Recommendations for group-based behavioral interventions to prevent adolescent pregnancy, human immunodeficiency virus, and other sexually transmitted infections: comprehensive risk reduction and abstinence education

Preventing HIV and HSV-2 through knowledge and attitudes: A replication study of a multi-component community-based intervention in Zimbabwe

INTRODUCTION

Approximately two-thirds of HIV-infected individuals reside in sub-Saharan Africa. The region accounts for 68% of the new HIV infections occurring worldwide with almost one-half of these infections being among young adults aged 12-24 years. Cowan and colleagues conducted a community-based, multi-component HIV intervention aimed at youth in rural Zimbabwe. Despite some changes in knowledge and attitudes, the community-based intervention did not affect the prevalence of HIV or HSV-2. We selected this frequently cited study for replication since it incorporates individual-, community-, and structural- level intervention components that are often considered in global HIV/AIDS prevention programs. Additionally, the intervention could be easily scaled-up, which is especially important in the context of limited resources. Although this study indicated no intervention effects in reducing HIV, the authors acknowledged some key methodological challenges. Our replication analysis provided important insights regarding the impact of these challenges to the interpretation of the results of this study.

METHODS

Our replication study focused on replicating Cowan's findings and assessing the robustness of Cowan's results to alternative analytical models based on their study design. We determined how out-migration occurring during Cowan's study may have affected the population characteristics, the intervention exposure level, and the study findings. While the original intervention targeted knowledge and attitudes as a mechanism to decrease HIV/HSV-2, the Cowan study evaluated the intervention effects on knowledge, attitudes, and prevalence of HIV or HSV-2 separately. To better identify the pathway describing the interrelationship among the intervention and knowledge, attitudes, and prevalence of HIV or HSV-2, we assessed whether increases in knowledge or attitudes were associated with decreased HIV or HSV-2 prevalence.

RESULTS

We replicated the original findings with minor discrepancies during the pure replication. Our additional analyses revealed that the study population characteristics changed over time in ways that may have affected outcomes. These changes also affected the levels of intervention exposure, with 48.7% males and 75.5% females of the intervention group receiving low-level exposure. Both genders with higher level intervention exposure experienced higher increments in multiple knowledge, attitude, and sexual risk behavior outcomes. Unfortunately, these did not translate to a significant reduction in HIV or HSV-2 regardless of the level and combination of knowledge and attitude domains. However, males receiving high-level intervention exposure compared to control indicated significantly lower odds of having HIV or HSV-2 under a Bayesian modeling paradigm.

CONCLUSIONS

Our findings suggest a more robust conclusion on the study intervention effects. Further study based on a design that more consistently maximizes the exposure level of the intervention is necessary and should ideally be an evaluated goal in similar studies. Evaluation of the intervention impact for key subgroups of the target population is important and would better advise the use and scale-up of the evaluated interventions in various contexts. Our observation of a consistent lack of relationship between knowledge/attitudes and HIV/HSV-2 suggests a need to explore and include relevant additional and or complementary interventions, e.g., promoting effective skills in reducing risky sexual behaviors and addressing cultural and structural bottlenecks that may reduce HIV/HSV-2 risk among youth.

Young People and HIV: A Call to Action

HIV is having a significant impact on young people, among whom the rate of new diagnoses is high and health disparities are more pronounced. Incidence is increasing among young gay and bisexual men, and, among Black males, the largest percentage of new infections occur among those aged between 13 and 24 years. Youths are least likely to experience the health and prevention benefits of treatment. Nearly half of young people with HIV are not diagnosed; among those diagnosed, nearly a quarter are not linked to care, and three quarters are not virally suppressed. Addressing this burden will require renewed efforts to implement effective prevention strategies across multiple sectors, including educational, social, policy, and health care systems that influence prevention knowledge, service use, and treatment options for youths.

Re-examining the effectiveness of monogamy as an STI-preventive strategy

The utility of monogamy (in practice) as a strategy for preventing sexually transmitted infections (STIs) was investigated. By reviewing recent literature surrounding monogamous relationships and sexual behaviors, the authors determined that monogamy might not prevent against STIs as expected. First, the authors elucidate the ways in which public health officials and the general public define and interpret monogamy and discuss how this contributes to monogamy as an ineffectual STI prevention strategy. Second, the authors provide evidence that individuals' compliance with monogamy is likely to be low, similar to rates of compliance with other medical advice. Lastly, the authors draw upon recent research findings suggesting that people who label themselves as monogamous are less likely to engage in safer sex behaviors than people who have an explicit agreement with their partner to be non-monogamous. Future research and clinical directions to promote sexual health and destigmatize sexual behaviors are considered.

HIV-Related Knowledge and Perceptions by Academic Major: Implications for University Interventions

Most universities offer human sexuality courses, although they are not required for graduation. While students in health-related majors may receive sexuality education in formal settings, majority of college students never receive formal sexual health or HIV/AIDS-related education, which may lead to elevated engagement in high-risk sexual behaviors. This study examines perceived knowledge about HIV/AIDS, perceived risk, and perceived consequences among college students by two distinct classifications of academic majors. Data were collected from 510 college students. Binary and multinomial logistic regressions were performed to compare HIV-related covariates by academic major category. Limited differences were observed by science, technology, engineering, and mathematics categorization. Relative to health and kinesiology majors, those who self-reported being "completely knowledgeable" about HIV were less likely to be physical sciences, mathematics, engineering, and business (PMEB) (OR = 0.41, P = 0.047) or education, humanities, and social sciences majors (OR = 0.25, P = 0.004). PMEB majors were less likely to report behavioral factors as a risk for contracting HIV (OR = 0.86, P = 0.004) and perceived acquiring HIV would be more detrimental to their quality of life (OR = 2.14, P = 0.012), but less detrimental to their mental well-being (OR = 0.58, P = 0.042). Findings can inform college-wide campaigns and interventions to raise HIV/AIDS awareness and improve college health.

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.