Comparative Effectiveness of Web-Based vs. Educator-Delivered HIV Prevention for Adolescent Substance Users: A Randomized, Controlled Trial

Systematic review: risk sexual behavior, sexually transmitted infections, and adolescent pregnancy prevention interventions

In many countries, there is a high number of teenage pregnancies, Sexually Transmitted Infections (STIs), and unsafe sexual behavior, so there is a need for adolescent health intervention programs to change behavior. The effectiveness of comprehensive interventions in various contexts to reduce teenage pregnancy, STIs, and related sexual risk behaviors is reviewed in this systematic. This study aimed to identify risk sexual behavior, sexually transmitted infections, and adolescent pregnancy prevention interventions. Literature search strategy from January 2008 to December 2022 through electronic databases. Key words 'teenage prenancy' OR 'teen pregnancy' OR 'pregnancy adolescence', AND 'maternal education', AND 'randomised clinical trial', AND 'risk behavior'. Articles that were deemed worthy of following the PRISMA guidelines were 28 articles. Most studies looked at school-based, individual, community, clinic, and family-based care. Most studies were followed up after intervention at intervals from one month to seven years, and the majority of the population and sample were adolescents with ages ranging from 13 to 18 years. Implementation of research in urban, suburban, and rural areas. This program has proven successful in preventing pregnancy, contraceptive use, STI and HIV, sexual behavior, dropping out of school, knowledge about pregnancy, sexuality, attitudes towards sexuality, intention to change risky sexual behavior, self-efficacy, and increasing parent-children. This article describes some basic trends in adolescent pregnancy prevention interventions in several countries that can be used as a reference for health programs. Unproven effectiveness can be implemented in conjunction with other interventions that have a high-quality impact.

Scaling up delivery of HIV services in Africa through harnessing trends across global emerging innovations

Globally, innovations for HIV response present exciting opportunities to enhance the impact and cost-effectiveness of any HIV program. However, countries especially in the African region are not on equal footing to effectively harness some of the existing innovations to accelerate impact on HIV services delivery. This paper aims to add to the discourse on innovative solutions to support countries to make informed decisions related to technologies that can be adapted in different contexts to strengthen HIV programs. A scoping review which involved a search of innovations that can be used in response to the HIV epidemic was carried out between June 2021 and December 2022. The results showed that a high level of technological advancement occurred in the area of digital technologies and devices. Out of the 202 innovations, 90% were digital technologies, of which 34% were data collection and analytics, 45% were mobile based applications, and 12% were social media interventions. Only 10% fell into the category of devices, of which 67% were rapid diagnostic tools (RDTs) and 19% were drone-based technologies among other innovative tools. The study noted that most of the innovations that scaled relied on a strong ICT infrastructure backbone. The scoping review presents an opportunity to assess trends, offer evidence, and outline gaps to drive the adoption and adaptation of such technologies in Africa.

Blended smartphone intervention for patients in opioid maintenance treatment in Iran: protocol for a randomized controlled trial

BACKGROUND

The pattern of substance use in Iran is characterized by a high prevalence of opioid use and opioid use disorder (OUD). Although opioid maintenance therapy (OMT) has been introduced in Iran, approximately 50% of people with opioid use disorder remain unreached. Moreover, psychosocial treatment of OUD and common mental health symptoms during OMT is limited. Digital interventions have been shown to improve psychological distress, depression, anxiety, and post-traumatic stress disorder symptoms. In addition, providing psychoeducation and risk reduction counseling to prevent communicable diseases like HIV and infectious hepatitis is common via the Internet. However, despite these promising advances, no smartphone intervention in OMT has been investigated for the treatment of OUD and common comorbid mental health symptoms.

OBJECTIVE

We examine the effectiveness of adding a blended smartphone intervention based on community reinforcement approach, motivational interviewing- and cognitive behavioral therapy compared to OMT as usual that aims to improve OMT outcomes and addresses common mental health symptoms in OMT patients in Iran.

METHOD

Adults with opioid dependence entering 8 treatment centers in Tehran, Iran will be randomly assigned to receive either OMT plus a smartphone intervention or OMT as usual. The primary outcomes will be the percentage of negative urine tests for illicit, non-prescribed use of opioids (opium, heroin, tramadol) and treatment retention. Secondary outcomes will include the longest period of abstinence from the illicit, non-prescribed use of opioids (opium, heroin, and tramadol) confirmed by urine samples, changes in communicable disease risk-taking behaviors, changes in stress and common mental health symptoms, and client satisfaction. Data analysis will follow the intention-to-treat principle and employ (generalized) linear mixed models.

DISCUSSION

This study will provide substantial knowledge for designing effective blended interventions for OUD. Moreover, it will investigate if treatment retention and OMT-related outcomes and common mental health symptoms can be improved by adding a smartphone intervention to OMT.

TRIAL REGISTRATION

https://en.irct.ir/trial/53578 .

The effectiveness of digital sexual health interventions for young adults: a systematic literature review (2010-2020)

There has been a proliferation of digital sexual health interventions targeting adolescents; however, limited evaluative reviews have compared the effectiveness of multiple digital tools for sexual health literacy and behaviour change. This study conducted a systematic literature review, screened 9881 records and analysed 61 studies. Findings suggest that websites and mobile phones dominate digital sexual health interventions, with a majority effectively delivering cognitive (e.g. awareness and attitudes about sexual and reproductive health) and behavioural outcomes (e.g. abstinence and use of contraception). The most popular sexual health promotion mechanisms were interactive websites, text messaging and phone calls, and online education programmes, followed by mobile applications-fewer studies in this review utilized social media, games and multimedia. Previous reviews focused on single outcome measures (e.g. sexually transmitted infection testing) to assess interventions' effectiveness. The current review moves beyond single outcome measures to cover a wider range of behavioural and non-behavioural sexual health issues and contexts covered in the literature. Four main categories were analysed as outcomes: cognitive perceptions, promoting sexual health-related behaviours, promoting sexual health-related products and services, and impact (viral load). Seventy-nine per cent of interventions focused on preventive sexual health behaviours and products (e.g. condoms) and services (e.g. HIV testing). Overall, 75% of studies effectively changed sexual health behaviour and cognitive perceptions. However, the digital-only tools did not vary from the blended formats, in influence outcomes, even after categorizing them into behavioural or non-behavioural outcomes. Compared to previous systematic reviews, more studies from the last decade used rigorous research design in the form of randomized controlled trials, non-randomized control trials, and quasi-experiments and lasted longer.

Establishing a Working Definition of User Experience for eHealth Interventions of Self-reported User Experience Measures With eHealth Researchers and Adolescents: Scoping Review

BACKGROUND

Across eHealth intervention studies involving children, adolescents, and their parents, researchers have measured user experience to assist with intervention development, refinement, and evaluation. To date, no widely accepted definitions or measures of user experience exist to support a standardized approach for evaluation and comparison within or across interventions.

OBJECTIVE

We conduct a scoping review with subsequent Delphi consultation to identify how user experience is defined and measured in eHealth research studies, characterize the measurement tools used, and establish working definitions for domains of user experience that could be used in future eHealth evaluations.

METHODS

We systematically searched electronic databases for published and gray literature available from January 1, 2005, to April 11, 2019. We included studies assessing an eHealth intervention that targeted any health condition and was designed for use by children, adolescents, and their parents. eHealth interventions needed to be web-, computer-, or mobile-based, mediated by the internet with some degree of interactivity. We required studies to report the measurement of user experience as first-person experiences, involving cognitive and behavioral factors reported by intervention users. We appraised the quality of user experience measures in included studies using published criteria: well-established, approaching well-established, promising, or not yet established. We conducted a descriptive analysis of how user experience was defined and measured in each study. Review findings subsequently informed the survey questions used in the Delphi consultations with eHealth researchers and adolescent users for how user experience should be defined and measured.

RESULTS

Of the 8634 articles screened for eligibility, 129 articles and 1 erratum were included in the review. A total of 30 eHealth researchers and 27 adolescents participated in the Delphi consultations. On the basis of the literature and consultations, we proposed working definitions for 6 main user experience domains: acceptability, satisfaction, credibility, usability, user-reported adherence, and perceived impact. Although most studies incorporated a study-specific measure, we identified 10 well-established measures to quantify 5 of the 6 domains of user experience (all except for self-reported adherence). Our adolescent and researcher participants ranked perceived impact as one of the most important domains of user experience and usability as one of the least important domains. Rankings between adolescents and researchers diverged for other domains.

CONCLUSIONS

Findings highlight the various ways in which user experience has been defined and measured across studies and what aspects are most valued by researchers and adolescent users. We propose incorporating the working definitions and available measures of user experience to support consistent evaluation and reporting of outcomes across studies. Future studies can refine the definitions and measurement of user experience, explore how user experience relates to other eHealth outcomes, and inform the design and use of human-centered eHealth interventions.

Interactive digital interventions for prevention of sexually transmitted HIV

BACKGROUND

Digital technology offers good opportunities for HIV prevention. This systematic review assesses the effectiveness of interactive digital interventions (IDIs) for prevention of sexually transmitted HIV.

METHODS

We conducted a systematic search for randomized controlled trials (RCTs) of IDIs for HIV prevention, defining 'interactive' as producing personally tailored material. We searched databases including the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, grey literature, reference lists, and contacted authors if needed.Two authors screened abstracts, applied eligibility and quality criteria and extracted data. Meta-analyses used random-effects models with standardized mean differences (SMD) for continuous outcomes and odds ratios (OR) for binary outcomes, assessing heterogeneity using the I2 statistic.

RESULTS

We included 31 RCTs of IDIs for HIV prevention. Meta-analyses of 29 RCTs comparing IDIs with minimal interventions (e.g. leaflet, waiting list) showed a moderate increase in knowledge (SMD 0.56, 95% CI 0.33 to 0.80), no effect on self-efficacy (SMD 0.13, 95% CI 0.00 to 0.27), a small improvement in intention (SMD 0.16, 95% CI 0.06 to 0.26), improvement in HIV prevention behaviours (OR 1.28, 95% CI 1.04 to 1.57) and a possible increase in viral load, but this finding is unreliable.We found no evidence of difference between IDIs and face-to-face interventions for knowledge, self-efficacy, intention, or HIV-related behaviours in meta-analyses of five small RCTs. We found no health economic studies.

CONCLUSION

There is good evidence that IDIs have positive effects on knowledge, intention and HIV prevention behaviours. IDIs are appropriate for HIV prevention in a variety of settings.Supplementary Video Abstract, http://links.lww.com/QAD/B934.

Evaluating the Effectiveness of a Web-Based Program (POP4Teens) to Prevent Prescription Opioid Misuse Among Adolescents: Randomized Controlled Trial

Background

Prescription opioid (PO) use is common among adolescents in the United States. Despite recent declines from unprecedented peaks in adolescent PO use (eg, in 2012-2013), there is seemingly paradoxical evidence that PO-related consequences (eg, opioid use disorder and overdoses) are increasing. These trends and their possible consequences emphasize the importance of prevention efforts targeting PO misuse. To our knowledge, we have developed the first interactive web-based program (POP4Teens [P4T]) focused specifically on the prevention of PO misuse among adolescents.

Objective

This study aimed to evaluate the effectiveness of P4T, a web-based program designed to prevent adolescent PO misuse, in comparison with JustThinkTwice (JTT), an active control website, on PO-related attitudes, knowledge, risk perception, and intentions to use.

Methods

We conducted a web-based randomized controlled trial in 2018. A total of 406 adolescents (aged 12-17 years) were randomly assigned to either P4T or JTT. The outcome variables were attitudes, knowledge, and risk perceptions associated with PO misuse, intentions to use POs, and program feedback. Data were collected at baseline and at 1, 3, and 6 months.

Results

Both programs resulted in significant and sustained improvements in intention to use POs, increased perceived risk, impacted expectancies consistent with prevention, and improved PO refusal skills. P4T produced significantly greater increases in PO-related knowledge than JTT did, and it was reportedly easier to use and more liked. Baseline scores for youth reporting past-year medical use of POs, friends who engage in nonmedical use of POs, and/or poor mental health underscored their at-risk status compared with youth from the other groups.

Conclusions

P4T positively impacted all study variables that are known to prevent PO misuse among teens. Moreover, its web-based nature simplifies the dissemination and implementation of this novel tool designed to help meet the challenges of the evolving national opioid crisis.

Trial Registration

ClinicalTrials.gov NCT02737696; https://clinicaltrials.gov/ct2/show/NCT02737696

Electronic and other new media technology interventions for HIV care and prevention: a systematic review

INTRODUCTION

Electronic and other new media technologies (eHealth) can facilitate large-scale dissemination of information and effective delivery of interventions for HIV care and prevention. There is a need to both monitor a rapidly changing pipeline of technology-based care and prevention methods and to assess whether the interventions are appropriately diversified. We systematically review and critically appraise the research pipeline of eHealth interventions for HIV care and prevention, including published studies and other funded projects.

METHODS

Two peer-reviewed literature databases were searched for studies describing the development, trial testing or implementation of new technology interventions, published from September 2014 to September 2018. The National Institutes of Health database of grants was searched for interventions still in development. Interventions were included if eHealth was utilized and an outcome directly related to HIV treatment or prevention was targeted. We summarized each intervention including the stage of development, eHealth mode of delivery, target population and stage of the HIV care and prevention continua targeted.

RESULTS AND DISCUSSION

Of 2178 articles in the published literature, 113 were included with 84 unique interventions described. The interventions utilize a variety of eHealth technologies and target various points on the prevention and care continua, with greater emphasis on education, behaviour change and testing than linkage to medical care. There were a variety of interventions for HIV care support but none for PrEP care. Most interventions were developed for populations in high income countries. An additional 62 interventions with funding were found in the development pipeline, with greater emphasis on managing HIV and PrEP care.

CONCLUSIONS

Our systematic review found a robust collection of eHealth interventions in the published literature as well as unpublished interventions still in development. In the published literature, there is an imbalance of interventions favouring education and behaviour change over linkage to care, retention in care, and adherence, especially for PrEP. The next generation of interventions already in the pipeline might address these neglected areas of care and prevention, but the development process is slow. Researchers need new methods for more efficient and expedited intervention development so that current and future needs are addressed.

The Effect of Technology-Based Programmes on Changing Health Behaviours of Adolescents: Systematic Review

Technology-based applications in the health field have been increasing in recent years. Since they attract adolescents' attention, technology-based applications can be used in health-promoting interventions. This systematic literature review was conducted to determine the effect of technology-based programmes in changing adolescent health behaviors. In the literature review, 16 randomized controlled empirical studies with full text published in English between 2011 and 2016 in the PubMed and Science Direct databases were investigated. The sample of the studies investigated under the scope of this study consisted of adolescents in the age range of 12-24 years. The intervention time was determined to be a minimum of two weeks and a maximum of 24 months. When the resulting studies were examined, the model was used in some of the studies. The intervention methods used for adolescents were generally presented as informing, counseling services, protection, behavioral change development, self-assessment, goal development and problem-solving. It was observed that the majority of the studies were Internet and computer-based, and some were mobile phone-based. In 56.25% of the studies, the development in the studied health behaviors was found to be significant. In addition, 62.5% of the adolescents stated that they were satisfied with technology-based programmes. In the studies, some of the difficulties in the use of technology included the participants' withdrawing from the research, their having difficulties in accessing the website, and other technical problems. The use of technology in health promotion is becoming widespread, especially among adolescents, which increases the success of behavioural change. However, further randomized controlled studies are needed in the field to increase evidence-based knowledge.

A Virtual Reality–Based Psychological Treatment in Long-Term Hospitalization: A Case Study

The aim of this article is to provide preliminary efficacy of a psychological intervention for children and young patients to help them to improve resilience, coping strategies for pain, anxiety, and general emotional discomfort in long-term hospitalization using a virtual reality videogame and telepsychology. A case study illustration in an adolescent was 15-year-old Spanish boy hospitalized in the pediatric ward and prescribed dialysis is presented to provide some clinical evidence of the treatment’s strategic feasibility and efficacy for this population. Patient was pre, post, and follow-up assessed anxiety, affective, resilience, and avoidance. Space Academy is a virtual reality–based treatment with positive psychology and third-wave therapy components that consist in understanding the basic aspects of their disease, to promote emotional perception and regulation and promote and develop resilience. Results show good acceptability and feasibility, improved state and trait anxiety, resilience, and emotional competence in controlling behavior. The case illustration shows improvements in anxiety resilience and acceptance. The use of information and communication technologies in psychology is an advance in clinical and health care psychology.

Entertainment-Education Videos as a Persuasive Tool in the Substance Use Prevention Intervention "keepin' it REAL"

Based on social cognitive theory and narrative engagement theory, the current study examined hypothesized indirect effects of engagement with keepin' it REAL (kiR) curriculum entertainment-education (E-E) videos on youth alcohol use via youth drug offer refusal efficacy. Students in 7th grade (N = 1,464) at 25 public schools in two Midwestern states were randomly assigned to one of the two versions of the kiR curriculum, the kiR urban version and the kiR rural version. Each version had their own set of five culturally-grounded E-E videos depicting communicative skills to refuse drug offers. Differential effects for engagement components were expected depending on the degree of cultural matching. Pre/post surveys were administered at the beginning and the end of 7th grade. Structural equation modeling analysis resulted in partial support for the research hypotheses. Rural youth receiving the urban curriculum who reported higher interest in the E-E videos were more likely to report having higher refusal efficacy, and in turn, less likely to use alcohol. Rural youth receiving the rural curriculum who identified with the E-E video main characters were more likely to report having higher refusal efficacy, and in turn, less likely to use alcohol. Implications for E-E health promotion are discussed.

A Systematic Review on Effect of Electronic Media on Diet, Exercise, and Sexual Activity among Adolescents

Context

Electronic media has become a part of day-to-day life for all, and particularly more so for children and adolescents. Exposure to electronic media may be beneficial as well as harmful.

Aim

The aim of the study is to systematically synthesize existing published and non-published empirical evidence on the effect of exposure to electronic media on diet, exercise, and sexual activity.

Methodology

Two reviewers independently searched online databases such as MEDLINE, CENTRAL, and EMBASE. We applied no language, date, or publication restrictions.

Selection Criteria

We included randomized control trials that assessed the effect of exposure of electronic media on diet, exercise, and sexual activity in participants between 5 and 19 years.

Study Selection Data Extraction

Two reviewers independently screened studies identified in electronic search and independently extracted data and assessed the risk of bias of included studies.

Data Analysis

We had planned to use the risk ratio or odds ratio for dichotomous data, and mean difference (MD) or standardized MD for continuous data. However, as included studied differed in types of intervention and reporting of outcomes, we did not undertake meta-analysis.

Main Results

All included trials were parallel randomized controlled trials except for one that was a crossover trial. Eight studies reported the effect of electronic media on diet and exercise, two on diet, two on exercise, and one on sexual activity. Quality of evidence was rated as "very low" for all outcomes due to too little information or too few data to be able to reach to any conclusions.

Conclusions

There is a little body of evidence that limits conclusions. We need to comprehend as to how to swap undesirable effects of electronic media and make it more desirable.

Registration of Systematic Review

This systematic review has been registered at PROSPERO International prospective register of systematic reviews (Registration number: PROSPERO 2018 CRD42018086935) available at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=86935.

Randomized Controlled Trials of Technology-Based HIV/STI and Drug Abuse Preventive Interventions for African American and Hispanic Youth: Systematic Review

BACKGROUND

HIV/sexually transmitted infections (STIs) and drug abuse remain significant public health concerns in the United States, and African American and Hispanic youth are disproportionately affected. Although technology-based interventions are efficacious in preventing and reducing HIV/STI and licit/illicit drug use behaviors, relatively little is known regarding the state of the science of these interventions among African American and Hispanic youth.

OBJECTIVE

The aim of this review is to identify and examine randomized controlled trials (RCTs) of technology-based HIV/STI and/or drug abuse preventive interventions for African American and Hispanic youth.

METHODS

We searched electronic databases (ie, PubMed, Proquest, PsycINFO, Ebscohost, Google Scholar) to identify studies between January 2006 and October 2016. RCTs of technology-based interventions targeting African American and Hispanic youth HIV/STI risk behaviors, including sexual risk, licit and illicit drug use, and HIV/STI testing were included.

RESULTS

Our search revealed a total of three studies that used an RCT design and included samples comprised of >50% African American and/or Hispanic youth. The follow-up assessments ranged from two weeks to six months and the number of participants in each trial ranged from 72 to 141. The three interventions were theory-driven, interactive, and tailored. The long-term effects of the interventions were mixed, and outcomes included reductions in sex partners, licit drug use, and condomless anal sex acts.

CONCLUSIONS

Although technology-based interventions seem promising in the prevention of HIV/STI and drug abuse among African American and Hispanic youth, more research is needed.

Implementation of a Web-Based Organ Donation Educational Intervention: Development and Use of a Refined Process Evaluation Model

Background

The lack of available organs is often considered to be the single greatest problem in transplantation today. Internet use is at an all-time high, creating an opportunity to increase public commitment to organ donation through the broad reach of Web-based behavioral interventions. Implementing Internet interventions, however, presents challenges including preventing fraudulent respondents and ensuring intervention uptake. Although Web-based organ donation interventions have increased in recent years, process evaluation models appropriate for Web-based interventions are lacking.

Objective

The aim of this study was to describe a refined process evaluation model adapted for Web-based settings and used to assess the implementation of a Web-based intervention aimed to increase organ donation among African Americans.

Methods

We used a randomized pretest-posttest control design to assess the effectiveness of the intervention website that addressed barriers to organ donation through corresponding videos. Eligible participants were African American adult residents of Georgia who were not registered on the state donor registry. Drawing from previously developed process evaluation constructs, we adapted reach (the extent to which individuals were found eligible, and participated in the study), recruitment (online recruitment mechanism), dose received (intervention uptake), and context (how the Web-based setting influenced study implementation) for Internet settings and used the adapted model to assess the implementation of our Web-based intervention.

Results

With regard to reach, 1415 individuals completed the eligibility screener; 948 (67.00%) were determined eligible, of whom 918 (96.8%) completed the study. After eliminating duplicate entries (n=17), those who did not initiate the posttest (n=21) and those with an invalid ZIP code (n=108), 772 valid entries remained. Per the Internet protocol (IP) address analysis, only 23 of the 772 valid entries (3.0%) were within Georgia, and only 17 of those were considered unique entries and could be considered for analyses. With respect to recruitment, 517 of the 772 valid entries (67.0%) of participants were recruited from a Web recruiter. Regarding dose received, no videos from the intervention website were watched in their entirety, and the average viewing duration was 17 seconds over the minimum. With respect to context, context analysis provided us with valuable insights into factors in the Internet environment that may have affected study implementation. Although only active for a brief period of time, the Craigslist website advertisement may have contributed the largest volume of fraudulent responses.

Conclusions

We determined fraud and low uptake to be serious threats to this study and further confirmed the importance of conducting a process evaluation to identify such threats. We suggest checking participants’ IP addresses before study initiation, selecting software that allows for automatic duplicate protection, and tightening minimum requirements for intervention uptake. Further research is needed to understand how process evaluation models can be used to monitor implementation of Web-based studies.

Computer-Based Prevention and Intervention to Reduce Substance Use in Youth

Purpose of Review

Computer-based programs for substance use prevention and intervention among youth are on the ascendancy. Whether delivered by computer per se or by electronic tablet or smartphone, technology-driven programs are harmonious with how young people access information and interact with their worlds. This review examines recent evidence on computer-based programs aimed at substance use among youth, with particular attention to results from randomized trials.

Recent Findings

Outcome studies of computer-based, substance use-related programs published over the past 5 years reveal mixed results amidst diverse intervention approaches and delivery settings. Many studies are marred by high attrition. Notable in the recent literature is the international nature of technology-driven substance use prevention and intervention programs. With some exceptions, most programs appear to not have been customized for their recipient populations. Though few in number, the highest-quality studies of computer-based programs show positive outcomes in reduced substance use rates.

Summary

Based on recent findings, considerable work needs to happen before computer-delivered approaches are a proven means for reducing substance use among youth. Original programs, expressly developed for subgroups of youth, are in short supply. Though controlled designs are becoming commonplace, too many studies of computer-based programs suffer from flaws-including high rates of attrition-that limit the discovery of positive outcomes.

A Randomized-Controlled Trial of Computer-based Prevention Counseling for HIV-Positive Persons (HPTN 065)

OBJECTIVE

Decreasing the risk of HIV transmission from HIV-positive individuals is an important public health priority. We evaluated the effectiveness of a computer-based sexual risk reduction counseling intervention (CARE+) among HIV-positive persons enrolled in care.

METHODS

HIV-positive eligible participants (N=1075) were enrolled from 11 care sites in the Bronx, NY and Washington, DC and randomized 1:1 to either a tablet-based self-administered CARE+ intervention or standard of care (SOC). The primary outcome was the proportion of participants reporting any unprotected vaginal/anal sex at last sex, among all partners, HIV-negative or HIV-unknown-status partners and for primary and non-primary partners.

RESULTS

At baseline, 7% of participants in both arms reported unprotected sex with an HIV-negative or HIV-unknown-status partner, while 13% in the CARE+ arm and 17% in the SOC arm reported unprotected sex with any partner. Most participants (88%) were on antiretroviral therapy (ART) at baseline. There was no significant difference in changes over time in unprotected vaginal/anal sex between the CARE+ and SOC arms for any partners (p=0.67) or either HIV-negative or HIV-unknown-status partners (p=0.40). At the Month 12 visit, most participants (85%) either strongly agreed or agreed that computer counseling would be a good addition to in-person counseling by a provider.

CONCLUSION

The CARE+ intervention was not effective at reducing sexual risk behaviors among HIV-positive patients in care, most of whom were on ART. Further research may be warranted around the utility of computer-based counseling for HIV prevention.

School-based interventions for preventing HIV, sexually transmitted infections, and pregnancy in adolescents

BACKGROUND

School-based sexual and reproductive health programmes are widely accepted as an approach to reducing high-risk sexual behaviour among adolescents. Many studies and systematic reviews have concentrated on measuring effects on knowledge or self-reported behaviour rather than biological outcomes, such as pregnancy or prevalence of sexually transmitted infections (STIs).

OBJECTIVES

To evaluate the effects of school-based sexual and reproductive health programmes on sexually transmitted infections (such as HIV, herpes simplex virus, and syphilis), and pregnancy among adolescents.

SEARCH METHODS

We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) for published peer-reviewed journal articles; and ClinicalTrials.gov and the World Health Organization's (WHO) International Clinical Trials Registry Platform for prospective trials; AIDS Educaton and Global Information System (AEGIS) and National Library of Medicine (NLM) gateway for conference presentations; and the Centers for Disease Control and Prevention (CDC), UNAIDS, the WHO and the National Health Service (NHS) centre for Reviews and Dissemination (CRD) websites from 1990 to 7 April 2016. We handsearched the reference lists of all relevant papers.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), both individually randomized and cluster-randomized, that evaluated school-based programmes aimed at improving the sexual and reproductive health of adolescents.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, evaluated risk of bias, and extracted data. When appropriate, we obtained summary measures of treatment effect through a random-effects meta-analysis and we reported them using risk ratios (RR) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included eight cluster-RCTs that enrolled 55,157 participants. Five trials were conducted in sub-Saharan Africa (Malawi, South Africa, Tanzania, Zimbabwe, and Kenya), one in Latin America (Chile), and two in Europe (England and Scotland). Sexual and reproductive health educational programmesSix trials evaluated school-based educational interventions.In these trials, the educational programmes evaluated had no demonstrable effect on the prevalence of HIV (RR 1.03, 95% CI 0.80 to 1.32, three trials; 14,163 participants; low certainty evidence), or other STIs (herpes simplex virus prevalence: RR 1.04, 95% CI 0.94 to 1.15; three trials, 17,445 participants; moderate certainty evidence; syphilis prevalence: RR 0.81, 95% CI 0.47 to 1.39; one trial, 6977 participants; low certainty evidence). There was also no apparent effect on the number of young women who were pregnant at the end of the trial (RR 0.99, 95% CI 0.84 to 1.16; three trials, 8280 participants; moderate certainty evidence). Material or monetary incentive-based programmes to promote school attendanceTwo trials evaluated incentive-based programmes to promote school attendance.In these two trials, the incentives used had no demonstrable effect on HIV prevalence (RR 1.23, 95% CI 0.51 to 2.96; two trials, 3805 participants; low certainty evidence). Compared to controls, the prevalence of herpes simplex virus infection was lower in young women receiving a monthly cash incentive to stay in school (RR 0.30, 95% CI 0.11 to 0.85), but not in young people given free school uniforms (Data not pooled, two trials, 7229 participants; very low certainty evidence). One trial evaluated the effects on syphilis and the prevalence was too low to detect or exclude effects confidently (RR 0.41, 95% CI 0.05 to 3.27; one trial, 1291 participants; very low certainty evidence). However, the number of young women who were pregnant at the end of the trial was lower among those who received incentives (RR 0.76, 95% CI 0.58 to 0.99; two trials, 4200 participants; low certainty evidence). Combined educational and incentive-based programmesThe single trial that evaluated free school uniforms also included a trial arm in which participants received both uniforms and a programme of sexual and reproductive education. In this trial arm herpes simplex virus infection was reduced (RR 0.82, 95% CI 0.68 to 0.99; one trial, 5899 participants; low certainty evidence), predominantly in young women, but no effect was detected for HIV or pregnancy (low certainty evidence).

AUTHORS' CONCLUSIONS

There is a continued need to provide health services to adolescents that include contraceptive choices and condoms and that involve them in the design of services. Schools may be a good place in which to provide these services. There is little evidence that educational curriculum-based programmes alone are effective in improving sexual and reproductive health outcomes for adolescents. Incentive-based interventions that focus on keeping young people in secondary school may reduce adolescent pregnancy but further trials are needed to confirm this.

Technology-based Interventions for Preventing and Treating Substance Use Among Youth

Preventing or mitigating substance use among youth generally involves 3 different intervention frameworks: universal prevention, selective prevention, and treatment. Each of these levels of intervention poses unique therapeutic and implementation challenges. Technology-based interventions provide solutions to many of these problems by delivering evidence-based interventions in a consistent and cost-effective manner. This article summarizes the current state of the science of technology-based interventions for preventing substance use initiation and mitigating substance use and associated consequences among youth.