges this gap by offering a case example of the planning, development, and use of a synthesis and translation product called Promoting Science-based Approaches to Teen Pregnancy Prevention using Getting To Outcomes. The case presented documents the process used for developing the synthesis and translation product, reports on efforts to engage the Prevention Support system to use the product, and how we approached building interaction between the Synthesis and Translation System and the Support System partners. Practice-oriented evaluation data are also presented. Implications for practice, policy and research are discussed.

Substance use and sexual behavior among recent Hispanic immigrant adolescents: effects of parent-adolescent differential acculturation and communication

OBJECTIVES

To ascertain the effects of parent-adolescent acculturation gaps, perceived discrimination, and perceived negative context of reception on adolescent cigarette smoking, alcohol use, sexual activity, and sexual risk taking. We used an expanded, multidimensional model of acculturation.

METHOD

A sample of 302 recently immigrated parent-adolescent dyads (152 from Miami and 150 from Los Angeles) completed measures of acculturation (Hispanic and American practices and identifications, and individualist and collectivist values) and parent-adolescent communication. Adolescents completed measures of recent cigarette smoking, alcohol use, sexual behavior, and sexual risk taking.

RESULTS

Parent-adolescent gaps in American practices and ethnic identity, and perceptions of a negative context of reception, predicted compromised parent-adolescent communication. In Miami only, adolescent-reported communication negatively predicted odds of cigarette smoking, occasions of drunkenness, and number of sexual partners. Also in Miami only, parent-reported communication positively predicted these outcomes, as well as occasions of adolescent binge drinking, drunkenness, number of sexual partners, and odds of unprotected sex. The only significant findings in Los Angeles were protective effects of parent-reported communication on frequency of alcohol use and of binge drinking. Mediational effects emerged only in the Miami sample.

CONCLUSIONS

Effects of parent-adolescent acculturation gaps vary across Hispanic groups and receiving contexts. The especially strong parental control in many Mexican families may account for these differences. However, other important differences between Hispanic subgroups and communities of reception could also account for these differences. Prevention efforts might encourage Hispanic youth both to retain their culture of origin and to acquire American culture.

The efficacy of Familias Unidas on drug and alcohol outcomes for Hispanic delinquent youth: main effects and interaction effects by parental stress and social support

INTRODUCTION

Drug and alcohol use disproportionately affect Hispanic youth. Despite these disparities, few empirically supported preventive interventions are available to ameliorate this public health concern among Hispanic youth. This study examined the effects of Familias Unidas, relative to Community Practice, in reducing past 90-day substance use, alcohol and marijuana dependence, and having sex while under the influence of alcohol or drugs. Additionally, this study explored whether Familias Unidas' effects varied by environmental context, namely parental stress and social support for parents.

METHODS

A total of 242 delinquent Hispanic youth aged 12-17 years and their primary caregivers were randomized to either Familias Unidas or Community Practice and assessed at three time points.

RESULTS

Familias Unidas was efficacious in reducing past 90-day substance use, illicit drug use, and in reducing the proportion of youth with an alcohol dependence diagnosis, relative to Community Practice. Results also showed a reduction in the proportion of youth who reported having sex while under the influence of alcohol or drugs. No differences between conditions were observed in past 90-day alcohol use or marijuana dependence. Intervention effects on illicit drug use and alcohol dependence varied by environmental context. For example, Familias Unidas was most efficacious for adolescents with parents exhibiting high stress and lower levels of social support.

CONCLUSIONS

Familias Unidas was efficacious in reducing some drug and alcohol related outcomes. The findings also support the concept of targeting family-based interventions, such as Familias Unidas, for adolescents with parents exhibiting high stress and low levels of social support.

Condom use: slippage, breakage, and steps for proper use among adolescents in alternative school settings

BACKGROUND

School-based human immunodeficiency virus (HIV)/sexually transmitted infection (STI), and pregnancy prevention programs often focus on consistent and correct condom use. Research on adolescents' experience using condoms, including condom slippage/breakage, is limited. This exploratory study examines proper condom use and the occurrence of condom slippage/breakage among alternative school youth.

METHODS

Data are from an HIV/STI prevention trial for youth in continuation school settings (N = 776). Analyses included separate hierarchical logistic regression analyses to explore the relationship between potential correlates and each outcome variable.

RESULTS

Students' use of steps for proper condom use varied-73.8% put on the condom before sexual contact, 71.1% squeezed air from the tip, and 92.0% unrolled the condom fully. Notably, 28.5% reported condom slippage/breakage. Results from the regression analyses showed that 4 sets of variables (demographic, substance use, sexual risk behaviors, and condom psychosocial factors) were associated with putting on a condom before sexual contact; none of the variable sets were associated with the other 2 condom steps measured. For slippage/breakage, the demographic and sexual risk behaviors were significant correlates; steps for proper condom use approached statistical significance (p = .058).

CONCLUSIONS

This study extends the limited research on how adolescents use condoms, and highlights important targets for prevention interventions.

Growth in alcohol use as a developmental predictor of adolescent girls' sexual risk-taking

Adolescent sexual risk-taking is common and often occurs under the influence of alcohol. Although alcohol use emerges in early adolescence, there is little empirical research examining whether growth in alcohol use during this developmental period predicts later risky sexual behavior. Such information could provide a critical opportunity for the prevention of sexually transmitted infections and unwanted teenage pregnancies. The current study examined alcohol use as a developmental mediator of the relationship between conduct problems, impulsivity, poverty, race and menarche assessed at age 11, and sexual risk-taking among girls at age 16. The sample comprised 499 participants of the Pittsburgh Girls Study (57.7% African American and 42.3% European American) interviewed annually for 6 years between age 11 and 16. The results of the conditioned latent growth curve model showed that the rate of increase in alcohol use, and African American race, predicted higher rates of sexual risk-taking at age 16. However, European American race predicted the intercept and slope of alcohol use. When mediation was tested, the results showed that age 12 use and an increase in propensity for alcohol use between 12 and 15 explained the relationship between European American race and later risky sex, but this was not the case for African American girls. Use of alcohol at age 12 also mediated the association between early menarche and subsequent sexual risk-taking. The implications of the findings for sexual risk prevention are discussed.

Children, adolescents, and the media: health effects

The media can be a powerful teacher of children and adolescents and have a profound impact on their health. The media are not the leading cause of any major health problem in the United States, but they do contribute to a variety of pediatric and adolescent health problems. Given that children and teens spend >7 hours a day with media, one would think that adult society would recognize its impact on young people's attitudes and behaviors. Too little has been done to protect children and adolescents from harmful media effects and to maximize the powerfully prosocial aspects of modern media.

Predicting condom use attitudes, norms, and control beliefs in Hispanic problem behavior youth: the effects of family functioning and parent-adolescent communication about sex on condom use

Hispanic problem behavior youth are at an increased risk of engaging in HIV risk behaviors, including low condom use. However, relatively little research has examined factors that affect condom use in this population. Although research indicates that family processes, such as higher levels of family functioning and open parent-adolescent communication about sex, and condom use attitudes, norms, and control beliefs as depicted by the theory of planned behavior have an effect on condom use behaviors, the combination of the two factors has received minimal attention. The purpose of this study was to examine the effect of family functioning on condom use intentions and behaviors through communication about sex and condom use attitudes, parental norms, and control beliefs. A cross-sectional study of 171 predominately male (73.1%) sexually active Hispanic problem behavior adolescents (mean age = 14.88 years) was conducted. Structural equation modeling was used to test the study hypothesis. Findings largely support the overall model and suggest that family functioning had an indirect effect on condom use intention and behavior through communication about sex, condom use attitudes, and control beliefs. Family functioning, however, did not have an indirect effect on condom use intention and behavior through communication about sex and parental norms. Implications for prevention science and future research are discussed.

Clinical depression and condom use attitudes and beliefs among African American adolescent females

Depression, HIV, and other sexually transmitted diseases (STDs) are growing concerns among African American adolescent females. Theoretical models contribute to identification of mediators of condom use; however, minimal research has addressed the explicit relationship between clinical depression and condom use in African American adolescent females. The authors report results from quantitative surveys with clinically depressed (n = 64) and nondepressed (n = 64) African American adolescent females in two large metropolitan cities in the eastern United States. Theoretical mediators of condom use in the study sample-attitudes, subjective norms, perceived behavioral control, and intentions-were investigated. Significant differences existed between the groups in condom use frequency (U = 356.5, p = .037); however, there were no statistically significant differences in condom use attitudes and beliefs. Although clinically depressed and nondepressed African American adolescent females may hold similar attitudes and beliefs about condom use, differences in condom use frequency may be a psychopathologic occurrence.

Efficacy of a randomized cell phone-based counseling intervention in postponing subsequent pregnancy among teen mothers

Adolescent mothers in Washington, DC have a high rate of subsequent teen pregnancies, often within 24 months. Children of teen mothers are at risk for adverse psychosocial outcomes. When adolescents are strongly attached to parents, schools, and positive peers, they may be less likely to repeat a pregnancy. This study tested the efficacy of a counseling intervention delivered by cell phone and focused on postponing subsequent teen pregnancies by strengthening healthy relationships, reproductive practices, and positive youth assets. The objective of this study was to compare time to a repeat pregnancy between the intervention and usual care groups, and, secondarily, to determine whether treatment intensity influenced time to subsequent conception. Primiparous pregnant teens ages 15-19, were recruited in Washington, DC. Of 849 teens screened, 29.3% (n = 249) met inclusion criteria, consented to participate, and completed baseline measures. They were then randomized to the intervention (N = 124) or to usual care (N = 125). Intervention group teens received cell phones for 18 months of counseling sessions, and quarterly group sessions. Follow-up measures assessed subsequent pregnancy through 24 months post-delivery. A survival analysis compared time to subsequent conception in the two treatment groups. Additional models examined the effect of treatment intensity. By 24 months, 31% of the intervention and 36% of usual care group teens had a subsequent pregnancy. Group differences were not statistically significant in intent-to-treat analysis. Because there was variability in the degree of exposure of teens to the curriculum, a survival analysis accounting for treatment intensity was performed and a significant interaction with age was detected. Participants who were aged 15-17 years at delivery showed a significant reduction in subsequent pregnancy with increased levels of intervention exposure (P < 0.01), but not those ≥ 18 years. Adolescents ≥ 18 years faced considerable challenges to treatment success. Individual, social, and contextual factors are all important to consider in the prevention of repeat teen pregnancy. Cell phone-based approaches to counseling may not be the most ideal for addressing complex, socially-mediated behaviors such as this, except for selective subgroups. A lack of resources within the community for older teens may interfere with program success.

The effectiveness of group-based comprehensive risk-reduction and abstinence education interventions to prevent or reduce the risk of adolescent pregnancy, human immunodeficiency virus, and sexually transmitted infections: two systematic reviews for the Guide to Community Preventive Services

CONTEXT

Adolescent pregnancy, HIV, and other sexually transmitted infections (STIs) are major public health problems in the U.S. Implementing group-based interventions that address the sexual behavior of adolescents may reduce the incidence of pregnancy, HIV, and other STIs in this group.

EVIDENCE ACQUISITION

Methods for conducting systematic reviews from the Guide to Community Preventive Services were used to synthesize scientific evidence on the effectiveness of two strategies for group-based behavioral interventions for adolescents: (1) comprehensive risk reduction and (2) abstinence education on preventing pregnancy, HIV, and other STIs. Effectiveness of these interventions was determined by reductions in sexual risk behaviors, pregnancy, HIV, and other STIs and increases in protective sexual behaviors. The literature search identified 6579 citations for comprehensive risk reduction and abstinence education. Of these, 66 studies of comprehensive risk reduction and 23 studies of abstinence education assessed the effects of group-based interventions that address the sexual behavior of adolescents, and were included in the respective reviews.

EVIDENCE SYNTHESIS

Meta-analyses were conducted for each strategy on the seven key outcomes identified by the coordination team-current sexual activity; frequency of sexual activity; number of sex partners; frequency of unprotected sexual activity; use of protection (condoms and/or hormonal contraception); pregnancy; and STIs. The results of these meta-analyses for comprehensive risk reduction showed favorable effects for all of the outcomes reviewed. For abstinence education, the meta-analysis showed a small number of studies, with inconsistent findings across studies that varied by study design and follow-up time, leading to considerable uncertainty around effect estimates.

CONCLUSIONS

Based on these findings, group-based comprehensive risk reduction was found to be an effective strategy to reduce adolescent pregnancy, HIV, and STIs. No conclusions could be drawn on the effectiveness of group-based abstinence education.

Sexual risk avoidance and sexual risk reduction interventions for middle school youth: a randomized controlled trial

PURPOSE

To evaluate the efficacy of two, theory-based, multimedia, middle school sexual education programs in delaying sexual initiation.

METHODS

Three-armed, randomized controlled trial comprising 15 urban middle schools; 1,258 predominantly African American and Hispanic seventh grade students followed into ninth grade. Both programs included group and individualized, computer-based activities addressing psychosocial variables. The risk avoidance (RA) program met federal abstinence education guidelines; the risk reduction (RR) program emphasized abstinence and included computer-based condom skills-training. The primary outcome assessed program impact on delayed sexual initiation; secondary outcomes assessed other sexual behaviors and psychosocial outcomes.

RESULTS

Participants were 59.8% females (mean age: 12.6 years). Relative to controls, the RR program delayed any type of sexual initiation (oral, vaginal, or anal sex) in the overall sample (adjusted odds ratio [AOR]: .65, 95% CI: .54-.77), among females (AOR: .43, 95% CI: .31-.60), and among African Americans (AOR: .38, 95% CI: .18-.79). RR students also reduced unprotected sex at last intercourse (AOR: .67, 95% CI: .47-.96), frequency of anal sex in the past 3 months (AOR: .53, 95% CI: .33-.84), and unprotected vaginal sex (AOR: .59, 95% CI: .36-.95). The RA program delayed any sexual initiation among Hispanics (AOR: .40, 95% CI: .19-.86), reduced unprotected sex at last intercourse (AOR: .70, 95% CI: .52-.93), but increased the number of recent vaginal sex partners (AOR: 1.69, 95% CI: 1.01-2.82). Both programs positively affected psychosocial outcomes.

CONCLUSIONS

The RR program positively affected sexually inexperienced and experienced youth, whereas the RA program delayed initiation among Hispanics and had mixed effects among sexually experienced youth.

Methods for conducting community guide systematic reviews of evidence on effectiveness and economic efficiency of group-based behavioral interventions to prevent adolescent pregnancy, human immunodeficiency virus, and other sexually transmitted infections: comprehensive risk reduction and abstinence education

This paper describes methods used to conduct systematic reviews and meta-analyses and economic reviews of group-based behavioral interventions for adolescents to prevent pregnancy, HIV, and other sexually transmitted infections. The steps described include developing a conceptual approach, defining the interventions, identifying outcome and moderator variables, searching the literature, abstracting the data, and analyzing the results. In addition, identification of potential harms and benefits, applicability of results, barriers to implementation, and research gaps are described.

Impact of school-based HIV prevention program in post-conflict Liberia

This paper presents findings of a feasibility study to adapt and evaluate the impact of an evidence-based HIV prevention intervention on sexual risk behaviors of in-school 6th grade youth in post-conflict Liberia (n = 812). The study used an attention-matched, group randomized controlled trial. Four matched pairs of elementary/middle schools in Monrovia, Liberia, were randomly assigned to either an adapted eight-module HIV prevention or a general health curriculum. Three- and nine-month impacts of the intervention on sexual risk behaviors and on mediating variables are presented. The intervention significantly impacted protective peer norms and positive condom attitudes and increased frequency of condom use at the nine-month follow-up. The intervention did not impact sexual initiation or multiple sex partnerships. Future intervention research should address the salient pressures that are unique to post-conflict settings and include longer follow-up time periods and smaller class sizes to meaningfully impact sexual initiation and multiple sex partnerships.

Clinical depression and HIV risk-related sexual behaviors among African-American adolescent females: unmasking the numbers

Clinically depressed and nondepressed African-American adolescent females aged 13-19 years (N=131) were interviewed and surveyed to determine the relationship between depression and HIV risk-related sexual behaviors. Narratives indicate that the psychopathology of depression may create situations where the target population could become exposed to HIV. Specifically, depressed participants described feelings of loneliness, isolation, and wanting somebody to "comfort them" as aspects of depression that affect the decisions they make about sex and relationships. In essence, sex was viewed as a stress reliever, an anti-depressant and a way to increase self-esteem. They shared that even if they did not feel like having sex, they might just "git it over wit" so their partners would stop asking. Some also discussed financial and emotional stability offered by older, more sexually experienced partners. These age-discordant relationships often translated into trusting that their partners knew what was best for their sexual relationships (i.e., having unprotected sex). Sixty-nine percent (n=88) of the sample reported engaging in sexual activity. Given their mean age (16 ± 1.9 years) participants had been sexually active for 2 ± 1.8 years. The adolescents reported an average of 2 ± 1.8 sexual partners within the past three months. Depressed participants reported a higher frequency of having ever had sex (78% vs. 59%, χ(2)=5.236, p=0.022), and had a higher mean number of sexual partners (2 vs. 1, t=-2.023, p= 0.048) and sexual encounters under the influence of drugs and alcohol (8 vs. 2, t=-3.078, p=0.005) in the past three months. The results of this study can guide the modification and/or development of tailored HIV/sexually transmitted infection (STI) prevention programs. The findings provide explicit, psychologically and culturally relevant information regarding the interaction between depression, self-medicating behaviors and risk for HIV/STIs among clinically depressed African-American adolescent females.

An evaluation of immediate outcomes and fidelity of a drug abuse prevention program in continuation high schools: project towards no drug abuse (TND)

The present study provides an implementation fidelity, process, and immediate outcomes evaluation of Project Towards No Drug Abuse (TND), a drug prevention program targeting continuation high school youth (n=1426) at risk for drug abuse. A total of 24 schools participated in three randomized conditions: TND Only, TND and motivational interviewing follow-up, and no treatment control. Fidelity was high: across program schools the curriculum was implemented as intended and was received favorably by students. Relative to controls, intervention conditions produced effects on hypothesized mediators, including greater gains in program related knowledge, greater reductions in drug use intentions, and positive changes in motivation. However, few generalizations to attitudes and intentions regarding risky sexual behavior were found. The pattern of results suggests that the experimental manipulations worked as intended.

Reducing sexual risk taking behaviors among adolescents who engage in transactional sex in post-conflict Liberia

Transactional sex (TS) has been correlated with HIV/STD infection, pregnancy, early marriage, and sexual violence in sub-Saharan Africa (SSA). Few Western-based HIV prevention programs adapted for SSA have examined intervention impacts for this group. This article examines whether an HIV prevention intervention, delivered to sixth-grade students in Liberia (age range 14-17) and found to increase condom use and other mediators for the larger sample, significantly impacted sexual behaviors and mediators for those who engaged in TS. Using an attention-matched, group-randomized controlled design, four matched pairs of elementary schools in Monrovia, Liberia, were randomly assigned to an adapted eight-module HIV prevention or a general health curriculum. Nine-month impacts of the intervention on sexual risk behaviors and mediators for those who engaged in TS, when compared with other study participants, are presented. Twelve percent of our sample of sixth graders (n = 714) ever engaged in TS. The majority of females reported being promised something in exchange for sex (52%), whereas the majority of males (52%) reported being both the giver and recipient of gifts in exchange for sex. Compared with other students, those who engaged in TS reported greater increases in the number of sex partners, reported greater frequency of sexual intercourse, were more likely to try to get pregnant or someone else pregnant, and reported greater reductions in protective sexual attitudes and HIV risk perception at the nine month follow-up, in both the intervention and the control groups. Our intervention, although successful for the general in-school adolescent sample, did not impact risk behaviors or mediators for adolescents who engaged in TS. Future research should explore the complex sexual economy in which TS is embedded and consider adapting HIV prevention interventions to the needs of this high-risk group.

Choice-disability and HIV infection: a cross sectional study of HIV status in Botswana, Namibia and Swaziland

Interpersonal power gradients may prevent people implementing HIV prevention decisions. Among 7,464 youth aged 15-29 years in Botswana, Namibia and Swaziland we documented indicators of choice-disability (low education, educational disparity with partner, experience of sexual violence, experience of intimate partner violence (IPV), poverty, partner income disparity, willingness to have sex without a condom despite believing partner at risk of HIV), and risk behaviours like inconsistent use of condoms and multiple partners. In Botswana, Namibia and Swaziland, 22.9, 9.1, and 26.1% women, and 8.3, 2.8, and 9.3% men, were HIV positive. Among both women and men, experience of IPV, IPV interacted with age, and partner income disparity interacted with age were associated with HIV positivity in multivariate analysis. Additional factors were low education (for women) and poverty (for men). Choice disability may be an important driver of the AIDS epidemic. New strategies are needed that favour the choice-disabled.

Does Powerlessness Explain Elevated HIV Risk Amongst Tajik Labor Migrants? An Ethnographic Study

To investigate the role of powerlessness in elevated HIV risk among labor migrants, we compared internal verses external male migrant workers from Tajikistan using minimally structured interviews and focused field observations. The sample included 30 male labor migrants who traveled to work in Regar, Tajikistan (internal labor migrants), and 30 who traveled to work in Moscow, Russia (external labor migrants). Though powerlessness did not appear to account for whether labor migrants engaged in more HIV risk behaviors, the harsh living and working conditions of external labor migration impacted how the migrants manifested these HIV risks by amplifying group masculine norms and behaviors. Progress in preventing HIV infection amid the difficult social conditions of labor migration is contingent upon adequate conceptualization of how such conditions impact HIV risk behaviors.

A comparative study of interventions for delaying the initiation of sexual intercourse among Latino and black youth

CONTEXT

Latino and black adolescents are disproportionately affected by STDs, including HIV, and unintended pregnancies. Few parent-based interventions have targeted these youth, focused on early adolescence and had high participation rates.

METHODS

Between 2003 and 2009, a randomized clinical trial was conducted with 2,016 Latino and black mother-adolescent dyads in New York City. Adolescents were eligible if they were in grade 6 or 7. Dyads were assigned to one of three conditions: a parent-based intervention, Families Talking Together (FTT); an adolescent-only intervention, Making a Difference! (MAD); or a combined FTT+MAD intervention. Respondents completed questionnaires at baseline and 12 months later. Single-degree-of-freedom contrasts and logistic regression analysis were used to evaluate differences in outcomes by intervention.

RESULTS

The proportion of youth who reported ever having engaged in vaginal intercourse increased over the study period by eight percentage points among those in the MAD group, five points in the FTT group and three points in the combined group; the differences among these increases were not statistically significant. Adolescents in the two FTT groups were significantly more likely than those in the MAD group to indicate that their mother had talked to them about not having intercourse (79% vs. 68%). They also scored higher than youth in the MAD group on measures of communication and perceived maternal attributes, and lower on activities that might lead to risky behaviors.

CONCLUSIONS

The proportions of adolescents who initiated intercourse during the study period were not significantly different across groups, implying that the interventions were comparable. Findings suggest that FTT may have led to improved parenting behaviors.

Adolescent health-risk sexual behaviors: effects of a drug abuse intervention

Adolescents who abuse substances are more likely to engage in health-risking sexual behavior (HRSB) and are at particularly high risk for HIV/AIDS. Thus, substance abuse treatment presents a prime opportunity to target HIV-risk behaviors. The present study evaluated a one-session HIV-risk intervention embedded in a controlled clinical trial for drug-abusing adolescents. The trial was conducted in New Mexico and Oregon with Hispanic and Anglo adolescents. Youths were randomly assigned to individual cognitive behavior therapy (CBT) or to an integrated behavioral and family therapy (IBFT) condition, involving individual and family sessions. The HIV-specific intervention was not associated with change. IBFT and CBT were both efficacious in reducing HIV-risk behaviors from intake to the 18-month follow-up for high-risk adolescents. For low-risk adolescents, CBT (versus IBFT) was more efficacious in suppressing HRSB. These data suggest that drug abuse treatments can have both preventative and intervention effects for adolescents, depending on their relative HIV-risk.

Identifying the causal pathways from religiosity to delayed adolescent sexual behavior

This study used the Integrative Model as a framework to examine whether religiosity delays onset of coitus among a longitudinal sample of virgins, and investigated the causal pathways of this relationship. In addition, this study examined the behavioral beliefs about the consequences of engaging in sex, which distinguishes between youth who vary in level of religiosity. A further analysis was also conducted to examine whether religiosity offers protective effects in terms of progression toward sexual intercourse on a sexual behavior index. The sexual behavior index assumes a progressive nature of sexual behaviors, and includes the following seven behaviors: kissing, having breasts touched (touching for boys), genital touching, receiving oral sex, vaginal intercourse, giving oral sex, and receiving (or giving) anal sex. Religiosity at baseline was negatively associated with sexual debut one year later. This relationship was mediated through attitudes toward personally engaging in sexual intercourse. Religiosity at baseline was also negatively associated with scores on the sexual behavior index one year later. These results suggest that religiosity offers protective effects for both coital and noncoital sexual behaviors.

Effects of a family intervention in reducing HIV risk behaviors among high-risk Hispanic adolescents: a randomized controlled trial

OBJECTIVE

To determine the efficacy of a family intervention in reducing human immunodeficiency virus (HIV) risk behaviors among Hispanic delinquent adolescents.

DESIGN

Randomized controlled trial.

SETTING

Miami-Dade County Public School System and Miami-Dade County's Department of Juvenile Services, Florida.

PARTICIPANTS

A total of 242 Hispanic delinquent youth aged 12 to 17 years and their primary caregivers completed outcome assessments at baseline and 3 months after intervention.

INTERVENTION

Participants were randomized to either Familias Unidas (120 participants), a Hispanic-specific, family intervention designed to reduce HIV risk behaviors among Hispanic youth, or a community practice control condition (122 participants).

MAIN OUTCOME MEASURES

Self-reported measures included unprotected sexual behavior, engaging in sex while under the influence of alcohol and/or drugs, number of sexual partners, and incidence of sexually transmitted diseases. Family functioning (eg, parent-adolescent communication, positive parenting, and parental monitoring) was also assessed via self-report measures.

RESULTS

Compared with community practice, Familias Unidas was efficacious in increasing condom use during vaginal and anal sex during the past 90 days, reducing the number of days adolescents were under the influence of drugs or alcohol and had sex without a condom, reducing sexual partners, and preventing unprotected anal sex at the last sexual intercourse. Familias Unidas was also efficacious, relative to community practice, in increasing family functioning and most notably in increasing parent-adolescent communication and positive parenting.

CONCLUSION

These results suggest that culturally tailored, family-centered prevention interventions may be appropriate and efficacious in reducing HIV risk behaviors among Hispanic delinquent adolescents.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01257022.

Predicting condom use using the Information-Motivation-Behavioral Skills (IMB) model: a multivariate latent growth curve analysis

BACKGROUND

The Information-Motivation-Behavioral Skills (IMB) model often guides sexual risk reduction programs even though no studies have examined covariation in the theory's constructs in a dynamic fashion with longitudinal data.

PURPOSE

Using new developments in latent growth modeling, we explore how changes in information, motivation, and behavioral skills over 9 months relate to changes in condom use among STD clinic patients.

METHODS

Participants (N = 1281, 50% female, 66% African American) completed measures of IMB constructs at three time points. We used parallel process latent growth modeling to examine associations among intercepts and slopes of IMB constructs.

RESULTS

Initial levels of motivation, behavioral skills, and condom use were all positively associated, with behavioral skills partially mediating associations between motivation and condom use. Changes over time in behavioral skills positively related to changes in condom use.

CONCLUSIONS

Results support the key role of behavioral skills in sexual risk reduction, suggesting these skills should be targeted in HIV prevention interventions.

"And let me see them damn papers!" The role of STI/AIDS screening among urban African American and Puerto Rican youth in the transition to sex without a condom

Common strategies employed in preventing STI/AIDS transmission among young adults in America include abstinence, monogamy and safer sex. These strategies require a high level of vigilance and responsibility and, according to inner city participants in Project PHRESH.comm, neither option is always desirable, available, or rational in the context of their lived experiences. This article reports findings from Project PHRESH.comm, a mixed-method, ethnographic study incorporating data from focus group discussions, semi-structured interviews, coital diaries, systematic cultural assessments and a structured survey designed to explore concepts of risk and decision making about condom use among at risk African American and Puerto Rican young adults aged 18-25 years in Hartford, CT. We found that many young adults from our study population rely on a strategy of using clinic-sponsored STI/AIDS screening when wanting to discontinue condom use with a partner. While our data suggest that screening is a common strategy used by many couples to transition to having sex without a condom, the data also show that most youth do not maintain monogamy even in long-term, serious relationships. Thus, sharing test results may provide a false sense of security in the sexual culture of inner city, minority youth.

HIV/STD risk behaviors among in-school adolescents in post-conflict Liberia

We conducted a randomized trial to address the health needs of in-school adolescents in Liberia, where we analyzed data from a behavioral survey administered to 820 students from eight urban schools. Our findings suggest that adolescents are at significant risk for HIV and other sexually transmitted diseases (STDs): 36% of respondents were sexually experienced, 34% of those had first sex at ages 14 or younger, 66% of first sexual encounters were unprotected, and 16% were described as "forced." Also, females were more likely to have older boyfriends (Pearson's chi square = 19.2, p = .0001) and sex resulting in pregnancies (Pearson's chi square = 11.5, p = .01), while males were more likely to have a greater number of sexual partners (Pearson's chi square = 5.6, p = .05) in the previous 3 months. We recommend further research to explore challenges associated with implementing behavioral-driven studies in post-conflict environments.

The Experience of Sexual Risk Communication in African American Families Living With HIV

Mother-daughter communication plays an influential role in adolescent development. The impact of maternal HIV infection on family communication is not clear. This study explores how living with HIV impacts sexual risk communication between mothers and daughters and whether maternal HIV status influences adolescent choices about engagement in HIV risk behaviors. Data were collected from 12 African American women and 10 of their adolescent daughters through focus groups. Both mothers and daughters shared information about issues that promoted and inhibited communication and engagement in risk behaviors. Findings show that HIV status served as a mechanism for behavioral change related to communication and risk engagement behaviors. Therefore, HIV-infected mothers should be supported in communicating values and expectations to their daughters.

Social networks of homeless youth in emerging adulthood

Little is known about the social networks of homeless youth in emerging adulthood despite the importance of this information for interventions to reduce health risks. This study examined the composition of social networks, and the risks and supports present within them, in a random sample of 349 homeless youth (33.4% female, 23.9% African American, 17.7% Hispanic) between the ages of 18 and 24. Social network members who were met on the street were among the most likely to be perceived as engaging in risky sex, as well as to engage in substance use with the youth. Youth were more likely to count on relatives and sex partners for support compared to other network members, but they also were more likely to use substances with sex partners and perceived them as engaging in risky sex. Interventions may need to recognize the importance of intimate relationships during the developmental stage of emerging adulthood by enhancing supportive bonds and reducing substance use and risky sex in these relationships.

Applications in bridging the gap: a community-campus partnership to address sexual health disparities among African-American youth in the south

Risky sexual behavior among African-American youth increases risks for sexually transmitted diseases and unintended pregnancy. This article describes a community-academic partnership to assess The 2 HYPE Abstinence Club, a program combining abstinence education with stress management and creative arts promotion for African-American youth ages 12-18. Bi-directional learning and communication systems were established to facilitate culturally relevant evaluation approaches, quality assurance in data collection, and action-based protocols for on-going improvement. Assessment tools included self-administered surveys and focus groups to gauge intervention effectiveness and perceptions regarding abstinence, sexual peer norms and intervention characteristics. Statistically significant increases in the understanding of abstinence benefits and sexual activity risks were observed and youth identified goal-setting and refusal skills as most important program components. Youth-instructor relationships and the integration of hip-hop were reasons cited for sustained participation. This assessment partnership represents a rapport with minority youth and a participatory evaluation approach adding programmatic and evidence-based value to intervention efforts.

Condom social marketing program to prevent HIV/AIDS in post-conflict Liberia

BACKGROUND

Youths in sub-Saharan Africa (SSA) account for a large burden of the global HIV/STI crises. As such, strategies directed at promoting behavioral modifications would be critical to reducing the prevalence of risky sexual behaviors among high risk adolescents in post-conflict environments.

OBJECTIVES

This study describes a condom promotion strategy to prevent HIV/STIs among highly vulnerable urban youth in a post-conflict, resource-constrained environment via the provision of both male and female condoms to nontraditional venues like music and photo shops, ice cream parlors, money exchange centers and beauty salons.

METHODS

Community members in the designated catchment areas volunteered their services and the use of their small businesses to support this endeavor.

RESULTS

In this paper, we describe the condom promotion strategy and its implications within the context of a community-based participatory social marketing program to prevent risky sexual behaviors among highly vulnerable urban youth in a post-conflict country.

CONCLUSION

We postulate that this approach may likely increase condom use among urban youth in Monrovia, the capital city of Liberia.

HIV prevention among African American youth: how well have evidence-based interventions addressed key theoretical constructs?

Certain constructs are demonstrated in the research literature to be related to HIV risk behaviors among African American adolescents. This study examines how well these constructs are addressed in evidence-based interventions (EBIs) developed for this population. A literature review on variables for sexual risk behaviors among African American adolescents was undertaken. Simultaneously, a review was conducted of the contents of HIV-prevention EBIs. To facilitate comparison, findings from both were organized into constructs from prominent behavior change theories. Analysis showed that environmental conditions and perceived norms were frequently associated with sexual risk behaviors in the literature, while EBIs devoted considerable time to knowledge, skills, and self-efficacy. Findings imply that (a) EBIs might be complemented with activities that focus on important constructs identified in the literature and (b) researchers should better assess the relationship between skill development and HIV risk behaviors. Implications for practice and research are discussed.

Cognitive-behavioural health-promotion intervention increases fruit and vegetable consumption and physical activity among South African adolescents: a cluster-randomised controlled trial

Rates of chronic diseases are high among Black South Africans but few studies have tested cognitive-behavioural health-promotion interventions to reduce this problem. We tested the efficacy of such an intervention among adolescents in a cluster-randomised controlled trial. We randomly selected 9 of 17 matched pairs of schools and randomised one school in each pair to the cognitive-behavioural health-promotion intervention designed to encourage health-related behaviours and the other to a human immunodeficiency virus (HIV)/sexually transmitted disease (STD) risk-reduction intervention that served as the control. Interventions were based on social cognitive theory, the theory of planned behaviour and qualitative data from the target population. Data collectors, blind to participants' intervention, administered confidential assessments at baseline and 3, 6 and 12 months post-intervention. Primary outcomes were fruit and vegetable consumption and physical activity. Participants were 1057 grade 6 learners (mean age = 12.4 years), with 96.7% retained at 12-month follow-up. Generalised estimating equations revealed that averaged over the follow-ups, a greater percentage of health-promotion intervention participants than HIV/STD control participants met 5-a-Day fruit and vegetable and physical activity guidelines. The intervention also increased health-promotion knowledge, attitude and intention, but did not decrease substance use or substance-use attitude and intention. The findings suggest that theory based and contextually appropriate interventions may increase health behaviours among young adolescents in sub-Saharan Africa.

Sex differences in approaching friends with benefits relationships

This research explored differences in how men and women approach "friends with benefits" (FWB) relationships. Specifically, this study examined sex differences in reasons for beginning such involvements, commitment to the friendship versus sexual aspects of the relationship, and partners'; anticipated hopes for the future. To do so, an Internet sample of individuals currently involved in FWB relationships was recruited. Results indicated many overall similarities in terms of how the sexes approach FWB relationships, but several important differences emerged. For example, sex was a more common motivation for men to begin such relationships, whereas emotional connection was a more common motivation for women. In addition, men were more likely to hope that the relationship stays the same over time, whereas women expressed more desire for change into either a full-fledged romance or a basic friendship. Unexpectedly, both men and women were more committed to the friendship than to the sexual aspect of the relationship. Although some additional similarities appeared, the findings were largely consistent with the notion that traditional gender role expectations and the sexual double standard may influence how men and women approach FWB relationships.

Health Promotion: Results of focus groups with African-American men

BACKGROUND: Almost half (49%) of the people diagnosed with HIV/AIDS in the United States (US) are African-Americans. Although African-Americans represent only about 13% of the overall population, they continue to account for a higher proportion of cases at all stages of HIV/AIDS. Most documented interventions targeting the African-American population have focused on women, children, men who have sex with men or drug addicts. METHODS: Six focus group sessions with African-American men (39) and women (15) were conducted in a heterogeneously populated American city. We used a pre-focus group questionnaire to collect data about the socio-economic background of the participants. In our focus group sessions we examined the feasibility of instituting a health promotion program for African-American men. RESULTS: The men who participated in the sessions showed great interest in attending the health promotion program. They had no prior knowledge of positive behavioral practices that could promote their individual health and well-being. HIV infection rates in the African-American population remain the highest in the US. CONCLUSION: The results of our focus group sessions showed that the heterosexual African-American men were eager to learn how to protect themselves against communicable and non-communicable diseases in health promotion programs.

Protecting and promoting: an integrative conceptual model for healthy development of adolescents

Resilience and positive youth development have substantial overlap and offer complementary perspectives on fostering healthy youth development. However, these two areas have not yet been fully integrated into a unified approach, one that has the potential to build on the interconnectedness of risk, protection, and assets within the ecological systems affecting adolescent development. This article draws on extant research to delineate linkages between the risk and resilience and positive youth development literatures. School-related outcomes are examined within an integrative conceptual model delineating eight developmental domains useful for future research on underlying mechanisms associated with healthy outcomes, as well as prevention and intervention efforts.

HIV/AIDS Knowledge and Self-Efficacy Among Nepalese Adolescents: A Peer Education Program

The purposes of this study were to develop and test the effectiveness of an HIV/AIDS peer education program in improving Nepalese adolescents HIV/AIDS knowledge and self-efficacy in one of the schools in Nepal. A modified format of the program “Teens for AIDS Prevention” (TAP) was used in this study. A quasi-experimental design was used to test the effectiveness of the peer education program. A convenience sample of 121 ninth grade Nepalese students from an urban high school participated at baseline. The final paired sample included 118 students. The results demonstrated a significant positive relationship between HIV/AIDS knowledge and self-efficacy. Nepalese adolescents’ HIV/AIDS knowledge and self-efficacy improved after the peer education intervention. Therefore, school personnel, health care providers, and government and nongovernment organizations should consider developing and implementing school-based HIV prevention programs such as the peer education program.

College students and condom attitude: validation of the Multi-Factor Attitude toward Condoms Scale (MFACS)

OBJECTIVE

Sexually transmitted infections and the human immunodeficiency virus incidence rates remain high among college-aged individuals. This study examined the validity and reliability of the Multi-Factor Attitude toward Condoms Scale (MFACS).

PARTICIPANTS

Participants were recruited from a large midwestern university during February and March 2009.

METHODS

Data were collected using in-class data collection with a test-retest design from undergraduate courses. A total of 442 surveys were collected during initial testing and 421 during retesting.

RESULTS

Reliability assessments indicated a sufficient Cronbach's alpha for the total scale (α = .805) and each subscale: affective (α = .790), perceived effectiveness (α = .795), and manageability (α = .751). Further analyses provide evidence of construct validity.

CONCLUSIONS

The study reaffirmed the psychometric properties of the MFACS among a sample of college students. The MFACS provides a contemporary way to examine condom attitudes as sexual health research is moving beyond only disease prevention efforts.

Can safer-sex promotion leaflets change cognitive antecedents of condom use? An experimental evaluation

An experimental evaluation of a safer sex promotion leaflet was undertaken to assess its capacity to change antecedent cognitions of condom use. The leaflet was identified in a previous study as addressing research-based cognitive antecedents of condom use. A pre-post-test experimental study including three conditions was conducted: (a) presentation of the leaflet; (b) presentation of the leaflet plus incentive for systematic processing; (c) no-leaflet control. The leaflet was evaluated in terms of its capacity to change eight cognitive correlates of condom use identified in a recent meta-analysis. The sample consisted of 230 tenth-grade students. Following baseline assessments, leaflet-induced change was measured immediately following the intervention and at a follow up 4 weeks post-intervention. The target leaflet alone did not result in significant changes in the cognitive antecedents of condom use compared with the control condition. However, in combination with an incentive for systematic processing, the target leaflet had a greater impact on cognitive antecedents than the no-leaflet control condition. The findings are discussed with regard to the development and evaluation of research-based health-promotion materials.

What do deaf high school students know about HIV?

Deaf adolescents who use American Sign Language (ASL) as their main communication mode are, like their hearing age peers, at risk for acquiring HIV. Many sources of HIV information (radio and television) are not accessible to these adolescents. Little is known about HIV knowledge base and risk behaviors of this group. The objective of this study was to develop and administer, on laptop computer, an HIV knowledge and risk survey in ASL. Findings among 700 deaf adolescent participants attending high schools for the deaf throughout the United States showed that, on average, students knew correct answers to approximately half (x = 7.2) of 14 knowledge items (median: 7.0; range: 0-14; sd = 3.8) on a highly reliable knowledge scale (α = .83). Knowledge score was found in multivariable analysis to be strongly related to receiving HIV information in school. This population is clearly in need of linguistically and culturally accessible HIV prevention education delivered in school.

School-based randomized controlled trial of an HIV/STD risk-reduction intervention for South African adolescents

OBJECTIVE

To test the efficacy of a school-based human immunodeficiency virus/sexually transmitted disease (HIV/STD) risk-reduction intervention for South African adolescents.

DESIGN

A cluster-randomized, controlled design with assessments of self-reported sexual behavior collected before intervention and 3, 6, and 12 months after intervention.

SETTING

Primary schools in a large, black township and a neighboring rural settlement in Eastern Cape Province, South Africa.

PARTICIPANTS

Nine of 17 matched pairs of schools were randomly selected. Sixth-grade students with parent or guardian consent were eligible.

INTERVENTIONS

Two 6-session interventions based on behavior-change theories and qualitative research. The HIV/STD risk-reduction intervention targeted sexual risk behaviors; the attention-matched health promotion control intervention targeted health issues unrelated to sexual behavior.

OUTCOME MEASURES

The primary outcome was self report of unprotected vaginal intercourse in the previous 3 months averaged over the 3 follow-ups. Secondary outcomes were other sexual behaviors.

RESULTS

A total of 1057 (94.5%) of 1118 eligible students (mean age, 12.4 years) participated, with 96.7% retained at the 12-month follow-up. Generalized estimating equation analyses adjusted for clustering from 18 schools revealed that, averaged over the 3 follow-ups, a significantly smaller percentage of HIV/STD risk-reduction intervention participants reported having unprotected vaginal intercourse (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.30-0.85), vaginal intercourse (OR, 0.62; 95% CI, 0.42-0.94), and multiple sexual partners (OR, 0.50; 95% CI, 0.28-0.89), when adjusted for baseline prevalences, compared with health-promotion control participants.

CONCLUSION

This is the first large-scale, community-level, randomized intervention trial to show significant effects on the HIV/STD sexual risk behavior of South African adolescents in the earliest stages of entry into sexual activity.

American Academy of Pediatrics. Policy statement--sexuality, contraception, and the media

From a health viewpoint, early sexual activity among US adolescents is a potential problem because of the risk of pregnancy and sexually transmitted infections. New evidence points to the media adolescents use frequently (television, music, movies, magazines, and the Internet) as important factors in the initiation of sexual intercourse. There is a major disconnect between what mainstream media portray-casual sex and sexuality with no consequences-and what children and teenagers need-straightforward information about human sexuality and the need for contraception when having sex. Television, film, music, and the Internet are all becoming increasingly sexually explicit, yet information on abstinence, sexual responsibility, and birth control remains rare. It is unwise to promote "abstinence-only" sex education when it has been shown to be ineffective and when the media have become such an important source of information about "nonabstinence." Recommendations are presented to help pediatricians address this important issue.

Taking It to the Pews: a CBPR-guided HIV awareness and screening project with black churches

Utilizing a community-based participatory research (CBPR) approach is a potentially effective strategy for exploring the development, implementation, and evaluation of HIV interventions in African American churches. This CBPR-guided study describes a church-based HIV awareness and screening intervention (Taking It to the Pews [TIPS]) that fully involved African American church leaders in all phases of the research project. Findings from the implementation and evaluation phases indicated that church leaders delivered TIPS Tool Kit activities on an ongoing basis (about twice a month) over a 9-month period. TIPS church members were highly exposed to TIPS activities (e.g., 91% reported receiving HIV educational brochures, 84% heard a sermon about HIV). Most (87%) believed that the church should talk about HIV, and 77% believed that the church should offer HIV screening. These findings suggest that implementing an HIV intervention in Black church settings is achievable, particularly when a CBPR approach is used.

Changes in sexual behaviours: from secular trends to public health policies

OBJECTIVE

To explore the relative contribution of secular trends and public health policies to changes in sexual behaviour.

DESIGN

Three random probability surveys of the sexual behaviour of people aged 18-69 years were conducted in 1970, 1992 and 2006 in France.

METHODS

Data of the 2006 survey (n = 12,364) were compared with those from two surveys carried out in 1970 (n = 2625) and 1992 (n = 20,055).

RESULTS

Over the last decades, median age at first intercourse has decreased by 4 years for women (22.0 in the 1930s vs. 17.6 in the 2000s) and 1 year for men (18.1 vs. 17.2). Lifetime number of sexual partners increased for women (1.8 in 1970 vs. 4.4 in 2006), but not for men (11.8 vs. 11.6). At the same time, the proportion of respondents, especially women, who reported nonpenetrative sexual practices and considered sexual intercourse essential to well being was on the increase. These changes are mainly attributed to an increase in women's social status. A marked increase in condom use was observed following the first AIDS/HIV prevention campaigns in the 1980s.

CONCLUSION

Public health interventions that are synergistic with trends in social norms are likely to be more effective than those that run counter to them. In France, sexual health and HIV prevention policies aimed at harm limitation appear to have chimed with secular trends. The evidence of greater diversification of sexual practices offers potential to increase the range of safer sex messages used in public health interventions.

Examining the theory of planned behavior applied to condom use: the effect-indicator vs. causal-indicator models

The authors investigated whether a causal-indicator model or an effect-indicator model of the theory of planned behavior (TPB) is more suitable for predicting behavioral intention and for which behaviors. No previous studies have evaluated this question using the same sample and same behavior. In this study, African American adolescents ages 12-17 participating in risk reduction classes were assessed on their initial attitudes, norms, perceived control, and intention regarding condom use. Second-order structural equation modeling indicated that the effect-indicator model exhibited superior fit above the causal-indicator model. Furthermore, modeling the behavioral antecedents in a causal way may not be as accurate due to the underlying uni-dimensional nature of attitudes, subjective norms, and control. The TPB was not disconfirmed as a suitable model for African American adolescents' regarding condom use. Prevention programs may benefit by focusing on adolescent behavior change with regard to the global components in order to influence more specific concepts of these social cognitions. Editors' Strategic Implications: Despite limitations including correlational data, this study yields implications for prevention programming and, more broadly, an important theoretical elaboration on effect-indicator and causal-indicator models of the TPB.

Effectiveness of an HIV/STD risk-reduction intervention for adolescents when implemented by community-based organizations: a cluster-randomized controlled trial

OBJECTIVES

We evaluated the effectiveness of an HIV/STD risk-reduction intervention when implemented by community-based organizations (CBOs).

METHODS

In a cluster-randomized controlled trial, 86 CBOs that served African American adolescents aged 13 to 18 years were randomized to implement either an HIV/STD risk-reduction intervention whose efficacy has been demonstrated or a health-promotion control intervention. CBOs agreed to implement 6 intervention groups, a random half of which completed 3-, 6-, and 12-month follow-up assessments. The primary outcome was consistent condom use in the 3 months prior to each follow-up assessment, averaged over the follow-up assessments.

RESULTS

Participants were 1707 adolescents, 863 in HIV/STD-intervention CBOs and 844 in control-intervention CBOs. HIV/STD-intervention participants were more likely to report consistent condom use (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.06, 1.84) than were control-intervention participants. HIV/STD-intervention participants also reported a greater proportion of condom-protected intercourse (beta = 0.06; 95% CI = 0.00, 0.12) than did the control group.

CONCLUSIONS

This is the first large, randomized intervention trial to demonstrate that CBOs can successfully implement an HIV/STD risk-reduction intervention whose efficacy has been established.