Motivational Strategies Can Augment HIV-Risk Reduction Programs

Motivational Interviewing and Self-care Practices in Adult Patients With Heart Failure: A Systematic Review and Narrative Synthesis

BACKGROUND

Heart failure contributes to frequent hospitalizations, large healthcare costs, and high mortality. Heart failure management includes patient adherence to strict self-care practices (ie, symptom recognition, limiting sodium and fluids, monitoring weight, maintaining an active lifestyle, and medication adherence as well as monitoring other medical conditions). These practices can be difficult to enact and maintain. Motivational interviewing, although not studied extensively in patients with heart failure, may enhance patients' abilities to enact and maintain self-care practices.

OBJECTIVE

The aim of this study was to examine the effectiveness of motivational interviewing on self-care practices in the adult population with heart failure.

METHODS

We conducted a narrative systematic review of peer-reviewed research literature focused on motivational interviewing in adult patients with heart failure. The following databases were searched from database inception to March 2019: MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, ERIC, Educational Resource Complete, and Scopus. Of 1158 citations retrieved, 7 studies met the inclusion criteria.

RESULTS

Outcomes were focused on self-care adherence (ie, maintenance, management, confidence), physical activity/exercise, and knowledge of self-care. Motivational interviewing has been effectively used either alone or in combination with other therapies and has been used in-home, over the telephone, and in hospital/clinic settings, although face-to-face interventions seem to be more effective. A number of limitations were noted in the included studies.

CONCLUSION

Motivational interviewing is a potentially effective adjunct to enhance self-care practices in patients with heart failure. Further high-quality research is needed to support changes in clinical practice.

Efficacy of motivational interviewing on enhancing self-care behaviors among patients with chronic heart failure: a systematic review and meta-analysis of randomized controlled trials

Although motivational interviewing (MI) seems to be promising for enhancing self-care behaviors (i.e., daily disease management and responses to symptoms) in patients with heart failure (HF), no quantitative pooling of effect sizes has been described to summarize and test its efficacy on self-care. Given that self-care behaviors of patients with HF are essential to enhance pharmacological adherence and disease management and optimize clinical outcomes, we sought to perform a systematic review of randomized control trials (RCTs) regarding MI's efficacy on enhancing self-care behaviors among patients with HF, synthesizing MI effects on self-care through meta-analyses. Nine randomized controlled trials were included. MI showed moderate effects on enhancing self-care confidence (Hedge's g = 0.768; 95%CI = 0.326-1.210; P = 0.001) and self-care management (i.e., responses to symptoms) (Hedge's g = 0.744; 95%CI = 0.256-1.232; P = 0.003) and large effects on improving self-care maintenance (i.e., adherence to treatment and symptom monitoring) (Hedge's g = 0.873; 95%CI  = 0.430-1.317; P < 0.001). No significant effects were found for enhancing the self-reported physical functioning (Hedge's g = -0.385; 95%CI = -1.063-0.294; P = 0.267) or the directly assessed physical functioning using the 6-min walking test (Hedge's g = -0.131; 95%CI = -0.981-0.720; P = 0.072). Although future research is still required to identify situation-specific indications regarding how MI should be implemented in relation to specific clinical conditions, this study showed that MI is an effective strategy to improve self-care in patients with HF.

Determinants of Behavior Change Intention Among Heterosexual Thai Males Diagnosed with Sexually Transmitted Diseases

This study sought to identify factors associated with intention to change sexual practices among heterosexual Thai males diagnosed with sexually transmitted infections (STIs). STI clinic patients (n = 247) reported their sexual behaviors and condom use during the previous 3 months. STI and HIV knowledge, motivation to change sexual practices, and behavioral skills were assessed. Then, self-reported behavior change intention, including consistent condom use, reducing number of sexual partners, not using drugs and alcohol when having sex, and refusal of condomless sex, was examined. Consistent condom use in the past 3 months by Thai males diagnosed with STIs was low across all types of sexual partners (lover 13.8%, casual partner 14.9%, and sex worker 2.5%). Risk reduction self-efficacy (p < 0.001), perceived benefits from condom use (p < 0.001), perceived barriers to condom use (p < 0.001), perceived risk for HIV (p < 0.05), and STI and HIV knowledge (p < 0.05) were significantly correlated with behavior change intention. Significant predictors of behavior change intention were risk reduction self-efficacy (p < 0.001), perceived benefits of condom use (p = 0.016), and perceived risk for HIV (p = 0.033). They explained 36% of behavior change intention variance. Intervention aimed at enhancing motivation and behavioral skills to adopt preventive behaviors should be developed to prevent recurrent STIs, including HIV infection, among heterosexual Thai males diagnosed with STIs.

Using a Mobile Health Intervention to Support HIV Treatment Adherence and Retention Among Patients at Risk for Disengaging with Care

Less than half of the 1.2 million HIV-infected individuals in the United States are in consistent medical care, with only a third receiving treatment resulting in viral suppression. Novel interventions to improve engagement are necessary to ensure medical adherence, improve long-term outcomes, and reduce HIV transmission. Mobile health (mHealth) strategies including cell phone and text messaging have shown success in the developing world for medical adherence, yet mHealth interventions have not been developed and evaluated to improve retention in HIV care in the United States. We conducted a 6-month pilot study investigating the use of a clinic-based bi-directional texting intervention to enhance engagement in HIV care among those with higher risk of loss to follow up, including those with a recent HIV diagnosis or those re-engaging in HIV care at a large urban clinic in New England.

Application of the Information-Motivation and Behavioral Skills (IMB) model in risky sexual behaviors amongst male students

As AIDS is not merely a hygienic problem but a disease that creates a great deal of economic, cultural, and social problems, it is necessary for most of the state and nongovernmental organizations and individuals to participate in both controlling AIDS and preventing it. As no effective vaccine or therapy for this disease exists currently, the only method for avoiding being afflicted by this disease is prevention. The present study aims to examine the Information-Motivation and Behavioral Skills (IMB) model in risky sexual behaviors. For this purpose, a group of 151 male students was sampled using a multistage random sampling method to complete the quality of HIV information questionnaire, national AIDS questionnaire, international AIDS questionnaire and global positive attitude to AIDS questionnaire. The results show that there is a significant relationship between the perception of HIV infection risk and sexual behavior. Thus, the perception of risk is considered the first step toward modifying sexual behaviors from risk-taking behaviors to safer behaviors.

The role of self-efficacy and motivation to explain the effect of motivational interviewing time on changes in risky sexual behavior among people living with HIV: a mediation analysis

Little is known about the amount of Motivational Interviewing (MI) needed to reduce risky sexual behavior among People Living with HIV/AIDS (PLWHA) or the roles self-efficacy and motivation to practice safer sex play. Among 183 PLWHA who received safer sex MI and were surveyed every 4 months over a 12 month period, we used hierarchical negative binomial regression models to examine the association between amount of counseling time and sexual risk behavior. We performed mediation analysis to evaluate whether changes in self-efficacy and motivation explained this association. This study found that as MI time and number of provided sessions increased, participants' sexual risk behavior decreased. The effect of MI time and number of sessions on sexual behavior was mediated by self-efficacy but not by motivation to practice safer sex.

Project MARS: Design of a Multi-Behavior Intervention Trial for Justice-Involved Youth

BACKGROUND

Marijuana and alcohol use are associated with increased sexual risk behavior among justice-involved youth. A multi-behavior intervention may reduce all three risk behaviors.

PURPOSE

To examine the relationships among multiple risk behaviors and the Theory of Planned Behavior (TPB) constructs guiding the development of the MARS (Motivating Adolescents to Reduce Sexual risk) intervention. We describe the MARS study design to inform the process through which a multi-behavior intervention trial can be implemented and evaluated.

METHODS

Participants completed questionnaires prior to randomization to one of three interventions.

RESULTS

Relationships were found between TPB constructs and risk behavior. A single latent variable was inadequate to capture all three risk behaviors.

CONCLUSIONS

Interventions to reduce sexual risk behavior can include content related to the role of substance use in influencing sexual risk behavior with only minimal modifications to the curriculum, and preliminary data suggest a common theory can apply across risk behaviors.

Sex and relationships on the street: how homeless men judge partner risk on Skid Row

Homeless men in the U.S. represent a large and growing population, and have elevated rates of HIV/AIDS and sexual risk behaviors, including unprotected sex with women. We conducted qualitative interviews (n = 30) with homeless men using shelters and meal lines in downtown Los Angeles (Skid Row) to better understand how such men view the risks of sexual encounters with female partners. Men living on Skid Row perceived multiple risks, including HIV and unwanted pregnancy as well as emotional trauma, loss of resources, exacerbation of drug addiction, and physical attack. Respondents described using visual and behavioral cues, social reputation, geographical location, feelings of trust, perceived relationship seriousness, and medically inaccurate "folk" beliefs to judge whether partners were risky and/or condom use was warranted. Medically inaccurate beliefs suggest the potential utility of evidence-based interventions to change such beliefs. We also consider implications for relationships on the street and housing interventions.

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.

Randomized controlled trial of brief interventions to reduce college students' drinking and risky sex

The present study tested the proposition that an intervention to reduce alcohol use among college students will also reduce their risky sexual behavior. In a randomized controlled trial, 154 heavy-drinking, predominantly White, heterosexual college students at behavioral risk for infection with HIV and other sexually transmitted diseases were assigned to receive no intervention or a two-session, in-person, motivational interviewing-based intervention focused on (a) reducing alcohol risk behavior, (b) reducing HIV risk behavior, or (c) reducing both alcohol and HIV risk behavior. Three-month retrospective assessments of alcohol use and sexual behavior were conducted at intake and at 3-, 6-, 9-, 12-, and 15-month follow-up appointments. During follow-up, participants who received the single-focus alcohol risk-reduction intervention drank less frequently and consumed fewer drinks per drinking day as compared with no-intervention control participants, but did not differ from control participants in their frequency of intercourse without a condom or number of sexual partners. Participants who received the single-focus HIV risk-reduction intervention evidenced fewer unprotected sex events during follow-up, as compared with control participants. The number of sexual partners reported during follow-up did not differ by condition. Effects of the interventions did not vary significantly over time and were not moderated by participant gender. Results suggest that intervening to reduce alcohol use may not reduce risky sexual behavior among nonminority college students, but that a brief motivational intervention targeting HIV risk behavior may have utility for reducing the frequency of unprotected sex in this population.

A meta-analysis of the efficacy of HIV/AIDS prevention interventions in Asia, 1995-2009

The HIV/AIDS epidemic continues to grow in pockets across Asia, despite early successes at curtailing its spread in countries like Thailand. Recent evidence documents dramatic increases in incidence among risk groups and, alarmingly, the general population. This meta-analysis summarizes the sexual risk-reduction interventions for the prevention of HIV-infection that have been evaluated in Asia. Sexual risk-reduction outcomes (condom use, number of sexual partners, incident sexually transmitted infections [STI], including HIV) from 46 behavioral intervention studies with a comparison condition and available by August 2010 were included. Overall, behavioral interventions in Asia consistently reduced sexual risk outcomes. Condom use improved when interventions sampled more women, included motivational content, or did not include STI testing and treatment. Incident HIV/STI efficacy improved most when interventions sampled more women, were conducted more recently, or when they included STI counseling and testing. Sexual frequency efficacy improved more in interventions that were conducted in countries with lower human development capacities, when younger individuals were sampled, or when condom skills training was included. Behavioral interventions for reducing sexual risk in Asia are efficacious; yet, the magnitude of the effects co-varies with specific intervention and structural components. The impact of structural factors on HIV intervention efficacy must be considered when implementing and evaluating behavioral interventions. Implications and recommendations for HIV/AIDS interventions are discussed.

Human immunodeficiency virus risk behavior among female substance abusers

HIV is an increasingly critical and costly health problem for American women. Substance use plays a major role in human immunodeficiency virus (HIV) infection in women. There are several plausible explanations for the association between substance use and HIV risk behavior. Pregnant substance abusers are a population deserving special attention given the prevalence of risk behavior in this population and the added risk of perinatal transmission of HIV. Current guidelines for the screening and treatment of HIV among pregnant women and their infants are delineated. Substance abuse treatment has a limited impact on HIV risk behavior in female substance abusers. Similarly, traditional knowledge-based and skill-based HIV risk reduction interventions have modest efficacy in this population. Hence, there is a need to develop new interventions that directly target sex-related and drug-related HIV risk behavior among female substance abusers. Recent work suggests that the incorporation of motivational interviewing components into traditional HIV risk reduction interventions may be a promising new direction for the field.

Secondary prevention of HIV infection: the current state of prevention for positives

PURPOSE OF REVIEW

To provide a state-of-the-science review of the literature on secondary prevention of HIV infection or 'prevention for positives' (PfP) interventions.

RECENT FINDINGS

Early work on PfP focused on understanding the dynamics of risky behavior among People Living with HIV/AIDS (PLWH) and on designing, implementing, and evaluating a limited number of interventions to promote safer sexual and drug use behavior in this population (i.e., PfP interventions). Previous meta-analyses demonstrated that PfP interventions can effectively promote safer behavior. However, the understanding of risk dynamics among PLWH and the extant number and breadth of effective PfP interventions were scant. Recent work has addressed some of these problems, yielding greater understanding of risk dynamics and providing additional, effective interventions. Still, only a modest number of recent, rigorously evaluated, effective interventions have been identified. New ideas for creating stronger, more integrated, and effective PfP interventions have emerged that will guide future intervention research and practice.

SUMMARY

There remains much to be done to understand why, when, and under what conditions PLWH practice risk. Substantial work also needs to be performed to design, implement, rigorously evaluate, and when effective, to disseminate widely, additional, evidence-based PfP interventions targeting diverse populations. Directing such interventions to populations of PLWH at greatest risk for transmission of HIV has the potential to yield significant impact on the pandemic.

Influencing risk behavior of sexually transmitted infection clinic visitors: efficacy of a new methodology of motivational preventive counseling

A quasi-experimental study was conducted at a Dutch sexually transmitted infection (STI) clinic to compare the effects of educational counseling and motivational interviewing (MI)-based HIV/STI counseling on determinants of condom use and partner notification at 6-month follow-up. It also examined the feasibility of MI-based counseling in a busy real-life clinic. The counseling approaches were historically compared: respondents in the control condition were recruited between April and July 2005, those in the experimental condition between September and December 2005. The study involved 428 participants. These were all high-risk clients of the STI clinic. Their mean age was 33.7 years, and 39.6% were female. The study showed that MI-based counseling had a more positive effect on self-efficacy, intentions to use condoms with casual partners, and long-term condom use with steady partners. It had no adversarial outcomes on other social cognitions or behaviors compared to educational counseling. Furthermore, MI-based counseling is experienced as a more respectful and structured way of counseling. MI-based counseling was relatively easily implemented into the current clinic procedures. In addition to the implementation of the training, neither specialized staff nor additional or longer client visits were needed. However, some nurses indicated that the new method required more personal investment and effort. Limitations of the current study are the low response rates, the high educational level of most participants, and the small sample size regarding partner notification. Nonetheless, we conclude that MI-based counseling was a more effective approach to preventive counseling compared to educational counseling and feasible in the busy real-life setting.

Motivation to reduce HIV risk behaviors in the context of the Information, Motivation and Behavioral Skills (IMB) model of HIV prevention

The Information-Motivation-Behavioral Skills (IMB) model of health behavior was tested in a sample of 391 men who have sex with men at high-risk for HIV transmission. Prospective analyses of IMB predictors of unprotected anal intercourse (UAI) confirmed a good fit. Self-rated motivation was a significant predictor of UAI, as were behavioral skills. However, the lack of information and motivational constructs that predicted behavior suggests that the IMB model is limited as a theory and has its greatest utility as a framework for guiding HIV risk reduction interventions for men who have sex with men at high-risk for HIV infection.

Alcohol use, expectancies, and sexual sensation seeking as correlates of HIV risk behavior in heterosexual young adults

Most theoretical models of HIV risk behavior have not considered the role of personality factors, and few studies have examined mechanisms accounting for dispositional influences on sexual risk taking. This study elaborated on a conceptual model emphasizing sexual sensation seeking, alcohol expectancies, and drinking before sex as key predictors of HIV risk (S. C. Kalichman, L. Tannenbaum, & D. Nachimson, 1998). Multiple groups structural equation modeling was used to determine whether gender moderated relationships among these variables in a sample of 611 heterosexual, young adult drinkers (49% women, 76% Caucasian, mean age = 25 years). The model provided an excellent fit to the data, and gender differences were not substantiated. Sexual sensation seeking predicted HIV risk directly as well as indirectly via sex-related alcohol expectancies and drinking in sexual contexts. Findings suggest that expectancies and drinking before sex represent proximal mechanisms through which dispositional factors influence sexual risk outcomes. Moreover, these relationships appear to be similar in men and women. Interventions could benefit from targeting alcohol expectancies and drinking before sex in individuals with a dispositional tendency toward sexual risk taking.

Beliefs about treatments for HIV/AIDS and sexual risk behaviors among men who have sex with men, 1997-2006

Beliefs that HIV treatments reduce HIV transmission risks are related to increases in sexual risk behaviors, particularly unprotected anal intercourse among men who have sex with men (MSM). Changes in unprotected anal intercourse and prevention-related treatment beliefs were recently reported for surveys of mostly white gay men collected in 1997 and 2005. The current study extends this previous research by replicating the observed changes in behaviors and beliefs in anonymous community surveys collected in 2006. Results indicated clear and consistent increases in beliefs that HIV treatments reduce HIV transmission risks and increases in unprotected anal intercourse. These changes were observed for both HIV positive and non-HIV positive men. African American men endorsed the belief that HIV treatments protect against HIV transmission to a greater degree than White men. Results show that HIV prevention messages need to be updated to educate MSM about the realities of HIV viral concentrations and HIV transmission risks.

Addressing HIV Risk Behavior Among Pregnant Drug Abusers: An Overview

Both sex- and drug-related HIV risk behavior are common among pregnant drug abusers. In the absence of intervention, these behaviors are likely to continue throughout pregnancy, placing the women and their unborn children at risk of contracting HIV. Drug treatment programs have been found to have limited impact on these behaviors. Although certain drug risk behaviors have been shown to decrease during drug treatment, sex-related risk behavior remains largely unaffected. Similarly, knowledge- and skill-based HIV risk reduction interventions have demonstrated modest efficacy. Therefore, there is a need to develop new interventions that directly target sex- and drug-related HIV risk behavior among pregnant drug abusers, taking advantage of a period in the women's lives in which the potential negative consequences of risk behavior are more significant given the possible impact on their unborn children and in which there may be a heightened desire to make healthier behavior choices. Recent work suggests that a promising new direction for the field may be incorporating motivational interviewing components into traditional HIV risk reduction interventions, which focus on providing HIV risk information and building sex- and drug-related HIV risk reduction skills.

A controlled study of a spirituality-focused intervention for increasing motivation for HIV prevention among drug users

Spiritual Self-Schema (3-S) therapy is a manual-guided intervention for increasing motivation for HIV prevention that integrates a cognitive model of self within a Buddhist framework suitable for people of all faiths. In this controlled study, 72 methadone-maintained clients received either standard care and 8 weeks of 3-S therapy, or standard care alone. At treatment completion, 3-S clients reported significantly greater increases in spiritual practices, expression of spiritual qualities, and motivation for HIV prevention. They were also less likely to have engaged in HIV risk behavior. Correlational analyses showed that attendance at 3-S therapy sessions was significantly positively related to spiritual practice at treatment completion and to motivation for HIV prevention, and that both attendance at 3-S sessions and motivation for HIV preventive behavior were significantly negatively related to HIV risk behavior. Completion of 3-S therapy predicted posttreatment HIV preventive behavior, controlling for pretreatment behavior, demographics, and addiction severity measures (odds ratio = 8.89; 95% confidence interval = 1.62-48.93).

An RCT of the effect of motivational interviewing on medication adherence in hypertensive African Americans: rationale and design

BACKGROUND

Hypertension disproportionately affects African Americans compared to whites, and it is the single most common explanation for the disparity in mortality between African Americans and whites. Adherence with antihypertensive medications can help reduce risk of negative hypertension-related outcomes. Motivational interviewing is a promising patient-centered approach for improving adherence in patients with chronic diseases. In this paper we describe the rationale and design of an ongoing randomized controlled trial testing the effectiveness of motivational interviewing versus usual care in improving medication adherence among 190 African American uncontrolled hypertensive patients, who receive care in a primary care setting.

METHODS

The usual care group receives standard medical care, while those in the intervention group receive standard care plus four sessions of motivational interviewing at 3-month intervals for a period of 1 year. This technique consists of brief, patient-driven counseling sessions to facilitate initiation and maintenance of behavior change. The primary outcome is adherence to prescribed antihypertensive medication, assessed with the electronic medication events monitoring system (MEMS) and the Morisky self-report adherence questionnaire. Secondary outcomes are within-patient changes in blood pressure, self-efficacy, and intrinsic motivation between baseline and 12 months. We report the baseline sociodemographic and clinical characteristics of the participants.

CONCLUSIONS

Despite the potential utility of motivational interviewing, little is known about its effectiveness in improving medication adherence among hypertensive patients, especially African Americans. In addition to the baseline data this study has generated, this trial should provide data with which we can assess the effectiveness of this approach as a behavioral intervention.

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.

Reasons for unsafe sex among a community sample of people with HIV/AIDS

In a sample of 117 HIV positive men and women, 34 (29%) were identified as engaging in risky sexual behavior in the past six months and were asked for reasons they did so. Analysis using broad categories revealed that partner-related reasons and hedonistic reasons were the most frequent reasons overall (71%). More male (87%) than female (60%) responses were captured by those two categories. Differences by partner status, viral load and age were not as pronounced. Specific interventions and intervention frameworks are suggested.

Sexual activity and risk taking in young heterosexual men: the relevance of sexual arousability, mood, and sensation seeking

In this research we explored three aspects of personality relevant to sexual activity and sexual risk taking in heterosexual men. Men with low inhibition of sexual arousal in the face of risk (low SIS2) reported more partners with whom they use no condoms and more lifetime "one night stands." Men who experience increased sexual interest in states of depression (MSQ) reported more partners in the past year and more one night stands. The disinhibition subscale of the Sensation Seeking Scale was predictive of whether sexual intercourse had occurred in the past 6 months, and also of the number of sexual partners in the past year. A measure of an intention to practice safer sex was strongly related to measures of sexual arousability and inhibition (SIS/SES). We discuss some clear similarities and also some interesting differences with a parallel study of gay men. Individual differences in sexual excitation and inhibition proneness and the relation between mood and sexuality are clearly relevant to high-risk sexual behavior and should be taken into consideration when designing behavioral interventions.

Patterns of sexual risk behaviors and psychiatric disorders in a community sample of young adults

This cross-sectional study documents significant associations between patterns of sexual risk behaviors and psychiatric diagnoses in a multiethnic community sample of young adults (N = 1803) in South Florida. Self-report data regarding sexual behavior and psychiatric symptoms were collected in structured interviews in a follow-up of an earlier school-based study. Cluster analysis was used to group participants with regard to levels of sexual risk behaviors during the past year. Chi-square analysis and ANOVA identified significant associations between cluster membership and (a) lifetime and (b) past year diagnoses for affective disorders, conduct disorder, antisocial personality disorder, alcohol abuse/dependence, marijuana abuse/dependence, and other drug abuse/dependence. In addition, higher levels of sexual risk behaviors were associated with higher levels of cumulative lifetime psychiatric disorders. Implications for selected prevention of sexually transmitted diseases (STDs) and the treatment of psychiatric disorders in young adulthood are discussed.

HIV sexual risk-reduction interventions for youth: a review and methodological critique of randomized controlled trials

The authors review and provide a methodological critique of randomized controlled studies of HIV risk reduction interventions that measured sexual risk behavior outcomes with adolescents. Studies conducted in school, community, and health care settings were reviewed. Overall, 13 of 23 interventions (57%) were effective in reducing sexual risk behavior. Methodological strengths of extant studies included an emphasis on a theoretical framework, evaluation of both individualized and group-intervention formats, use of multiple assessments of risk behavior (including biological outcomes), and inclusion of efficacy and effectiveness trials. Methodological limitations included limited evaluation of theoretical mediators of risk reduction, failure to report effect sizes, and lack of sustained findings. Inconsistencies were found in data analytic procedures and reporting, including how nested designs, skewed data, and attrition were addressed. Recommendations for designing methodologically rigorous interventions are provided.

Access to services and maintenance of safer sex practices among people living with HIV/AIDS

Access to services and their relationship to the maintenance of long-term safer sex practices are addressed in this study of 360 HIV+ adults recruited from outpatient medical facilities. Protease inhibitors, antiviral therapies, and entitlements were reported as the most needed services, while entitlements and money to pay for housing were reported as the largest unmet needs. Differences across ethnic and gender groups were observed. One-third of all respondents reported at least one occasion of unprotected anal or vaginal intercourse in the previous six months. The practice of unsafe sex was found to be significantly related to both the number of needed services and the number of unmet needs, even after controlling for demographic variables. In addition, a higher proportion of those who engaged in unsafe sex reported a higher need for psychological counseling and social support. These findings underscore the important linkage between access to services with avoidance of high-risk sexual behavior in HIV+ persons. Implications for the delivery of culturally appropriate, gender-specific and community-based interventions are discussed.

Psychosocial correlates of HIV risk behavior in adolescent girls

OBJECTIVE

To present the preintervention data collected for a pilot HIV-prevention randomized controlled trial specifically developed for single, sexually active adolescent girls.

DESIGN

Comparative, descriptive design using confidential self-administered questionnaires.

SETTING

An urban family planning clinic that provided gynecologic services to adolescents.

PARTICIPANTS

One hundred twenty-nine single, sexually active adolescent girls 15 to 19 years of age (44% minority, 34% economically disadvantaged).

MAIN OUTCOME MEASURES

In addition to demographics and risk behaviors, the following were assessed: HIV-related information (i.e., knowledge) and motivation to reduce risk (i.e., perceived vulnerability, readiness to change HIV risk behaviors, behavioral intentions, pros and cons of condom use, and confidence in condom use).

RESULTS

Assessments revealed limited HIV-related knowledge, ambivalence regarding risk reduction, and considerable risk behaviors. Compared with girls at lower risk for HIV infection (i.e., consistent condom users), those at higher risk (i.e., inconsistent or noncondom-users) were more likely to be White and older and to have better HIV-related knowledge but less motivation to reduce risk (i.e., behavioral intentions to use condoms, condom-use confidence) than girls at lower risk.

CONCLUSION

These data document (a) the need for HIV prevention interventions targeted to all sexually active adolescent girls and (b) the importance of including a motivational component in the intervention.

Modeling condom-use stage of change in low-income, single, urban women

This study was undertaken to identify and test a model of the cognitive antecedents to condom use stage of change in low-income, single, urban women. A convenience sample of 537 women (M=30 years old) attending two urban primary health care settings in western New York State anonymously completed questionnaires based primarily on two leading social-cognitive models, the transtheoretical model and the information-motivation-behavioral skills model. We used structural equation modeling to examine the direct and indirect effects of HIV-related knowledge, social norms of discussing HIV risk and prevention, familiarity with HIV-infected persons, general readiness to change sexual behaviors, perceived vulnerability to HIV, and pros and cons of condom use on condom-use stage of change. The results indicated two models that differ by partner type. Condom-use stage of change in women with steady main partners was influenced most by social norms and the pros of condom use. Condom-use stage of change in women with "other" types (multiple, casual, or new) of sexual partners was influenced by HIV-related knowledge, general readiness to change sexual behaviors, and the pros of condom use. These findings suggest implications for developing gender-relevant HIV-prevention interventions.

Development and psychometric evaluation of the brief HIV Knowledge Questionnaire

This research evaluated the psychometric properties of a brief self-report measure of HIV-related knowledge, the 18-item HIV Knowledge Questionnaire (HIV-KQ-18). Low-income men and women (N = 1,019) responded to 27 items that represented the domain of interest. Item analyses indicated that 18 items, with item-total correlations ranging from .24 to .57, be retained. Additional analyses demonstrated the HIV-KQ-18's internal consistency across samples (alphas = .75-.89), test-retest stability across several intervals (rs = .76- .94), and strong associations with a much longer, previously validated measure (rs = .93-.97). Data from three clinical trials indicated that the HIV-KQ-18 detected knowledge gains in treated participants when compared to untreated controls. We conclude that the HIV-KQ-18 is internally consistent, stable, sensitive to the change resulting from intervention, and suitable for use with low-literacy populations.

A motivational interviewing perspective on resistance in psychotherapy

This article applies the motivational interviewing approach to resistance, which is conceptualized as the product of an interaction between the therapist and client rather than a static client characteristic. The underlying principles of motivational interviewing also are discussed, as are the overall therapeutic goals when using this approach. Sources of the resistance between the therapist and client are reviewed, as well as specific recommendations for responding. The motivational interviewing approach to resistance is applied to each of the three case vignettes.

Conducting meta-analyses of HIV prevention literatures from a theory-testing perspective

Using illustrations from HIV prevention research, the current article advocates approaching meta-analysis as a theory-testing scientific method rather than as merely a set of rules for quantitative analysis. Like other scientific methods, meta-analysis has central concerns with internal, external, and construct validity. The focus of a meta-analysis should only rarely be merely describing the effects of health promotion, but rather should be on understanding and explaining phenomena and the processes underlying them. The methodological decisions meta-analysts make in conducting reviews should be guided by a consideration of the underlying goals of the review (e.g., simply effect size estimation or, preferably theory testing). From the advocated perspective that a health behavior meta-analyst should test theory, the authors present a number of issues to be considered during the conduct of meta-analyses.

HIV risk sensitization following a detailed sexual behavior interview: a preliminary investigation

We administered a detailed structured interview of sexual HIV risk behavior to 110 college students (46% women; mean age = 19.7 years; range = 18-41 years) and assessed their perceived risk of HIV infection before and after the interview. The sexual behavior assessment consisted of 29 single-item frequency questions, followed by a 90-day Timeline Followback interview. Results indicate that sexually active participants experienced HIV risk sensitization during the interview, whereas participants who were not sexually active did not. Among the sexually active participants, those who had multiple sexual partners were more sensitized to their risk than participants with only one partner, and those who engaged in vaginal sex evidenced increased risk perception, but participants who had only oral sex did not. These findings indicate that detailed sexual behavior assessments influence participants' motivation to reduce their risk behavior. This may be helpful in increasing the effectiveness of brief risk behavior interventions such as HIV counseling and testing. These findings may also have implications for the generalizability of HIV prevention interventions to contexts that do not include such detailed assessments.