Behavioral intervention to increase condom use among high-risk female adolescents

Sexual risk behaviour reduction interventions in primary care in Organization of Economic Cooperation and Development countries. A systematic review

BACKGROUND

Sexually transmitted infections are a major public health issue, both in France and worldwide. Primary healthcare professionals play a key role in sexual health and prevention, but few take on this subject. Prevention strategies are diverse, thus risk reduction strategies focussing on behavioural changes are still needed.

PURPOSE

We conducted a systematic review to analyse risk reduction interventions focussing on behavioural change in OECD countries in primary healthcare settings to help develop a prevention tool easy to apply in primary care.

METHODS

We searched for English- or French-language controlled trials in PubMed, Cochrane Library, Scopus, PsycINFO, PsycArticle, PBSC, SocINDEX, Google Scholar, and CAIRN, supplemented with the bibliographies of previous systematic reviews. Thirty controlled, randomized, or nonrandomized trials were included in the systematic review. We did not conduct any meta-analysis due to the diversity of populations, outcomes and study designs.

RESULTS

There are efficient interventions in primary healthcare settings for reducing sexual risk behaviours and/or incident STI. Their efficiency seems to grow with the length and intensity of the intervention. Most interventions target only young, high-risk patients, and their long-term impact is uncertain. Most included studies had an overall risk of bias estimated as high or with some concerns.

CONCLUSIONS

Some tools could be used in primary care, with possible efficiency though results are difficult to generalize, and value should be assessed in daily practice. Future research should also focus on older population given the epidemiological evolutions, but also lower-risk population to target all patients seen in primary care settings.

Expedited Partner Therapy in Female Adolescents: A Study of Acceptance and the Impact on Reinfection Rates

BACKGROUND

Given the high risk of sexually transmitted infections (STIs) in adolescents and young adults (AYAs), this study evaluated expedited partner therapy (EPT) acceptance and STI reinfection rates in female AYA before and after availability of EPT.

METHODS

The pre-EPT cohort was a 3-year (November 2012 to November 2015) retrospective chart review of female AYA positive for Chlamydia trachomatis (CT) and/or Trichomonas vaginalis (TV) before introduction of EPT. An EPT protocol for CT and TV infections was implemented after legalization in Ohio in 2016. The post-EPT cohort was a prospective review of patients positive for CT and TV for 2 years (5/2016-5/2018) after EPT introduction. We evaluated EPT acceptance and compared reinfection rates (positive test 1-6 months after initial infection) in the pre-EPT versus post-EPT cohorts and by EPT acceptance.

RESULTS

Among patients offered EPT, 28% (67/237) with CT and 25% (24/97) with TV accepted EPT. There were no significant differences in the reinfection rates for CT or TV in the pre-EPT versus post-EPT cohorts (CT: 24% (57/240) vs 20% (38/192), P = 0.42; TV: 23% (22/97) versus 14% (12/87), P = 0.11). Although lower, reinfections rates were not significantly different among patients who accepted versus did not accept EPT (CT, 13% (6/48) vs 21% (23/110), P = 0.50 and TV, 6% (1/18) vs 18% (9/49), P = 0.69).

CONCLUSIONS

Despite the implementation of an EPT protocol, STI reinfection rates among female AYA remained high, and many declined EPT. Further research is needed to identify barriers to the provision and acceptance of EPT and ways to address these factors.

Behaviour change techniques in brief interventions to prevent HIV, STI and unintended pregnancies: A systematic review

BACKGROUND

Behaviour-change interventions have been consistently considered an essential part of comprehensive HIV, STI and unintended pregnancy prevention. In 2015, the World Health Organization reviewed and assessed existing evidence on brief behavioural interventions, leading to the publication of Brief sexuality-related communication: recommendations for a public health approach. This guideline recommends the use of brief behaviour intervention and communication programmes to promote sexual health and to prevent HIV, STIs, and unintended pregnancies in primary health services, particularly sexual and reproductive health services.

OBJECTIVE

With the purpose of informing the development of a brief behaviour intervention in sexual and reproductive health, we conducted a systematic review of brief intervention to prevent HIV, STI and unintended pregnancies, to identify behaviour change techniques (BCTs) used in health care settings.

METHODS

Participants from all ages and genders were included. Brief interventions delivered in ≤ 60 minutes were included. Data was extracted, and interventions were coded following the Behaviour Change Techniques Taxonomy (BCTTv1) guidelines.

RESULTS

Of the 6.687 articles identified, 355 were reviewed and 37 studies were included. In effective interventions, we identified 48 behaviour change techniques (BCTs). A core set of 8 frequently used behaviour change techniques was identified: "Problem solving", "Feedback on behaviour", "Social support (unspecified)", "Instructions on how to perform the behaviour", "Information about health consequences", "Information about social and environmental consequences", "Demonstration of the behaviour" and "Credible source".

CONCLUSIONS

The technical content of brief behaviour interventions was identified in a reliable and standardized way providing preliminary indications on potentially effective techniques to achieve behaviour change.

Single-Session Behavioral Interventions for Sexual Risk Reduction: A Meta-Analysis

BACKGROUND

Evidence-based, single-session STI/HIV interventions to reduce sexual risk taking are potentially effective options for implementation in resource-limited settings and may solve problems associated with poor participant retention.

PURPOSE

The purpose of the study is to estimate the efficacy of single-session, behavioral interventions in reducing unprotected sex or increasing condom use.

METHODS

Data sources were searched through April 2013 producing 67 single-session interventions (52 unique reports; N = 20,039) that included outcomes on condom use and/or unprotected sex.

RESULTS

Overall, participants in single-session interventions reduced sexual risk taking relative to control groups (d ₊  = 0.19, 95 % CI = 0.11, 0.27). Within-group effects of the interventions were larger than the between-groups effects when compared to controls.

CONCLUSIONS

Brief, targeted single-session sexual risk reduction interventions demonstrate a small but significant effect and should be prioritized.

A Review of Expedited Partner Therapy for the Management of Sexually Transmitted Infections in Adolescents

Adolescents are at high risk of acquiring and becoming reinfected with sexually transmitted infections. Partner notification and treatment are essential to preventing the spread of sexually transmitted infections. Expedited partner therapy (EPT) is a method of partner treatment used by medical providers to treat patients' sexual partners without direct medical evaluation or counseling. The objective of this article is to review the current literature regarding EPT effectiveness, patients' attitudes and acceptance of EPT, and providers' views and practices surrounding the use of this method of partner treatment. In this article potential concerns associated with EPT use, current policy statements, and the legal status of EPT are discussed. EPT results in improved or equivalent rates of reinfection in adolescents and adults with Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Overall, patients are accepting of this method of partner treatment, however, providers continue to have concerns that limit its routine use. Additional studies in adolescents will help providers better understand if EPT is a useful method to prevent reinfection in this population.

The Role of Behavioral Counseling in Sexually Transmitted Disease Prevention Program Settings

BACKGROUND

Behavioral counseling for sexually transmitted disease (STD) prevention is recommended for persons at risk, and the body of evidence yields numerous interventions that have STD preventive efficacy. What is needed is a review of the subset of these interventions that could be feasible in clinical settings, especially settings in STD prevention programs.

METHODS

We reviewed existing systematic reviews of the literature and abstracted from them studies that fit the following criteria in that the interventions: (1) used no more than 60 minutes of contact time in 1 to 2 sessions, (2) were individual level and face to face, (3) took place in a clinical setting, (4) had STD outcomes available, (5) were based in the United States, (6) were peer reviewed, and (7) had a control group.

RESULTS

From 6 reviews (published 2006-2014) covering 91 studies, we found 13 analyses representing 11 intervention studies that fit the selection criteria. Of these 13, 5 returned lower STD rates in the intervention group at follow-up; one study reported a higher rate of STD in one subset of the intervention group (men who have sex with men). Studies with effects on STD at follow-up were quite similar to studies across populations, settings, and follow-up periods, although successful interventions were more likely to demonstrate behavioral effects as well (5/5 vs. 2/5 among 10 interventions measuring behavior change).

CONCLUSIONS

Counseling is likely to benefit some STD clinic attendees, although unlikely to benefit men who have sex with men. The balance of costs and benefits of implementing behavioral counseling in STD programs is unclear, but feasibility would be improved if behavioral counseling were implemented in the context of other prevention efforts. Because populations outside typical STD clinic settings could also benefit, programs may exercise a valuable role through partnerships.

Interventions for preventing unintended pregnancies among adolescents

BACKGROUND

Unintended pregnancy among adolescents represents an important public health challenge in high-income countries, as well as middle- and low-income countries. Numerous prevention strategies such as health education, skills-building and improving accessibility to contraceptives have been employed by countries across the world, in an effort to address this problem. However, there is uncertainty regarding the effects of these interventions, hence the need to review the evidence-base.

OBJECTIVES

To assess the effects of primary prevention interventions (school-based, community/home-based, clinic-based, and faith-based) on unintended pregnancies among adolescents.

SEARCH METHODS

We searched all relevant studies regardless of language or publication status up to November 2015. We searched the Cochrane Fertility Regulation Group Specialised trial register, The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015 Issue 11), MEDLINE, EMBASE, LILACS, Social Science Citation Index and Science Citation Index, Dissertations Abstracts Online, The Gray Literature Network, HealthStar, PsycINFO, CINAHL and POPLINE and the reference lists of articles.

SELECTION CRITERIA

We included both individual and cluster randomised controlled trials (RCTs) evaluating any interventions that aimed to increase knowledge and attitudes relating to risk of unintended pregnancies, promote delay in the initiation of sexual intercourse and encourage consistent use of birth control methods to reduce unintended pregnancies in adolescents aged 10 years to 19 years.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias, and extracted data. Where appropriate, binary outcomes were pooled using a random-effects model with a 95% confidence interval (Cl). Where appropriate, we combined data in meta-analyses and assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 53 RCTs that enrolled 105,368 adolescents. Participants were ethnically diverse. Eighteen studies randomised individuals, 32 randomised clusters (schools (20), classrooms (6), and communities/neighbourhoods (6). Three studies were mixed (individually and cluster randomised). The length of follow up varied from three months to seven years with more than 12 months being the most common duration. Four trials were conducted in low- and middle- income countries, and all others were conducted in high-income countries. Multiple interventionsResults showed that multiple interventions (combination of educational and contraceptive-promoting interventions) lowered the risk of unintended pregnancy among adolescents significantly (RR 0.66, 95% CI 0.50 to 0.87; 4 individual RCTs, 1905 participants, moderate quality evidence. However, this reduction was not statistically significant from cluster RCTs. Evidence on the possible effects of interventions on secondary outcomes (initiation of sexual intercourse, use of birth control methods, abortion, childbirth, sexually transmitted diseases) was not conclusive.Methodological strengths included a relatively large sample size and statistical control for baseline differences, while limitations included lack of biological outcomes, possible self-report bias, analysis neglecting clustered randomisation and the use of different statistical tests in reporting outcomes. Educational interventionsEducational interventions were unlikely to significantly delay the initiation of sexual intercourse among adolescents compared to controls (RR 0.95, 95% CI 0.71 to 1.27; 2 studies, 672 participants, low quality evidence).Educational interventions significantly increased reported condom use at last sex in adolescents compared to controls who did not receive the intervention (RR 1.18, 95% CI 1.06 to 1.32; 2 studies, 1431 participants, moderate quality evidence).However, it is not clear if the educational interventions had any effect on unintended pregnancy as this was not reported by any of the included studies. Contraceptive-promoting interventionsFor adolescents who received contraceptive-promoting interventions, there was little or no difference in the risk of unintended first pregnancy compared to controls (RR 1.01, 95% CI 0.81 to 1.26; 2 studies, 3,440 participants, moderate quality evidence).The use of hormonal contraceptives was significantly higher in adolescents in the intervention group compared to those in the control group (RR 2.22, 95% CI 1.07 to 4.62; 2 studies, 3,091 participants, high quality evidence)

AUTHORS' CONCLUSIONS

A combination of educational and contraceptive-promoting interventions appears to reduce unintended pregnancy among adolescents.  Evidence for programme effects on biological measures is limited. The variability in study populations, interventions and outcomes of included trials, and the paucity of studies directly comparing different interventions preclude a definitive conclusion regarding which type of intervention is most effective.

Cluster randomized controlled trial protocol: addressing reproductive coercion in health settings (ARCHES)

Background

Women ages 16–29 utilizing family planning clinics for medical services experience higher rates of intimate partner violence (IPV) and reproductive coercion (RC) than their same-age peers, increasing risk for unintended pregnancy and related poor reproductive health outcomes. Brief interventions integrated into routine family planning care have shown promise in reducing risk for RC, but longer-term intervention effects on partner violence victimization, RC, and unintended pregnancy have not been examined.

Methods/Design

The ‘Addressing Reproductive Coercion in Health Settings (ARCHES)’ Intervention Study is a cluster randomized controlled trial evaluating the effectiveness of a brief, clinician-delivered universal education and counseling intervention to reduce IPV, RC and unintended pregnancy compared to standard-of-care in family planning clinic settings. The ARCHES intervention was refined based on formative research. Twenty five family planning clinics were randomized (in 17 clusters) to either a three hour training for all family planning clinic staff on how to deliver the ARCHES intervention or to a standard-of-care control condition. All women ages 16–29 seeking care in these family planning clinics were eligible to participate. Consenting clients use laptop computers to answer survey questions immediately prior to their clinic visit, a brief exit survey immediately after the clinic visit, a first follow up survey 12–20 weeks after the baseline visit (T2), and a final survey 12 months after the baseline (T3). Medical record chart review provides additional data about IPV and RC assessment and disclosure, sexual and reproductive health diagnoses, and health care utilization. Of 4009 women approached and determined to be eligible based on age (16–29 years old), 3687 (92 % participation) completed the baseline survey and were included in the sample.

Discussion

The ARCHES Intervention Study is a community-partnered study designed to provide arigorous assessment of the short (3-4 months) and long-term (12 months) effects of a brief, clinician-delivered universal education and counseling intervention to reduce IPC, RC and unintended pregnancy in family planning clinic settings. The trial features a cluster randomized controlled trial design, a comprehensive data collection schedule and a large sample size with excellent retention.

Trial Registration

ClinicialTrials.gov NCT01459458. Registered 10 October 2011.

Programs to improve adolescent sexual and reproductive health in the US: a review of the evidence

BACKGROUND

US adolescents have high rates of teen pregnancy, childbearing, and sexually transmitted infections (STIs), highlighting the need to identify and implement effective programs that will help improve teen sexual and reproductive health.

MATERIALS AND METHODS

This review identified 103 random-assignment evaluations of 85 programs that incorporated intent-to-treat analyses and assessed impacts on pregnancy, childbearing, STIs, and their key determinants - sexual activity, number of sexual partners, condom use, and other contraceptive use - among teens. This review describes the evidence base for five broad program approaches, including abstinence education, comprehensive sex education, clinic-based programs, youth development programs, and parent-youth relationship programs. We also describe programs with impacts on key outcomes, including pregnancy/childbearing, STIs, and those that found impacts on both sexual activity and contraceptive use.

RESULTS

Our review identified 52 effective programs: 38 with consistent impacts on reproductive health outcomes, and 14 with mixed findings (across subpopulations, follow-ups, or multiple measures of a single outcome). We found that a variety of program approaches produced impacts on sexual and reproductive health outcomes. Parent-youth relationship programs and clinic-based program evaluations more frequently showed impacts than other program approaches, although we also identified a number of abstinence-education, comprehensive sex education, and youth-development programs with impacts on sexual and reproductive health outcomes. Overall, we identified nine program evaluations with impacts on teen pregnancies or births, five with impacts on reducing STIs, and 15 with impacts on both delaying/reducing sexual activity and increasing contraceptive use (including condom use).

CONCLUSION

Future efforts should conduct replications of existing program evaluations, identify implementation components linked to impacts, rigorously evaluate programs that appear promising, and expand the evidence base on programs that impact hormonal and long-acting contraceptive method use.

Risk evaluations and condom use decisions of homeless youth: a multi-level qualitative investigation

Background

Homeless youth are at higher risk for sexually transmitted infections and unwanted pregnancy than non-homeless youth. However, little is known about how they evaluate risk within the context of their sexual relationships. It is important to understand homeless youths' condom use decisions in light of their sexual relationships because condom use decisions are influenced by relationship dynamics in addition to individual attitudes and event circumstances. It is also important to understand how relationship level factors, sexual event circumstances, and individual characteristics compare and intersect.

Methods

To explore these issues, we conducted semi-structured interviews with 37 homeless youth in Los Angeles County in 2011 concerning their recent sexual relationships and analyzed the data using systematic methods of team-based qualitative data analysis.

Results

We identified themes of risk-related evaluations and decisions at the relationship/partner, event, and individual level. We also identified three different risk profiles that emerged from analyzing how different levels of risk intersected across individual respondents. The three profiles included 1) Risk Takers, who consistently engage in risk and have low concern about consequences of risk behavior, 2) Risk Avoiders, who consistently show high concern about protection and consistently avoid risk, and 3) Risk Reactors, those who are inconsistent in their concerns about risk and protection and mainly take risks in reaction to relationship and event circumstances.

Conclusions

Interventions targeting homeless youth should reflect multiple levels of risk behavior and evaluation in order to address the diversity of risk profiles. Relationship/partner-, event-, and individual-level factors are all important but have different levels of importance for different homeless youth. Interventions should be tailored to address the most important factor contributing to homeless youth reproductive needs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1419-9) contains supplementary material, which is available to authorized users.

Brief sexuality communication--a behavioural intervention to advance sexually transmitted infection/HIV prevention: a systematic review

BACKGROUND

Throughout the last decade substantial research has been undertaken to develop evidence-based behaviour change interventions for sexual health promotion. Primary care could provide an opportunistic entry for brief sexual health communication.

OBJECTIVES

We conducted a systematic review to explore opportunistic sexual and reproductive health services for sexual health communication delivered at primary health care level.

SEARCH STRATEGY

We searched for studies on PubMed, ProQuest, CINAHL, Jstor, Scopus/Science Direct, Cochrane database of systematic reviews, EBSCO, CINAHL, PsychoInfo, and Web of Knowledge. Both published and unpublished articles were reviewed.

SELECTION CRITERIA

All randomised controlled trials and controlled clinical trials were included. Participants of all ages, from adolescence onwards were included. Brief (10-60 minutes) interventions including some aspect of communication on sexual health issues were included.

DATA COLLECTION AND ANALYSIS

Data were extracted by two reviewers independently using a standardised form. Interventions differed from each other, hence meta-analysis was not performed, and results are presented individually.

MAIN RESULTS

A total of 247 articles were selected for full-text evaluation, 31 of which were included. Sexually transmitted infections (STIs)/HIV were less often reported in the intervention group compared with the control group. Condom use was higher in most studies in the intervention group. Numbers of sexual partners and unprotected sexual intercourse were lower in the intervention groups.

CONCLUSIONS

There is evidence that brief counselling interventions have some effect in the reduction and prevention of STIs/HIV. Some questions could not be answered, such as the effect over time and in different settings and population groups.

Factor structure and gender stability in the multidimensional condom attitudes scale

Sexually transmitted infections continue to trouble the United States and can be attenuated through increased condom use. Attitudes about condoms are an important multidimensional factor that can affect sexual health choices and have been successfully measured using the Multidimensional Condom Attitudes Scale (MCAS). Such attitudes have the potential to vary between men and women, yet little work has been undertaken to identify if the MCAS accurately captures attitudes without being influenced by underlying gender biases. We examined the factor structure and gender invariance on the MCAS using confirmatory factor analysis and item response theory, within-subscale differential item functioning analyses. More than 770 participants provided data via the Internet. Results of differential item functioning analyses identified three items as differentially functioning between the genders, and removal of these items is recommended. Findings confirmed the previously hypothesized multidimensional nature of condom attitudes and the five-factor structure of the MCAS even after the removal of the three problematic items. In general, comparisons across genders using the MCAS seem reasonable from a methodological standpoint. Results are discussed in terms of improving sexual health research and interventions.

A randomized trial comparing telephone versus in-person brief intervention to reduce the risk of an alcohol-exposed pregnancy

Brief, effective interventions are needed to reduce the risk of an alcohol-exposed pregnancy in women who drink and do not use effective contraception. The Healthy Choices study compared telephone and in-person administration of a brief intervention. In addition to indicators of alcohol use and effective contraception, compliance with the intervention was examined. Women between the ages of 18 and 44 who were drinking above recommended levels and not using effective contraception were randomly assigned to either a telephone (n=68) or in-person (n=63) brief (two sessions) intervention. Overall, participants showed small but significant reductions in alcohol use and larger increases in effective use of contraception. Risk of alcohol-exposed pregnancy was thus significantly reduced, largely due to improved contraception with minor reductions in alcohol use. There was no significant difference in success of the intervention between the two conditions (telephone versus in-person). These findings suggest telephone-based brief intervention may be equally successful and cost-effective in reducing the risk of an alcohol-exposed pregnancy and thus fetal alcohol syndrome.

Behavioral interventions for improving condom use for dual protection

BACKGROUND

Unprotected sex is a major risk factor for disease, disability, and mortality in many areas of the world due to the prevalence and incidence of sexually transmitted infections (STI) including HIV. The male condom is one of the oldest contraceptive methods and the earliest method for preventing the spread of HIV. When used correctly and consistently, condoms can provide dual protection, i.e., against both pregnancy and HIV/STI.

OBJECTIVES

We examined comparative studies of behavioral interventions for improving condom use. We were interested in identifying interventions associated with effective condom use as measured with biological assessments, which can provide objective evidence of protection.

SEARCH METHODS

Through September 2013, we searched computerized databases for comparative studies of behavioral interventions for improving condom use: MEDLINE, POPLINE, CENTRAL, EMBASE, LILACS, OpenGrey, COPAC, ClinicalTrials.gov, and ICTRP. We wrote to investigators for missing data.

SELECTION CRITERIA

Studies could be either randomized or nonrandomized. They examined a behavioral intervention for improving condom use. The comparison could be another behavioral intervention, usual care, or no intervention. The experimental intervention had an educational or counseling component to encourage or improve condom use. It addressed preventing pregnancy as well as the transmission of HIV/STI. The focus could be on male or female condoms and targeted to individuals, couples, or communities. Potential participants included heterosexual women and heterosexual men.Studies had to provide data from test results or records on a biological outcome: pregnancy, HIV/STI, or presence of semen as assessed with a biological marker, e.g., prostate-specific antigen. We did not include self-reported data on protected or unprotected sex, due to the limitations of recall and social desirability bias. Outcomes were measured at least three months after the behavioral intervention started.

DATA COLLECTION AND ANALYSIS

Two authors evaluated abstracts for eligibility and extracted data from included studies. For the dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% CI was calculated using a fixed-effect model. Cluster randomized trials used various methods of accounting for the clustering, such as multilevel modeling. Most reports did not provide information to calculate the effective sample size. Therefore, we presented the results as reported by the investigators. No meta-analysis was conducted due to differences in interventions and outcome measures.

MAIN RESULTS

Seven studies met our eligibility criteria. All were randomized controlled trials; six assigned clusters and one randomized individuals. Sample sizes for the cluster-randomized trials ranged from 2157 to 15,614; the number of clusters ranged from 18 to 70. Four trials took place in African countries, two in the USA, and one in England. Three were based mainly in schools, two were in community settings, one took place during military training, and one was clinic-based.Five studies provided data on pregnancy, either from pregnancy tests or national records of abortions and live births. Four trials assessed the incidence or prevalence of HIV and HSV-2. Three trials examined other STI. The trials showed or reported no significant difference between study groups for pregnancy or HIV, but favorable effects were evident for some STI. Two showed a lower incidence of HSV-2 for the behavioral-intervention group compared to the usual-care group, with reported adjusted rate ratios (ARR) of 0.65 (95% CI 0.43 to 0.97) and 0.67 (95% CI 0.47 to 0.97), while HIV did not differ significantly. One also reported lower syphilis incidence and gonorrhea prevalence for the behavioral intervention plus STI management compared to the usual-care group. The reported ARR were 0.58 (95% CI 0.35 to 0.96) and 0.28 (95% CI 0.11 to 0.70), respectively. Another study reported a negative effect on gonorrhea for young women in the intervention group versus the control group (ARR 1.93; 95% CI 1.01 to 3.71). The difference occurred among those with only one year of the intervention.

AUTHORS' CONCLUSIONS

We found few studies and little clinical evidence of effectiveness for interventions promoting condom use for dual protection. We did not find favorable results for pregnancy or HIV, and only found some for other STI. The overall quality of evidence was moderate to low; losses to follow up were high. Effective interventions for improving condom use are needed to prevent pregnancy and HIV/STI transmission. Interventions should be feasible for resource-limited settings and tested using valid and reliable outcome measures.

Monogamy on the Street: A Mixed-Methods Study of Homeless Men

In this study, we used a mixed methods approach to explore the determinants of relationship patterns and risky sex among homeless men living in downtown Los Angeles. This involved analysis of qualitative interviews focused on gender ideology and sexual events ( n = 30) as well as structured interviews ( n = 305) focused on homeless men’s sexual partners, sexual behaviors, and social networks. We found that men valued committed relationships but were frustrated by their lack of access to female partners (accentuated by the stigma attached to homeless males) and also by structural and logistical barriers to relationships. Some men reported monogamous relationships; such relationships were less likely with homeless or substance-using partners and more likely with partners central to men’s social networks.

Systematic review and narrative synthesis of the effectiveness of contraceptive service interventions for young people, delivered in health care settings

A systematic review and narrative synthesis to determine the effectiveness of contraception service interventions for young people delivered in health care premises was undertaken. We searched 12 key health and medical databases, reference lists of included papers and systematic reviews and cited reference searches on included articles. All retrieved literature was screened at title and abstract levels, and relevant articles were taken through to full paper appraisal. Data relating to study design, outcomes and quality were extracted by one reviewer and independently checked by a second reviewer. We included interventions that consisted of contraceptive service provision for young people, and also interventions to encourage young people to use existing contraceptive services. The searches identified 23 studies that met the inclusion criteria. The papers focused on: new adolescent services, outreach to existing services, advanced provision of emergency contraception, condom/contraceptive provision and advice and repeat pregnancy prevention. The literature in general is not well developed in terms of good quality effectiveness studies and key outcome measures. However, it is possible to make recommendations in terms of outreach versus targeted young people's services in health care settings, advanced provision of emergency contraception and long-acting reversible contraception to prevent repeat adolescent pregnancy.

Meta-analysis of single-session behavioral interventions to prevent sexually transmitted infections: implications for bundling prevention packages

Evidence-based, single-session behavioral interventions are urgently needed for preventing the spread of HIV and other sexually transmitted infections (STIs). To estimate the efficacy of single-session, behavioral interventions for STI prevention, we collected data from 29 single-session interventions (20 studies; n = 52 465) with an STI outcome. Infection with an STI was 35% less likely (odds ratio = 0.65; 95% confidence interval = 0.55-0.77) among intervention group participants than among control group participants. Single-session interventions offer considerable benefits in terms of disease prevention and create minimal burden for both the patient and the provider. Brief and effective STI prevention interventions are a valuable tool and can be readily adapted to bolster the benefits of biomedical technologies focusing on the prevention of HIV and other STIs.

HIV prevention interventions to reduce racial disparities in the United States: a systematic review

Racial and ethnic minorities are disproportionately affected by HIV/AIDS in the United States despite advances in prevention methodologies. The goal of this study was to systematically review the past 30 years of HIV prevention interventions addressing racial disparities. We conducted electronic searches of Medline, PsycINFO, CINAHL, and Cochrane Review of Clinical Trials databases, supplemented by manual searches and expert review. Studies published before June 5, 2011 were eligible. Prevention interventions that included over 50% racial/ethnic minority participants or sub-analysis by race/ethnicity, measured condom use only or condom use plus incident sexually transmitted infections or HIV as outcomes, and were affiliated with a health clinic were included in the review. We stratified the included articles by target population and intervention modality. Reviewers independently and systematically extracted all studies using the Downs and Black checklist for quality assessment; authors cross-checked 20% of extractions. Seventy-six studies were included in the final analysis. The mean DB score was 22.44--high compared to previously published means. Most of the studies were randomized controlled trials (87%) and included a majority of African-American participants (83%). No interventions were designed specifically to reduce disparities in HIV acquisition between populations. Additionally, few interventions targeted men who have sex with men or utilized HIV as a primary outcome. Interventions that combined skills training and cultural or interactive engagement of participants were superior to those depending on didactic messaging. The scope of this review was limited by the exclusion of non-clinic based interventions and intermediate risk endpoints. Interactive, skills-based sessions may be effective in preventing HIV acquisition in racial and ethnic minorities, but further research into interventions tailored to specific sub-populations, such as men who have sex with men, is warranted.

Efficacy of behavioral interventions to increase condom use and reduce sexually transmitted infections: a meta-analysis, 1991 to 2010

OBJECTIVE

In the absence of an effective HIV vaccine, safer sexual practices are necessary to avert new infections. Therefore, we examined the efficacy of behavioral interventions to increase condom use and reduce sexually transmitted infections (STIs), including HIV.

DESIGN

Studies that examined a behavioral intervention focusing on reducing sexual risk, used a randomized controlled trial or a quasi-experimental design with a comparison condition, and provided needed information to calculate effect sizes for condom use and any type of STI, including HIV.

METHODS

Studies were retrieved from electronic databases (eg, PubMed, PsycINFO) and reference sections of relevant papers. Forty-two studies with 67 separate interventions (N = 40,665; M age = 26 years; 68% women; 59% Black) were included. Independent raters coded participant characteristics, design and methodological features, and intervention content. Weighted mean effect sizes, using both fixed-effects and random-effects models, were calculated. Potential moderators of intervention efficacy were assessed.

RESULTS

Compared with controls, intervention participants increased their condom use [d+ = 0.17, 95% confidence interval (CI) = 0.04, 0.29; k = 67], had fewer incident STIs (d+ = 0.16, 95% CI = 0.04, 0.29; k = 62), including HIV (d+ = 0.46, 95% CI = 0.13, 0.79; k = 13). Sample (eg, ethnicity) and intervention features (eg, skills training) moderated the efficacy of the intervention.

CONCLUSIONS

Behavioral interventions reduce sexual risk behavior and avert STIs and HIV. Translation and widespread dissemination of effective behavioral interventions are needed.

Interventions for encouraging sexual behaviours intended to prevent cervical cancer

BACKGROUND

Human papillomavirus (HPV) is the key risk factor for cervical cancer. Continuing high rates of HPV and other sexually transmitted infections (STIs) in young people demonstrate the need for effective behavioural interventions.

OBJECTIVES

To assess the effectiveness of behavioural interventions for young women to encourage safer sexual behaviours to prevent transmission of STIs (including HPV) and cervical cancer.

SEARCH STRATEGY

Systematic literature searches were performed on the following databases: Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2009) Cochrane Gynaecological Cancer Review Group (CGCRG) Specialised Register, MEDLINE, EMBASE, CINAHL, PsychINFO, Social Science Citation Index and Trials Register of Promoting Health Interventions (TRoPHI) up to the end of 2009. All references were screened for inclusion against selection criteria.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of behavioural interventions for young women up to the age of 25 years that included, amongst other things, information provision about the transmission and prevention of STIs. Trials had to measure behavioural outcomes (e.g. condom use) and/or biological outcomes (e.g. incidence of STIs, cervical cancer).

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted. Meta-analysis was not considered appropriate due to heterogeneity between the interventions and trial populations.

MAIN RESULTS

A total of 5271 references were screened and of these 23 RCTs met the inclusion criteria. Most were conducted in the USA and in health-care clinics (e.g. family planning).The majority of interventions provided information about STIs and taught safer sex skills (e.g. communication), occasionally supplemented with provision of resources (e.g. free sexual health services). They were heterogeneous in duration, contact time, provider, behavioural aims and outcomes. A variety of STIs were addressed including HIV and chlamydia. None of the trials explicitly mentioned HPV or cervical cancer prevention.Statistically significant effects for behavioural outcomes (e.g. increasing condom use) were common, though not universal and varied according to the type of outcome. There were no statistically significant effects of abstaining from or reducing sexual activity. There were few statistically significant effects on biological (STI) outcomes. Considerable uncertainty exists in the risk of bias due to incomplete or ambiguous reporting.

AUTHORS' CONCLUSIONS

Behavioural interventions for young women which aim to promote sexual behaviours protective of STI transmission can be effective, primarily at encouraging condom use. Future evaluations should include a greater focus on HPV and its link to cervical cancer, with long-term follow-up to assess impact on behaviour change, rates of HPV infection and progression to cervical cancer. Studies should use an RCT design where possible with integral process evaluation and cost-effectiveness analysis where appropriate. Given the predominance of USA studies in this systematic review evaluations conducted in other countries would be particularly useful.

Sexual risk reduction interventions for patients attending sexually transmitted disease clinics in the United States: a meta-analytic review, 1986 to early 2009

Sexually transmitted disease (STD) patients are more likely to experience a future STD including human immunodeficiency virus (HIV). The aim of this study was to examine the efficacy of behavioral interventions to reduce sexual risk behavior and incident STDs among patients attending STD clinics in the United States. A meta-analysis of 32 studies with 48 separate interventions targeting STD patients (N = 67,538) was conducted. Independent raters coded study, sample, and intervention characteristics. Effect sizes, using both fixed- and random-effects models, were calculated. Potential moderators of intervention efficacy were assessed. Relative to controls, intervention participants increased their condom use and had fewer incident STDs, including HIV, across assessment intervals (d (+)s ranging from 0.05 to 0.64). Several sample (e.g., age and ethnicity) and intervention features (e.g., targeting intervention to a specific group) moderated the efficacy of the intervention. Behavioral interventions targeted to STD clinic patients reduce sexual risk behavior and prevent HIV/STDs. Widespread use of behavioral interventions in STD clinics should be a public health priority.

Are we going to close social gaps in HIV? Likely effects of behavioral HIV-prevention interventions on health disparities

Although experimental behavioral interventions to prevent HIV are generally designed to correct undesirable epidemiological trends, it is presently unknown whether the resulting body of behavioral interventions is adequate to correct the social disparities in HIV-prevalence and incidence present in the United States. Two large, diverse-population meta-analytic databases were reanalyzed to estimate potential perpetuation and change in demographic and behavioral gaps as a result of introducing the available behavioral interventions advocating condom use. This review suggested that, if uniformly applied across populations, the analyzed set of experimental (i.e. under testing) interventions is well poised to correct the higher prevalence and incidence among males (vs. females) and African-Americans and Latinos (vs. other groups), but ill poised to correct the higher prevalence and incidence among younger (vs. older) people, as well as men who have sex with men, injection-drug users, and multiple partner heterosexuals (vs. other behavioral groups). Importantly, when the characteristics of the interventions most efficacious for each population were included in the analyses of behavior change, results replicated with three exceptions. Specifically, after accounting for interactions of intervention and facilitator features with characteristics of the recipient population (e.g. gender), there was no behavior change bias for men who have sex with men, younger individuals changed their behavior more than older individuals, and African-Americans changed their behavior less than other groups.

Social disparities in the receipt of contraceptive services among sexually experienced adolescent females

Social disparities in the receipt of contraceptive services were assessed among a sample of 2,031 sexually experienced adolescent females 15 to 18 years of age using secondary data from the National Longitudinal Study of Adolescent Health (Add Health). Findings revealed no social disparities in receipt of contraceptive services; rather, adolescent females who had a parent with less than a high school degree were more likely to receive contraceptive services. Adolescents' individual characteristics, including perceptions of maternal disapproval of sexual activity and use of contraceptives, barriers in access to and use of birth control, health needs, and enabling resources were significantly associated with their receipt of contraceptive services. Neighborhood characteristics were not significantly associated with adolescents' receipt of services in this study.

A systematic review of randomised controlled trials of interventions promoting effective condom use

Background

Effective condom use can prevent sexually transmitted infections (STIs) and unwanted pregnancy. We conducted a systematic review and methodological appraisal of randomised controlled trials (RCTs) of interventions to promote effective condom use.

Methods

We searched for all RCTs of interventions to promote effective condom use using the Cochrane Infectious Diseases Group's trials register (Oct 2006), CENTRAL (Issue 4, 2006), MEDLINE (1966 to Oct 2006), EMBASE (1974 to Oct 2006), LILACS (1982 to Oct 2006), IBSS (1951 to Oct 2006) and Psychinfo (1996 to Oct 2006). We extracted data on allocation sequence, allocation concealment, blinding, loss to follow-up and measures of effect. Effect estimates were calculated.

Results

We identified 139 trials. Seven out of ten trials reported reductions in ‘any STI’ with five statistically significant results. Three out of four trials reported reductions in pregnancy, although none was statistically significant. Only four trials met all the quality criteria. Trials reported a median of 11 (IQR 7–17) outcome measures. Few trials used the same outcome measure. Altogether, 10 trials (7%) used the outcome ‘any STI’, 4 (3%) self-reported pregnancy and 22 (16%) used ‘condom use at last sex’.

Conclusions

The results are generally consistent with modest benefits but there is considerable potential for bias due to poor trial quality. Because of the low proportion of trials using the same outcome the potential for bias from selective reporting of outcomes is considerable. Despite the public health importance of increasing condom use there is little reliable evidence on the effectiveness of condom promotion interventions.

Interventions for preventing unintended pregnancies among adolescents

BACKGROUND

Unintended pregnancy among adolescents represent an important public health challenge in developed and developing countries. Numerous prevention strategies such as health education, skills-building and improving accessibility to contraceptives have been employed by countries across the world, in an effort to address this problem. However, there is uncertainty regarding the effects of these intervention, and hence the need to review their evidence-base

OBJECTIVES

To assess the effects of primary prevention interventions (school-based, community/home-based, clinic-based, and faith-based) on unintended pregnancies among adolescents.

SEARCH STRATEGY

We searched electronic databases (CENTRAL, PubMed, EMBASE) ending December 2008. Cross-referencing, hand-searching, and contacting experts yielded additional citations.

SELECTION CRITERIA

We included both individual and cluster randomized controlled trials (RCTs) evaluating any interventions that aimed to increase knowledge and attitudes relating to risk of unintended pregnancies, promote delay in the initiation of sexual intercourse and encourage consistent use of birth control methods to reduce unintended pregnancies in adolescents aged 10-19 years.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial eligibility and risk of bias in studies that met the inclusion criteria. Where appropriate, binary outcomes were pooled using random effects model with a 95% confidence interval (Cl).

MAIN RESULTS

Forty one RCTs that enrolled 95,662 adolescents were included. Participants were ethnically diverse. Eleven studies randomized individuals, twenty seven randomized clusters (schools (19), classrooms (5), and communities/neighbourhoods (3). Three studies were mixed (individually and cluster randomized). The length of follow up varied from 3 months to 4.5 years. Data could only be pooled for a number of studies (15) because of variations in the reporting of outcomes. Results showed that multiple interventions (combination of educational and contraceptive interventions) lowered the rate of unintended pregnancy among adolescents. Evidence on the possible effects of interventions on secondary outcomes (initiation of sexual intercourse, use of birth control methods, abortion, childbirth, sexually transmitted diseases) is not conclusive.Methodological strengths included a relatively large sample size and statistical control for baseline differences, while limitations included lack of biological outcomes, possible self-report bias, analysis neglecting clustered randomization and the use of different statistical test in reporting outcomes.

AUTHORS' CONCLUSIONS

Combination of educational and contraceptive interventions appears to reduce unintended pregnancy among adolescents. Evidence for program effects on biological measures is limited. The variability in study populations, interventions and outcomes of included trials, and the paucity of studies directly comparing different interventions preclude a definitive conclusion regarding which type of intervention is most effective.

Repeat infection with Chlamydia and gonorrhea among females: a systematic review of the literature

Determining the magnitude of chlamydia and gonorrhea reinfection is critical to inform evidence-based clinical practice guidelines related to retesting after treatment. PubMed was used to identify peer-reviewed English language studies published in the past 30 years that estimated reinfection rates among females treated for chlamydia or gonorrhea. Included in this analysis were original studies conducted in the United States and other industrialized countries that reported data on chlamydia or gonorrhea reinfection in females. Studies were stratified into 3 tiers based on study design. Reinfection rates were examined in relation to the organism, study design, length of follow-up, and population characteristics. Of the 47 studies included, 16 were active cohort (Tier 1), 15 passive cohort (Tier 2), and 16 disease registry (Tier 3) studies. The overall median proportion of females reinfected with chlamydia was 13.9% (n = 38 studies). Modeled chlamydia reinfection within 12 months demonstrated peak rates of 19% to 20% at 8 to 10 months. The overall median proportion of females reinfected with gonorrhea was 11.7% (n = 17 studies). Younger age was associated with higher rates of both chlamydia and gonorrhea reinfection. High rates of reinfection with chlamydia and gonorrhea among females, along with practical considerations, warrant retesting 3 to 6 months after treatment of the initial infection. Further research should investigate effective interventions to reduce reinfection and to increase retesting.

The efficacy of HIV/STI behavioral interventions for African American females in the United States: a meta-analysis

OBJECTIVES

We evaluated the efficacy of HIV behavioral interventions for African American females in the United States, and we identified factors associated with intervention efficacy.

METHODS

We conducted a comprehensive literature review covering studies published from January 1988 to June 2007, which yielded 37 relevant studies. Data were analyzed using mixed-effects models and meta-regression.

RESULTS

Overall, behavioral interventions had a significant impact on reductions in HIV-risk sex behaviors (odds ratio [OR] = 0.63; 95% confidence interval [CI] = 0.54, 0.75; n = 11 239; Cochrane Q(32) = 84.73; P < .001) and sexually transmitted infections (STIs; OR = 0.81; 95% CI = 0.67, 0.98; n = 8760; Cochrane Q(16) = 22.77; P = .12). Greater intervention efficacy was observed in studies that specifically targeted African American females used gender- or culture-specific materials, used female deliverers, addressed empowerment issues, provided skills training in condom use and negotiation of safer sex, and used role-playing to teach negotiation skills.

CONCLUSIONS

Behavioral interventions are efficacious at preventing HIV and STIs among African American females. More research is needed to examine the potential contribution of prevention strategies that attend to community-level and structural-level factors affecting HIV infection and transmission in this population.

A cluster randomized controlled trial of an adolescent HIV prevention program among Bahamian youth: effect at 12 months post-intervention

Behavioral interventions based on the Protection Motivation Theory (PMT) have been demonstrated to reduce HIV risk behavior among mid- and older adolescents in different settings across the globe but have not been evaluated among Caribbean nations and have received limited evaluation among pre-adolescents. To determine (1) the effectiveness among pre-adolescents in The Bahamas of a PMT-based HIV prevention program "Focus on Youth in the Caribbean" (FOYC) and (2) the role of the targeted PMT constructs in intervention effect. 1,360 sixth grade youth (10-11 years of age) from 15 urban schools in New Providence, The Bahamas were randomized by school to receive either FOYC or a control condition. Data collected at baseline, 6 and 12 months post intervention were analyzed. A five-step scheme was used to assess sexual behavior progression, ranging from "1" = "a virgin without intention to have sex" to "5" = "having sex without a condom". Group-based trajectory analysis was utilized in assessing the program effect. Two sexual behavior progression patterns were detected: slow progressors and quick progressors. Receiving FOYC reduced the likelihood for adolescents to become quick progressors (adjusted OR = 0.77, 95% CI: 0.64-1.00). The observed effectiveness was especially impacted by a subset of the targeted PMT constructs. FOYC effectively delays sexual risk among Bahamian pre-adolescents. The group-based trajectory analysis provides an analytical approach for assessing interventions among adolescents with low rates and diverse progression patterns of sexual activity.

Psychosocial predictors of HIV-associated sexual behaviors and the efficacy of prevention interventions in adolescents at-risk for HIV infection: what works and what doesn't work?

The HIV epidemic among adolescents in the United States is inherently tied to individual, psychosocial, and cultural phenomena. Expanding intervention development and implementation to incorporate a broader spectrum of determinants of adolescents' sexual risk for sexually transmitted infections (STIs)/HIV acquisition may provide an opportunity to prevent disease transmission more effectively. To address the STI/HIV prevention needs of adolescents, we highlight research assessing adolescents' sexual risk behavior and place the findings in the context of the diverse array of psychosocial factors influencing adolescents. This synthesis provides an opportunity to examine why adolescents engage in risky sexual behavior and to review the effectiveness of theory-based prevention programs. Subsequently, we offer recommendations for improving future programs aimed at reducing the incidence of STI/HIV infection among adolescents.

HIV prevention interventions in adolescent girls: what is the state of the science?

BACKGROUND AND PURPOSE

Adolescent girls now represent one of the fastest growing groups of persons infected with HIV. A systematic review was undertaken to identify and critique the most scientifically rigorous HIV prevention interventions identified in the literature that focused on adolescent girls. Due to the limited number of randomized controlled trials (RCTs) in adolescent girls, the search was extended to identify any NIH-funded studies underway to provide an additional dimension to our understanding of the state of the science in this area.

METHOD

An extensive search of the Cochrane database of systematic reviews, PubMed, Medline, PsycInfo, CINAHL, and CRISP was undertaken. Ultimately, six completed RCTs targeted at adolescent girls and measuring behavioral outcomes were critiqued and summarized. Key strengths and limitations were identified. Four additional studies were also summarized but were not critically reviewed because of their ongoing nature.

FINDINGS

Most intervention studies targeted at adolescent girls have been shown to affect change in HIV risk-related behaviors to varying degrees. Most intervention studies have been conducted using predominantly racial minority samples in the United States. Clinically relevant components of successful interventions include the combination of providing information and behavioral skills training, as well as enhancing motivation to reduce risk within these interventions. Considerable diversity in study methods (e.g., intervention, measures, outcomes assessed) was noted, thus limited research evidence has been amassed to guide practice implications.

CONCLUSIONS AND IMPLICATIONS

The state of the science for evidence-based practice is severely restricted in the area of gender-specific HIV prevention interventions for adolescent girls despite worldwide epidemiological trends that identify them as a high-risk group. The critical need for full-scale longitudinal interventions provided to both groups and individuals is evident. Studies that target various subpopulations of adolescent girls as well as those that address diverse cultures throughout the world are needed. Research in progress will provide further evidence of the efficacy of individual versus group-based interventions.

Who participates in which health promotion programs? A meta-analysis of motivations underlying enrollment and retention in HIV-prevention interventions

This meta-analysis examines whether exposure to HIV-prevention interventions follows self-validation or risk-reduction motives. The dependent measures used in the study were enrolling in an HIV-prevention program and completing the program. Results indicated that first samples with low prior condom use were less likely to enroll than samples with high prior condom use. Second, samples with high knowledge were less likely to stay in an intervention than were those with low knowledge. Third, samples with medium levels of motivation to use condoms and condom use were more likely to complete an intervention than were those with low or high levels. Importantly, those patterns were sensitive to the interventions' inclusions of information-, motivation-, and behavioral-skills strategies. The influence of characteristics of participants, the intervention, and the recruit procedure are reported.

The efficacy of behavioral interventions in reducing HIV risk sex behaviors and incident sexually transmitted disease in black and Hispanic sexually transmitted disease clinic patients in the United States: a meta-analytic review

OBJECTIVES

Interventions targeting sexually transmitted disease (STD) clinic patients provide an important opportunity to modify high-risk sex behaviors related to HIV/STD transmission. Identifying efficacious interventions for blacks and Hispanics is urgently needed because these 2 groups are disproportionately affected by the HIV/STD epidemics.

GOAL

This meta-analysis evaluates the efficacy of behavioral interventions in reducing unprotected sex and incident STD among black and Hispanic STD clinic patients.

STUDY DESIGN

Comprehensive searches, including electronic databases (1988-2004), hand searches of journals (January 2004 to June 2005), reference lists of articles, and contacts with researchers, identified 18 randomized, controlled trials meeting the selection criteria.

RESULTS

Interventions significantly reduced unprotected sex (odds ratio [OR] = 0.77; 95% confidence interval [CI] = 0.68-0.87; 14 trials; N = 11,590) and incident STD (OR = 0.85; 95% CI = 0.73-0.998; 13 trials; N = 16,172).

CONCLUSIONS

Behavioral interventions provide an efficacious means of HIV/STD prevention for blacks and Hispanics who attend STD clinics.

A decade in review: building on the experiences of past adolescent STI/HIV interventions to optimise future prevention efforts

The major purpose of this article is to systematically review and synthesise empirical findings from selected adolescent STI/HIV interventions conducted in the United States between 1994 and 2004. Specifically, the most current adolescent STI risk reduction interventions conducted in diverse venues, such as in the community, schools, clinics, and specialised adolescent centres (that is, detention homes and drug programmes) were examined for reported efficacy, and were assessed for programmatic and methodological strengths and weaknesses. Next, a subset of programmatic characteristics was identified that were associated with the efficacy of STI risk reduction programmes both within a particular venue, as well as across all venues. Finally, we discuss the research and practice implications of these findings for optimising future evidence based STI risk reduction programmes for adolescents in the United States.

Antenatal Herpes Serologic Screening

OBJECTIVE

Calls for universal antenatal type-specific herpes simplex virus (HSV) screening to prevent neonatal herpes have recently increased and would affect the four million pregnant women and their partners annually in the United States. We undertook this review to assess the appropriateness of such screening, making relevant comparisons to established antenatal human immunodeficiency virus (HIV) and hepatitis B virus (HBV) screening programs.

DATA SOURCES

We conducted a full PubMed and bibliographic search for relevant literature in English available from 1966 through February 2006, using the terms "genital herpes," "neonatal herpes," "decision analysis" or "cost-effectiveness analysis," and "herpes and pregnancy" or "antenatal herpes screening." Comparison literature was obtained by replacing "herpes" with "HBV" or "HIV".

METHODS OF STUDY SELECTION

We appraised antenatal type-specific HSV screening using well-established criteria for a good screening program, which we articulated as questions. Of 455 articles we selected those that addressed at least one of the questions and were pertinent to the U.S. population.

TABULATION, INTEGRATION, AND RESULTS

We found that neonatal HSV is rare and its incidence is imprecisely defined. There is a lack of evidence supporting the effectiveness of interventions to prevent maternal acquisition of new infection in late pregnancy, which accounts for 60-80% of neonatal herpes. The consequences of universal screening are incompletely understood but include the potential for unnecessary cesarean deliveries and medical treatment, maternal psychosocial stress, and discord among partners. The available evidence indicates universal screening is not cost-effective. In contrast, antenatal HIV and HBV screening programs better satisfy accepted criteria for screening.

CONCLUSION

On the basis of this appraisal, universal antenatal type-specific HSV screening to prevent neonatal herpes does not adequately satisfy criteria of a good screening program, and we recommend against its adoption.

Identification of high-risk behaviors among victimized adolescents and implications for empirically supported psychosocial treatment

An adolescent's possible response to being the victim of interpersonal violence is not limited to posttraumatic stress disorder and depression but may also involve a host of developmental effects, including the occurrence of high-risk behaviors that may have a significant and negative impact on the adolescent's psychological and physical health. Identifying such high-risk behaviors, understanding their possible link to a previous victimization incident, and implementing interventions that have been demonstrated to reduce such behaviors may help decrease potential reciprocal interactions between these areas. Clinicians in psychiatric practice may be in a unique position to make these connections, since parents of adolescents may perceive a greater need for mental health services for youth engaging in problematic externalizing behaviors than for those displaying internalizing symptoms. In this article, the authors first describe high-risk behaviors, including substance use, delinquent behavior, risky sexual behaviors, and self-injurious behaviors, that have been linked with experiencing interpersonal violence. They then review empirically based treatments that have been indicated to treat these deleterious behaviors in order to help clinicians select appropriate psychosocial interventions for this population. Recommendations for future research on the treatment of high-risk behaviors in adolescents are also presented.

Conceptualizing the Influence of Social Agents of Behavior Change: A Meta-Analysis of the Effectiveness of HIV-Prevention Interventionists for Different Groups

A meta-analysis of 166 HIV-prevention interventions tested theoretical predictions about the effects of experts, lay community members, and similar and dissimilar others, as agents of change. In general, expert interventionists produced greater behavior change than lay community members, and the demographic and behavioral similarity between the interventionist and the recipients facilitated behavioral change. Equally importantly, there were differences across groups in the efficacy of various sources, especially among populations of low status and/or power. These findings support the hypothesis that unempowered populations are more sensitive to characteristics of the interventionists who can facilitate access to various resources. In addition, they suggest the need to ensure the availability of health professionals from diverse demographic and behavioral backgrounds.

A test of major assumptions about behavior change: a comprehensive look at the effects of passive and active HIV-prevention interventions since the beginning of the epidemic

This meta-analysis tested the major theoretical assumptions about behavior change by examining the outcomes and mediating mechanisms of different preventive strategies in a sample of 354 HIV-prevention interventions and 99 control groups, spanning the past 17 years. There were 2 main conclusions from this extensive review. First, the most effective interventions were those that contained attitudinal arguments, educational information, behavioral skills arguments, and behavioral skills training, whereas the least effective ones were those that attempted to induce fear of HIV. Second, the impact of the interventions and the different strategies behind them was contingent on the gender, age, ethnicity, risk group, and past condom use of the target audience in ways that illuminate the direction of future preventive efforts.

Enhancing recruitment and retention of minority young women in community-based clinical research

Women are disproportionately affected by the sexually transmitted infections (STI) epidemic, with African-Americans and Latinos at significantly higher risk for STIs than Caucasians. Successful recruitment and retention strategies used with young minority women in community-based STI prevention or intervention research have not been previously reported. This communication presents eight key strategies learned in the recruitment and retention of 16- to 21-year-old urban women participating in a 12-month randomized clinical trial designed to promote STI screening to decrease the duration of untreated chlamydia and gonorrhea infection. Strategies learned include: (1) Educate clinic staff on the rigors of study design; (2) Facilitate a team effort between clinical and research staff; modify recruitment procedures, as needed; (3) Provide prospective participants the option of enrolling by return appointment; (4) Anticipate a diminishing recruitment pool over time; (5) Set positive recruitment tone at the beginning of each clinic session; (6) Consider participants' mothers as important points of contact; (7) Match communication styles to participant contacts; and (8) Consider a variety of retention techniques. Together, these strategies helped to reinforce participant's commitment to the project, facilitated their attendance at interviews, and encouraged them to adhere to the treatment protocol.

Reducing the risk of sexually transmitted infections in genitourinary medicine clinic patients: a systematic review and meta-analysis of behavioural interventions

OBJECTIVES

Are behavioural interventions effective in reducing the rate of sexually transmitted infections (STIs) among genitourinary medicine (GUM) clinic patients?

DESIGN

Systematic review and meta-analysis of published articles.

DATA SOURCES

Medline, CINAHL, Embase, PsychINFO, Applied Social Sciences Index and Abstracts, Cochrane Library Controlled Clinical Trials Register, National Research Register (1966 to January 2004).

REVIEW METHODS

Randomised controlled trials of behavioural interventions in sexual health clinic patients were included if they reported change to STI rates or self reported sexual behaviour. Trial quality was assessed using the Jadad score and results pooled using random effects meta-analyses where outcomes were consistent across studies.

RESULTS

14 trials were included; 12 based in the United States. Experimental interventions were heterogeneous and most control interventions were more structured than typical UK care. Eight trials reported data on laboratory confirmed infections, of which four observed a greater reduction in their intervention groups (in two cases this result was statistically significant, p < 0.05). Seven trials reported consistent condom use, of which six observed a greater increase among their intervention subjects. Results for other measures of sexual behaviour were inconsistent. Success in reducing STIs was related to trial quality, use of social cognition models, and formative research in the target population. However, effectiveness was not related to intervention format or length.

CONCLUSIONS

While results were heterogeneous, several trials observed reductions in STI rates. The most effective interventions were developed through extensive formative research. These findings should encourage further research in the United Kingdom where new approaches to preventing STIs are urgently required.

A test of major assumptions about behavior change: a comprehensive look at the effects of passive and active HIV-prevention interventions since the beginning of the epidemic

This meta-analysis tested the major theoretical assumptions about behavior change by examining the outcomes and mediating mechanisms of different preventive strategies in a sample of 354 HIV-prevention interventions and 99 control groups, spanning the past 17 years. There were 2 main conclusions from this extensive review. First, the most effective interventions were those that contained attitudinal arguments, educational information, behavioral skills arguments, and behavioral skills training, whereas the least effective ones were those that attempted to induce fear of HIV. Second, the impact of the interventions and the different strategies behind them was contingent on the gender, age, ethnicity, risk group, and past condom use of the target audience in ways that illuminate the direction of future preventive efforts.

A programmatic and methodologic review and synthesis of clinic-based risk-reduction interventions for sexually transmitted infections: research and practice implications

The over-arching goal of this article is to systematically review and synthesize empirical findings for sexually transmitted disease risk-reduction programs that were developed and implemented specifically for adolescents seeking health care services at clinical venues. The objective is to examine the reported efficacy of these programs in reducing adolescents' sexually transmitted infection (STI)-associated behavior, in enhancing theoretically and empirically important psychosocial mediators associated with the adoption of STI-preventive behaviors, and, most important, in reducing adolescents' risk of acquiring an STI. In addition, our review assesses program and methodologic characteristics of the studies, determines compliance with standardized reporting guidelines, identifies a subset of program characteristics that are related to efficacy in terms of modifying adolescents' sexual risk behaviors, and examines the research and practice implications of these findings for implementing evidence-based STI risk-reduction programs in clinics.

Human papillomavirus infection: biology, epidemiology, and prevention

Over the past several decades, knowledge of the biology and epidemiology of human papillomavirus (HPV) infection has increased tremendously. However, there are still many unanswered questions concerning the interaction of the virus with its host. The virus has been identified as a necessary causal agent for cervical squamous neoplasia and has been linked to the development of neoplasia in several other mucosal sites. The viral oncogenes E6 and E7 are the major players in the virus' scheme to evade the immune system and use the host cell replication machinery to survive. Many risk factors for infection with HPV have been identified; however, the focus now centers on identifying risk factors for persistence of the infection as it is likely that transient infections play a very small role in the overall development of clinical disease. Prevention measures to date have centered around screening programs, mostly for cervical cancer, including the perfection of screening techniques and inclusion of molecular testing for HPV into screening regimens. The development of prophylactic and therapeutic vaccines has also increased as primary prevention measures appear to have the best hope for long-term effects on cancer incidence.

Innovative Approaches to the Prevention and Control of Bacterial Sexually Transmitted Infections

Bacterial STI continues to be a major problem in developed nations. Research and evolving standards of public health practice are cause for optimism and concern. Innovations in case-finding and treatment, particularly the application of NAATs to test for chlamydial infection in nonclinical settings, are successes that merit more widespread application. EPT, selective STI screening in men, and rescreening are all promising, but are not yet in widespread use and may face significant operational barriers. To date, public health efforts to alter sexual behavior, at least through specific interventions, are more discouraging. Although some behavioral interventions have been effective, none has been widely instituted. Moreover, the likelihood that existing behavioral interventions will be widely applied seems remote. Future research efforts in this area will need to focus less on proof-of-concept efficacy trials and more on developing and testing sustainable, cost-effective interventions that focus on those at greatest risk and that can be scaled-up within the existing public health infrastructure.

Review of Clinical Trials Testing the Effectiveness of Clinician Intervention Approaches to Prevent Sexually Transmitted Diseases in Adolescent Outpatients

OBJECTIVE

Identify approaches for improving clinician provision of sexually transmitted diseases (STDs) prevention services among outpatient adolescents.

METHODS

Reviewed all peer-reviewed, published clinical trials identified through computerized searches (MEDLINE, PsychINFO) evaluating STD prevention services to outpatient adolescents by clinicians.

RESULTS

Five trials were identified examining changes in clinician provision of STD prevention services. Two of these trials resulted in adolescent self-reported risk reduction but neither of these trials effectively demonstrated reductions in objectively measured STD incidence. Nine clinical trials were identified that compared clinician with non-clinician provision of STD prevention services. Four of these trials resulted in adolescent self-reported risk reduction, and one of these trials demonstrated a reduction in objectively measured STD incidence.

CONCLUSIONS

Trials indicate that improvement in outpatient adolescent STD incidence is possible with non-clinicians as interventionists, and perhaps clinicians as interventionists if clinicians are supported by other educational resources. Opportunities for personalized, interactive adolescent education appears key to intervention success. The clinician role that is tested in most trials is confined to a single brief encounter with little attention to: development of clinician skills, quality of psychosexual risk assessment and tailoring to meet individual adolescent need, systems-level resources and supports, the parental role, or the impact of incorporating prevention into an ongoing adolescent-clinician relationship.

Group-based HIV risk reduction intervention for adolescent girls: evidence of feasibility and efficacy

The purposes of this pilot study were (a) to assess the feasibility of a community-based, small group HIV risk reduction intervention with adolescent girls, and (b) to obtain preliminary evidence of the efficacy of this theoretically-guided intervention using a controlled design. The feasibility of the intervention was demonstrated by successfully implementing it with 33 sexually-active, single girls. Preliminary evidence of the efficacy of the intervention was obtained using a randomized trial with 62 sexually-active, single girls. Data obtained at a 3-month follow-up assessment showed that girls who received the HIV-related intervention improved their HIV-related knowledge and enhanced their motivation for risk reduction compared to girls who received a control (health promotion) intervention. Effect sizes suggest that the HIV intervention also reduced several risk behaviors (e.g., vaginal sex without a condom, giving oral sex, and alcohol and drug use before sex). Challenges to implementation and suggestions for intervention enhancement are discussed.

Randomized controlled trials of individual-level, population-level, and multilevel interventions for preventing sexually transmitted infections: what has worked?

BACKGROUND

Previous reviews of interventions to prevent sexually transmitted infections (STIs) focused mostly on human immunodeficiency virus (HIV) infection. We reviewed trials of interventions to prevent sexual transmission of any STI, employing a multilevel perspective.

METHODS

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, and recent unpublished presentations through 2003, to identify randomized controlled trials of preventive STI interventions having systematic, objective measurement of STI outcomes. We classified trials according to intervention target and level of randomization (individual, group, or community); impact target (acquisition, transmission, or complications of STI); and primary intervention modality.

RESULTS

Of 83 trials identified, 41 met inclusion criteria, including trials of 28 individual-level, 9 group-level, and 4 community-level interventions. Among individual- and group-level interventions, 32 targeted acquisition, 4 targeted transmission, and 1 targeted complications of STI. The 4 intervention modalities most often used included behavior change (12 studies), vaccination (7 studies), use of topical microbicides (10 studies), and prophylactic, curative, or suppressive therapy (10 studies). Community-level interventions had multiple impact targets, and 2 interventions used multiple modalities. Only 1 intervention showed efficacy against sexual transmission of HIV, but 22 (53.7%) showed effectiveness against other STIs.

CONCLUSION

Although many interventions have been found to be effective against STIs, few have been replicated, widely implemented, or carefully evaluated for effectiveness in other settings.

Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection

BACKGROUND

Many sex partners of persons with gonorrhea or chlamydial infections are not treated, which leads to frequent reinfections and further transmission.

METHODS

We randomly assigned women and heterosexual men with gonorrhea or chlamydial infection to have their partners receive expedited treatment or standard referral. Patients in the expedited-treatment group were offered medication to give to their sex partners, or if they preferred, study staff members contacted partners and provided them with medication without a clinical examination. Patients assigned to standard partner referral were advised to refer their partners for treatment and were offered assistance notifying partners. The primary outcome was persistent or recurrent gonorrhea or chlamydial infection in patients 3 to 19 weeks after treatment.

RESULTS

Persistent or recurrent gonorrhea or chlamydial infection occurred in 121 of 931 patients (13 percent) assigned to standard partner referral and 92 of 929 (10 percent) assigned to expedited treatment of sexual partners (relative risk, 0.76; 95 percent confidence interval, 0.59 to 0.98). Expedited treatment was more effective than standard referral of partners in reducing persistent or recurrent infection among patients with gonorrhea (3 percent vs. 11 percent, P=0.01) than in those with chlamydial infection (11 percent vs. 13 percent, P=0.17) (P=0.05 for the comparison of treatment effects) and remained independently associated with a reduced risk of persistent or recurrent infection after adjustment for other predictors of infection at follow-up (relative risk, 0.75; 95 percent confidence interval, 0.57 to 0.97). Patients assigned to expedited treatment of sexual partners were significantly more likely than those assigned to standard referral of partners to report that all of their partners were treated and significantly less likely to report having sex with an untreated partner.

CONCLUSIONS

Expedited treatment of sex partners reduces the rates of persistent or recurrent gonorrhea or chlamydial infection.

Developmentally appropriate sexual risk reduction interventions for adolescents: rationale, review of interventions, and recommendations for research and practice

BACKGROUND

Despite awareness of the need to design developmentally appropriate sexual risk reduction interventions for adolescents, limited information exists to identify the aspects of intervention design or content that make an intervention developmentally appropriate.

PURPOSE

(a) To clarify the rationale for designing developmentally appropriate interventions, (b) to review randomized controlled trials (RCTs) of adolescent sexual risk reduction interventions, (c) to identify developmentally appropriate strategies, (d) to examine the relationship between developmental appropriateness and sexual risk outcomes, and (e) to provide recommendations for research.

METHODS

The authors examined studies (n = 24) published before 2003 that evaluated a risk reduction intervention, sampled adolescents, used an RCT study design, and evaluated sexual behavior outcomes.

RESULTS

Content analysis indicated that the interventions tested were often tailored to the cognitive level of adolescents, as indicated by the use of exercises on decision making, goal setting and planning, and concrete explanation of abstract concepts. Interventions also addressed the social influences of risky sex such as peer norms and provided communication skills training. Overall, the interventions tested in RCTs were more effective in delaying the onset of sexual activity than in promoting abstinence among sexually active youth. Interventions with booster sessions were effective in reducing sexual risk behavior. The use of process measures, linked with developmental constructs, was rare. However, improvements in sexual communication skills and perceived norms for safer sex were associated with reductions in sexual risk outcomes.

CONCLUSIONS

Developmental transitions during adolescence influence sexual behavior and should be considered when developing and evaluating risk reduction interventions for youth. Future research should assess process measures of key developmental constructs as well as risk behavior and biological outcomes.