Prevention of gonorrhea and Chlamydia through behavioral intervention: results of a two-year controlled randomized trial in minority women

Application of ADAPT-ITT: adapting an evidence-based HIV/STI mother-daughter prevention intervention for Black male caregivers and girls

BACKGROUND

Black girls are disproportionately impacted by HIV and sexually transmitted infections (STIs), underscoring the urgent need for innovative strategies to enhance the adoption and maintenance of HIV/STI prevention efforts. Historically, Black male caregivers have been left out of girls' programming, and little guidance exists to inform intervention development for Black girls and their male caregivers. Engaging Black male caregivers in Black girls' sexual and reproductive health may reduce sexual risk-taking and improve the sustainability of preventative behaviors.

OBJECTIVE

This paper describes the formative phases, processes, and methods used to adapt an evidence-based mother-daughter sexual and reproductive health intervention for Black girls 9-18 years old and their male caregivers.

METHODS

We used the ADAPT-ITT model to tailor IMARA for Black girls and their male caregivers. Diverse qualitative methods (interviews, focus groups, and theater testing) were used throughout the adaption process.

RESULTS

Findings support using the ADAPT-ITT model to tailor an evidence-based HIV/STI intervention for Black girls and their Black male caregivers. Findings highlight the importance of community engagement and the use of qualitative methods to demonstrate the acceptability and feasibility of the adapted intervention. Key lessons learned are reviewed.

CONCLUSIONS

Adapting evidence-based interventions to incorporate Black girls and their Black male caregivers should be driven by a relevant theoretical framework that aligns with the target population(s). Adapting the intervention in partnership with the community has been shown to improve acceptability and feasibility as it is responsive to community needs. Using a systematic process like the ADAPT-ITT model will ensure that the new program is ready for efficacy trials.

Barber-Led HIV/Sexually Transmitted Infection Risk Reduction for Young African-American Men: Efficacy and Mediation in a Cluster Randomized Controlled Trial

PURPOSE

The aim of this study is to evaluate the efficacy and mediation of a culturally appropriate, theory-based HIV/STI (sexually transmitted infection) risk-reduction intervention delivered in barbershops by barbers via iPads to African-American young men in reducing sexual risk behaviors.

METHODS

In a cluster randomized controlled trial, 24 matched pairs of barbershops serving African-American men ages 18-24 in the 10 Philadelphia, PA zip codes with the highest HIV/AIDS prevalence were randomized to implement via iPads one of 2 interventions: "Shape Up! Barbers Building Better Brothers," an HIV/STI risk-reduction intervention based on the theory of planned behavior and formative research or an attention-matched violence-prevention control intervention. The primary outcome was self-reported consistent condom use 3, 6, and 12 months postintervention, controlling for baseline consistent condom use.

RESULTS

Participants were 618 men, 319 in the HIV/STI intervention and 299 in the control intervention. Generalized estimating equation analysis indicated that the direct effect of the HIV/STI intervention in increasing consistent condom use postintervention was nonsignificant (odds ratio = 1.13, 95% confidence interval: 0.73-1.75), adjusting for clustering among participants in barbershops and baseline condom use. However, mediation analysis using the product-of-coefficients approach revealed indirect effects of the intervention. Consistent with the theory of planned behavior, the intervention increased behavioral beliefs and self-efficacy regarding using condoms, which raised condom use intention, which, in turn, boosted consistent condom use.

DISCUSSION

Sexual risks among young African-American men can be reduced by barber-led theory-based, culturally appropriate HIV/STI risk-reduction interventions in barbershops in high HIV prevalence neighborhoods that increase behavioral beliefs and self-efficacy.

Development, Pre-Testing and Feasibility Testing of Multi-Component Interventions, Critical for Mental Health Promotion in Primary Care among Mexican-American Adolescents Living in Rural America

Rural America is often viewed as bereft of social problems facing urban America. Rural families, however, experience stressors due to low employment rates, fewer educational opportunities, a relatively increased incidence of poverty and limited access to mental health care. These families are at increased risk for substance use, violence and associated psychological distress that occurs when failing to cope with stress. Rural children, experiencing these stressors and affected by barriers of culture, poverty and remote access to mental health care, are at higher risk for these negative health outcomes. The need for culturally appropriate intervention tailored to the target population, rural Mexican-American adolescent women, is consistently supported by evidence. A one-size-fits-all approach most likely will not effectively impact behavior and health outcomes. The fact that few studies evaluated effects of mental health interventions on multiple outcomes including substance use, violence, unintended pregnancy and STI is problematic given previously noted associations. Evidence is needed to evaluate associations between mental health interventions and these outcomes. This manuscript presents results of preliminary studies, conducted using a multi-method research approach for development, pre-testing and feasibility testing of interventions for rural primary care settings. This methodology is appropriate when dealing with the complexity of social phenomena. It provides a look at an issue from all angles and thereby the cultural context and perspective informing intervention development. These multi-component interventions are critical for mental health promotion among Mexican-American adolescent women living in rural America.

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.

Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Approximately 20 million new cases of bacterial or viral sexually transmitted infections (STIs) occur each year in the US, and about one-half of these cases occur in persons aged 15 to 24 years. Rates of chlamydial, gonococcal, and syphilis infection continue to increase in all regions. Sexually transmitted infections are frequently asymptomatic, which may delay diagnosis and treatment and lead persons to unknowingly transmit STIs to others. Serious consequences of STIs include pelvic inflammatory disease, infertility, cancer, and AIDS.

OBJECTIVE

To update its 2014 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a review of the evidence on the benefits and harms of behavioral counseling interventions for preventing STI acquisition.

POPULATION

This recommendation statement applies to all sexually active adolescents and to adults at increased risk for STIs.

EVIDENCE ASSESSMENT

The USPSTF concludes with moderate certainty that behavioral counseling interventions reduce the likelihood of acquiring STIs in sexually active adolescents and in adults at increased risk, including for example, those who have a current STI, do not use condoms, or have multiple partners, resulting in a moderate net benefit.

RECOMMENDATION

The USPSTF recommends behavioral counseling for all sexually active adolescents and for adults at increased risk for STIs. (B recommendation).

Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Increasing rates of preventable sexually transmitted infections (STIs) in the US pose substantial burdens to health and well-being.

OBJECTIVE

To update evidence for the US Preventive Services Task Force (USPSTF) on effectiveness of behavioral counseling interventions for preventing STIs.

DATA SOURCES

Studies from the previous USPSTF review (2014); literature published January 2013 through May 31, 2019, in MEDLINE, PubMed (for publisher-supplied records only), PsycINFO, and Cochrane Central Register of Controlled Trials. Ongoing surveillance through May 22, 2020.

STUDY SELECTION

Good- and fair-quality randomized and nonrandomized controlled intervention studies of behavioral counseling interventions for adolescents and adults conducted in primary care settings were included. Studies with active comparators only or limited to individuals requiring specialist care for STI risk-related comorbidities were excluded.

DATA EXTRACTION AND SYNTHESIS

Dual risk of bias assessment, with inconsistent ratings adjudicated by a third team member. Study data were abstracted into prespecified forms. Pooled odds ratios (ORs) were estimated using the DerSimonian and Laird method or the restricted maximum likelihood method with Knapp-Hartung adjustment.

MAIN OUTCOMES AND MEASURES

Differences in STI diagnoses, self-reported condom use, and self-reported unprotected sex at 3 months or more after baseline.

RESULTS

The review included 37 randomized trials and 2 nonrandomized controlled intervention studies (N = 65 888; 13 good-quality, 26 fair-quality) recruited from primary care settings in the US. Study populations were composed predominantly of heterosexual adolescents and young adults (12 to 25 years), females, and racial and ethnic minorities at increased risk for STIs. Nineteen trials (n = 52 072) reported STI diagnoses as outcomes (3 to 17 months' follow-up); intervention was associated with reduced STI incidence (OR, 0.66 [95% CI, 0.54-0.81; I2 = 74%]). Absolute differences in STI acquisition between groups varied widely depending on baseline population STI risk and intervention effectiveness, ranging from 19% fewer to 4% more people acquiring STI. Thirty-four trials (n = 21 417) reported behavioral change outcomes. Interventions were associated with self-reported behavioral change (eg, increased condom use) that reduce STI risk (OR, 1.31 [95% CI, 1.10-1.56; I2 = 40%, n = 5253). There was limited evidence on persistence of intervention effects beyond 1 year. No harms were identified in 7 studies (n = 3458) reporting adverse outcomes.

CONCLUSIONS AND RELEVANCE

Behavioral counseling interventions for individuals seeking primary health care were associated with reduced incidence of STIs. Group or individual counseling sessions lasting more than 2 hours were associated with larger reductions in STI incidence, and interventions of shorter duration also were associated with STI prevention, although evidence was limited on whether the STI reductions associated with these interventions persisted beyond 1 year.

The frontiers of addressing antibiotic resistance in Neisseria gonorrhoeae

The sexually transmitted infection gonorrhea, caused by the Gram-negative bacterium Neisseria gonorrhoeae, can cause urethritis, cervicitis, and systemic disease, among other manifestations. N. gonorrhoeae has rapidly rising incidence along with increasing levels of antibiotic resistance to a broad range of drugs including first-line treatments. The rise in resistance has led to fears of untreatable gonorrhea causing substantial disease globally. In this review, we will describe multiple approaches being undertaken to slow and control this spread of resistance. First, a number of old drugs have been repurposed and new drugs are being developed with activity against Neisseria gonorrhoeae. Second, vaccine development, long an important goal, is advancing. Third, new diagnostics promise rapid detection of antibiotic resistance and a shift from empiric to tailored treatment. The deployment of these new tools for addressing the challenge of antibiotic resistance will require careful consideration to provide optimal care for all patients while extending the lifespan of treatment regimens.

[Follow-up and counselling after pelvic inflammatory disease: CNGOF and SPILF Pelvic Inflammatory Diseases Guidelines]

OBJECTIVES

To determine the procedures for follow-up and counselling of patients after pelvic inflammatory disease (PID).

METHODS

A search in the Cochrane database, PubMed, and Google was performed using keywords related to follow-up and PID to identify reports published between 1990 and 2018. All studies published in French and English relevant to the areas of focus were included. A level of evidence (LE) based on the quality of the data available was applied for each area of focus and used for the guidelines.

RESULTS

The rate of recurrent PID is 15 to 21%. They are related to a recurrent sexually transmitted infection (STI) in 20 to 34% of cases. Recurrence PID increase the risk of infertility and chronic pelvic pain (LE2). Follow-up is recommended after PID (grade C). The rate of patients lost to follow-up is around 40%. Follow-up is improved by personalized text message reminders (grade B). Vaginal sampling for detection of N. gonorrhoeae, C. trachomatis, (and M. genitalium) by nucleic acid amplification techniques is recommended 3 to 6 months after treatment of PID associated with STI to rule out possible reinfections (grade C). The use of condoms after PID associated with STI is recommended to reduce the risk of recurrences (grade C). The systematic use of contraceptive pills after PID is not recommended to prevent subsequent infertility and chronic pelvic pain. Vaginal sampling for microbiological diagnosis is recommended before the insertion of an intrauterine device (grade B). The risk of ectopic pregnancy is high in these women and must be kept in mind.

CONCLUSION

Patient counselling and microbiological testing after PID decrease the risk of STI and thus the recurrence of PID.

Prospective Predictors of Multiple Sexual Partners Among African American Men Who Have Sex with Men

Studies show that having sex with multiple partners increases the risk of acquiring and transmitting sexually transmitted diseases, including HIV. The present article reports prospective predictors of having multiple sexual partners among 505 African American men in Philadelphia who have sex with men (MSM) who participated in an intervention trial and attended a 6-month follow-up. Participants completed audio computer-assisted surveys of demographics, sexual behavior, and Reasoned Action Approach and Social Cognitive Theory mediators concerning multiple partners. We analyzed the incidence of self-reported multiple partners at the 6-month follow-up, controlling for treatment condition and baseline levels of the theoretical variables. The odds of having multiple partners decreased with increasing age (p < .03). Participants who said they were HIV positive had lower odds of having multiple partners (p < .009). The more pride participants reported in their identities as black or African American men, the lower the odds that they reported having multiple partners (p < .02). Adverse outcome expectancies accruing to multiple partners fully mediated the effect of black pride and partially mediated the effects of age on the odds of having multiple partners. Modifiable factors such as perceived negative outcome expectancies regarding having multiple sex partners should be addressed in designing interventions and prevention programs with the goal of decreasing the number of sexual partners among African American MSM.

Behavioral HIV Prevention Interventions Among Latinas in the US: A Systematic Review of the Evidence

Compared to White women, Latinas are 4 times more likely to contract HIV. In an effort to determine the overall state of the science meant to address this disparity, we reviewed the current HIV prevention intervention literature for U.S. Latinas. We searched 5 online electronic databases from their inception through July, 2014, for HIV prevention interventions including a majority sample of Latinas. Of 1041 articles identified, 20 studies met inclusion criteria. We documented study designs, participant characteristics, outcomes, theories used, and other intervention characteristics. Overall, HIV knowledge and attitudes were the predominant outcome; a small minority of studies included self-reported condom use or STD incidence. Strategies used to address cultural factors specific to Latinas and HIV included; lay health advisors, using ethnographic narratives, or using the Theory of Gender and Power, however few of the interventions adopted these strategies. This study identified several gaps in the intervention literature that need to be addressed. In addition to including more direct measures of decreased HIV risk (ex. condom use), more systematic use of strategies meant to address gender and cultural factors that may place Latinas at increased risk (e.g., gender inequity, traditional gender role norms such as machismo and marianismo, and relationship power dynamics).

C-SAFE: A Computer-Delivered Sexual Health Promotion Program for Latinas

This article describes the development and evaluation of C-SAFE (Sexual Awareness for Everyone), a computer-delivered sexual health promotion program for Latinas. We first describe the process of adapting an evidence-based, group-level intervention into an individually administered computer-delivered program. We then present the methods and results of a randomized control trial with 321 Latinas in California and Florida to test C-SAFE's preliminary efficacy in reducing sexual health risk. We found no statistically significant differences between the two conditions at a six-month follow-up in terms of sexual behaviors or attitudes toward sexually transmitted infections and condoms, although C-SAFE women reported fewer days in the past month when their mental health was not good (p = .02). C-SAFE condition women also reported more satisfaction than control condition women in their assessment of information presentation (on a scale of 1 = poor and 5 = excellent; C-SAFE = 4.45 vs. control = 4.25, p = .053) and having learned something new (C-SAFE = 95.1% vs. control = 79.3%, χ² < 0.001), with utility of content for Latinas approaching significance (C-SAFE = 4.50 vs. control = 4.31, p = .058). In conclusion we discuss the importance of teachable moments, matching of delivery modalities to implementation contexts, and possible directions for evidence-based sexual health promotion programs given the current sexual health landscape.

Substantiating the need for primary care-based sexual health promotion interventions for ethnic minority adolescent women experiencing health disparities

PURPOSE

Assess the context of psychological distress, violence, and substance use among African- and Mexican-American adolescent women with a history of STI, violence, or high sexual risk behavior. These adolescents experience multiple health disparities, limited access to care, and are at particularly high risk of adverse sexual health outcomes. The results will inform sexual health promotion interventions provided by advanced practice nurses in primary care-based settings for women experiencing these disparities.

METHODS

Analysis of self-report data obtained at study entry from African- and Mexican-American adolescent women (n = 559) enrolled in a randomized trial of a behavioral intervention for sexual risk reduction.

CONCLUSIONS

High levels of psychological distress, sexual risk behavior, sexually transmitted infection (STI), personal and friend/peer substance use, alcohol use, and violence were reported by women at study entry. Analyses found that STI, physical violence, and substance-using friends were twice as likely associated with personal substance use. Alcohol users were five times more likely to use other substances. Mexican Americans were three times more likely than African Americans to use substances.

IMPLICATIONS FOR PRACTICE

Recommendation is made for integration of multicomponent sexual health promotion interventions as advanced practice nurse provider services addressing these health disparities within primary care-based settings.

Is gonorrhea becoming untreatable?

An estimated 498 million new cases of curable sexually transmitted infections occur worldwide annually. Of these, 106 million are gonococcal infections, rendering gonorrhea the second most prevalent bacterial sexually transmitted infection after chlamydia. A decline in susceptibility to extended-spectrum cephalosporins, as well as treatment failures, have been identified worldwide. This, together with the associated epidemiological and socioeconomic burden, is of increasing concern. Currently, the effectiveness of antibiotic resistance control measures is limited. Barriers include the lack of therapeutic options, the difficulties of reducing high-risk sexual behavior and Neisseria gonorrhoeae's propensity to rapidly acquire resistance determinants. While the disease remains treatable for the moment, we need to anticipate and be prepared for the arrival and spread of untreatable gonorrhea by using a multifaceted approach and search for other, perhaps novel control strategies.

Preconception care: preventing and treating infections

Introduction

Infections can impact the reproductive health of women and hence may influence pregnancy related outcomes for both the mother and the child. These infections range from sexually transmitted infections (STIs) to TORCHS infections to periodontal disease to systemic infections and may be transmitted to the fetus during pregnancy, labor, delivery or breastfeeding.

Methods

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

Results

Preconception behavioral interventions significantly declines re-infection or new STI rates by 35% (95% CI: 20-47%). Further, condom use has been shown to be the most effective way to prevent HIV infection (85% protection in prospective studies) through sexual intercourse. Intervention trials showed that preconception vaccination against tetanus averted a significant number of neonatal deaths (including those specifically due to tetanus) when compared to placebo in women receiving more than 1 dose of the vaccine (OR 0.28; 95% CI: 0.15-0.52); (OR 0.02; 95% CI: 0.00-0.28) respectively.

Conclusion

Preconception counseling should be offered to women of reproductive age as soon as they test HIV-positive, and conversely women of reproductive age should be screened with their partners before pregnancy. Risk assessment, screening, and treatment for specific infections should be a component of preconception care because there is convincing evidence that treatment of these infections before pregnancy prevents neonatal infections.

Preconception care: delivery strategies and packages for care

The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.

Efficacy of an adapted HIV and sexually transmitted infection prevention intervention for incarcerated women: a randomized controlled trial

OBJECTIVES

We tested the efficacy of an adapted evidence-based HIV-sexually transmitted infection (STI) behavioral intervention (Providing Opportunities for Women's Empowerment, Risk-Reduction, and Relationships, or POWER) among incarcerated women.

METHODS

We conducted a randomized trial with 521 women aged 18 to 60 years in 2 correctional facilities in North Carolina in 2010 and 2011. Intervention participants attended 8 POWER sessions; control participants received a single standard-of-care STI prevention session. We followed up at 3 and 6 months after release. We examined intervention efficacy with mixed-effects models.

RESULTS

POWER participants reported fewer male sexual partners than did control participants at 3 months, although this finding did not reach statistical significance; at 6 months they reported significantly less vaginal intercourse without a condom outside of a monogamous relationship and more condom use with a main male partner. POWER participants also reported significantly fewer condom barriers, and greater HIV knowledge, health-protective communication, and tangible social support. The intervention had no significant effects on incident STIs.

CONCLUSIONS

POWER is a behavioral intervention with potential to reduce risk of acquiring or transmitting HIV and STIs among incarcerated women returning to their communities.

Structural and community-level interventions for increasing condom use to prevent the transmission of HIV and other sexually transmitted infections

BACKGROUND

Community interventions to promote condom use are considered to be a valuable tool to reduce the transmission of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). In particular, special emphasis has been placed on implementing such interventions through structural changes, a concept that implies public health actions that aim to improve society's health through modifications in the context wherein health-related risk behavior takes place. This strategy attempts to increase condom use and in turn lower the transmission of HIV and other STIs.

OBJECTIVES

To assess the effects of structural and community-level interventions for increasing condom use in both general and high-risk populations to reduce the incidence of HIV and STI transmission by comparing alternative strategies, or by assessing the effects of a strategy compared with a control.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, from 2007, Issue 1), as well as MEDLINE, EMBASE, AEGIS and ClinicalTrials.gov, from January 1980 to April 2014. We also handsearched proceedings of international acquired immunodeficiency syndrome (AIDS) conferences, as well as major behavioral studies conferences focusing on HIV/AIDS and STIs.

SELECTION CRITERIA

Randomized control trials (RCTs) featuring all of the following.1. Community interventions ('community' defined as a geographical entity, such as cities, counties, villages).2. One or more structural interventions whose objective was to promote condom use. These type of interventions can be defined as those actions improving accessibility, availability and acceptability of any given health program/technology.3. Trials that confirmed biological outcomes using laboratory testing.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and selected relevant studies, and conducted further risk of bias assessment. We assessed the effect of treatment by pooling trials with comparable characteristics and quantified its effect size using risk ratio. The effect of clustering at the community level was addressed through intra-cluster correlation coefficients (ICCs), and sensitivity analysis was carried out with different design effect values.

MAIN RESULTS

We included nine trials (plus one study that was a subanalysis) for quantitative assessment. The studies were conducted in Tanzania, Zimbabwe, South Africa, Uganda, Kenya, Peru, China, India and Russia, comprising 75,891 participants, mostly including the general population (not the high-risk population). The main intervention was condom promotion, or distribution, or both. In general, control groups did not receive any active intervention. The main risk of bias was incomplete outcome data.In the meta-analysis, there was no clear evidence that the intervention had an effect on either HIV seroprevalence or HIV seroincidence when compared to controls: HIV incidence (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.69 to 1.19) and HIV prevalence (RR 1.02, 95% CI 0.79 to 1.32). The estimated effect of the intervention on other outcomes was similarly uncertain: Herpes simplex virus 2 (HSV-2) incidence (RR 0.76, 95% CI 0.55 to 1.04); HSV-2 prevalence (RR 1.01, 95% CI 0.85 to 1.20); syphilis prevalence (RR 0.91, 95% CI 0.71 to 1.17); gonorrhoea prevalence (RR 1.16, 95% CI 0.67 to 2.02); chlamydia prevalence (RR 0.94, 95% CI 0.75 to 1.18); and trichomonas prevalence (RR 1.00, 95% CI 0.77 to 1.30). Reported condom use increased in the experimental arm (RR 1.20, 95% CI 1.03 to 1.40). In the intervention groups, the number of people reporting two or more sexual partners in the past year did not show a clear decrease when compared with control groups (RR 0.90, 95% CI 0.78 to 1.04), but knowledge about HIV and other STIs improved (RR 1.15, 95% CI 1.04 to 1.28, and RR 1.23, 95% CI 1.07 to 1.41, respectively). The quality of the evidence was deemed to be moderate for nearly all key outcomes.

AUTHORS' CONCLUSIONS

There is no clear evidence that structural interventions at the community level to increase condom use prevent the transmission of HIV and other STIs. However, this conclusion should be interpreted with caution since our results have wide confidence intervals and the results for prevalence may be affected by attrition bias. In addition, it was not possible to find RCTs in which extended changes to policies were conducted and the results only apply to general populations in developing nations, particularly to Sub-Saharan Africa, a region which in turn is widely diverse.

Addressing sexual health behaviour during emerging adulthood: a critical review of the literature

AIMS AND OBJECTIVES

In this critical literature review, we examine evidence-based interventions that target sexual behaviours of 18- to 25-year-old emerging adult women.

BACKGROUND

Nurses and clinicians implement theory-driven research programmes for young women with increased risk of HIV/AIDS and sexually transmitted infections. Strategies to decrease transmission of HIV and sexually transmitted infections are rigorously evaluated and promoted by public health agencies such as the United States Centers for Disease Control and Prevention. While many interventions demonstrate episodic reductions in sexual risk behaviours and infection transmission, there is little evidence they build sustainable skills and behaviours. Programmes may not attend to contextual and affective influences on sexual behaviour change.

DESIGN

Discursive paper.

METHODS

We conducted a conceptually based literature review and critical analysis of the Centers for Disease Control and Prevention's best-evidence and good-evidence HIV behavioural interventions. In this review, we examined three contextual and affective influences on the sexual health of emerging adult women: (1) developmental age, (2) reproduction and pregnancy desires and (3) sexual security or emotional responses accompanying relationship experiences.

RESULTS

Our analyses revealed intervention programmes paid little attention to ways age, desires for pregnancy or emotional factors influence sexual decisions. Some programmes included 18- to 25-year-olds, but they made up small percentages of the sample and did not attend to unique emerging adult experiences. Second, primary focus on infection prevention overshadowed participant desires for pregnancy. Third, few interventions considered emotional mechanisms derived from relationship experiences involved in sexual decision-making.

CONCLUSIONS

Growing evidence demonstrates sexual health interventions may be more effective if augmented to attend to contextual and affective influences on relationship risks and decision-making. Modifying currently accepted strategies may enhance sustainability of sexual health-promoting behaviours.

RELEVANCE TO CLINICAL PRACTICE

This study provides nurses and public health educators with recommendations for broadening the content of sexual health promotion intervention programming.

Toward an understanding of the context of anal sex behavior in ethnic minority adolescent women

Understanding the context of anal sex behavior among ethnic minority adolescent women has public health implications for behavioral sexual health promotion and risk reduction interventions. African-American (n = 94) and Mexican-American (n = 465) women (14-18 years of age) enrolled in a clinical trial completed semi-structured interviews to assess psychosocial and situational factors and relationships to sexual risk behavior, substance use, sexually transmitted infection/HIV acquisition, and violence. Bivariate analyses with comparisons by anal sex experiences identified differences by ethnicity and higher self-reported histories of sexual risk behaviors, substance use, violence, and stressful psychosocial and situational factors among adolescent women experiencing anal sex. Predictors of anal sex identified through logistic regression included Mexican-American ethnicity, ecstasy use, methamphetamine use, childhood sexual molestation, oral sex, and sex with friends for benefits.

A Meta-Analysis of the Efficacy of Behavioral Interventions to Reduce Risky Sexual Behavior and Decrease Sexually Transmitted Infections in Latinas Living in the United States

The objective of this meta-analysis was to determine the effect of behavioral interventions in reducing risky sexual behavior and incident sexually transmitted infections (STI) among Latina women living in the United States. Studies were found by systematically searching the MEDLINE, EMBASE, and PsychInfo databases without language restriction. Two independent reviewers screened abstracts and full texts of articles to find randomized control trials testing the effects of behavioral interventions aimed at changing risky sexual behavior among Latinas. Articles were selected using prespecified inclusion criteria. Two independent reviewers extracted data from the included trials in duplicate using a standardized data extraction form. Six randomized control trials met the inclusion criteria for a total of 2,909 participants. Using random effects models with inverse variance weighting, we found a protective effect of the behavioral intervention on reported risky sexual behavior (odds ratio = 0.52; 95% confidence interval = 0.42, 0.64) and on incident nonviral STI (odds ratio = 0.65; 95% confidence interval = 0.46, 0.93). Behavioral interventions targeted toward Latina populations are effective in reducing risky sexual behaviors and incident STI and should be considered by policymakers as a potential tool for HIV/STI prevention in this population.

Understanding problems with condom fit and feel: an important opportunity for improving clinic-based safer sex programs

The purpose of this study was to investigate gender differences and other demographic correlates of condom fit and feel problems among a diverse sample of adult condom users and to examine men's and women's perceptions and experiences with condom fit and feel problems. Participants were recruited from an electronic mailing list. The analytic sample (N = 949) included self-identified heterosexual men (n = 771) and women (n = 178) who reported using condoms for penile-vaginal or penile-anal intercourse in the past 3 months. Both quantitative and qualitative methods were applied. Of the sample, 38.3% reported experiencing at least one condom fit or feel problem. Problems with condom fit during sex did not differ significantly by gender (p = .73). Perceptions of specific condom use problems were organized into five themes: (1) decreased sensation, (2) lack of naturalness, (3) condom size complaints, (4) decreased pleasure, and (5) pain and discomfort. In this diverse sample, there was a high prevalence of condom fit and feel issues among women as well as men. These issues, mostly focused on loss of pleasure, represent a substantial public health problem and thus warrant attention in safer sex programs.

Strategies for partner notification for sexually transmitted infections, including HIV

BACKGROUND

Partner notification (PN) is the process whereby sexual partners of an index patient are informed of their exposure to a sexually transmitted infection (STI) and the need to obtain treatment. For the person (index patient) with a curable STI, PN aims to eradicate infection and prevent re-infection. For sexual partners, PN aims to identify and treat undiagnosed STIs. At the level of sexual networks and populations, the aim of PN is to interrupt chains of STI transmission. For people with viral STI, PN aims to identify undiagnosed infections, which can facilitate access for their sexual partners to treatment and help prevent transmission.

OBJECTIVES

To assess the effects of different PN strategies in people with STI, including human immunodeficiency virus (HIV) infection.

SEARCH METHODS

We searched electronic databases (the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE) without language restrictions. We scanned reference lists of potential studies and previous reviews and contacted experts in the field. We searched three trial registries. We conducted the most recent search on 31 August 2012.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) or quasi-RCTs comparing two or more PN strategies. Four main PN strategies were included: patient referral, expedited partner therapy, provider referral and contract referral. Patient referral means that the patient notifies their sexual partners, either with (enhanced patient referral) or without (simple patient referral) additional verbal or written support. In expedited partner therapy, the patient delivers medication or a prescription for medication to their partner(s) without the need for a medical examination of the partner. In provider referral, health service personnel notify the partners. In contract referral, the index patient is encouraged to notify partner, with the understanding that the partners will be contacted if they do not visit the health service by a certain date.

DATA COLLECTION AND ANALYSIS

We analysed data according to paired partner referral strategies. We organised the comparisons first according to four main PN strategies (1. enhanced patient referral, 2. expedited partner therapy, 3. contract referral, 4. provider referral). We compared each main strategy with simple patient referral and then with each other, if trials were available. For continuous outcome measures, we calculated the mean difference (MD) with 95% confidence intervals (CI). For dichotomous variables, we calculated the risk ratio (RR) with 95% CI. We performed meta-analyses where appropriate. We performed a sensitivity analysis for the primary outcome re-infection rate of the index patient by excluding studies with attrition of greater than 20%. Two review authors independently assessed the risk of bias and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We included 26 trials (17,578 participants, 9015 women and 8563 men). Five trials were conducted in developing countries. Only two trials were conducted among HIV-positive patients. There was potential for selection bias, owing to the methods of allocation used and of performance bias, owing to the lack of blinding in most included studies. Seven trials had attrition of greater than 20%, increasing the risk of bias.The review found moderate-quality evidence that expedited partner therapy is better than simple patient referral for preventing re-infection of index patients when combining trials of STIs that caused urethritis or cervicitis (6 trials; RR 0.71, 95% CI 0.56 to 0.89, I(2) = 39%). When studies with attrition greater than 20% were excluded, the effect of expedited partner therapy was attenuated (2 trials; RR 0.8, 95% CI 0.62 to 1.04, I(2) = 0%). In trials restricted to index patients with chlamydia, the effect was attenuated (2 trials; RR 0.90, 95% CI 0.60 to 1.35, I(2) = 22%). Expedited partner therapy also increased the number of partners treated per index patient (three trials) when compared with simple patient referral in people with chlamydia or gonorrhoea (MD 0.43, 95% CI 0.28 to 0.58) or trichomonas (MD 0.51, 95% CI 0.35 to 0.67), and people with any STI syndrome (MD 0.5, 95% CI 0.34 to 0.67). Expedited partner therapy was not superior to enhanced patient referral in preventing re-infection (3 trials; RR 0.96, 95% CI 0.60 to 1.53, I(2) = 33%, low-quality evidence). Home sampling kits for partners (four trials) did not result in lower rates of re-infection in the index case (measured in one trial), or higher numbers of partners elicited (three trials), notified (two trials) or treated (one trial) when compared with simple patient referral. There was no consistent evidence for the relative effects of provider, contract or other patient referral methods. In one trial among men with non-gonococcal urethritis, more partners were treated with provider referral than with simple patient referral (MD 0.5, 95% CI 0.37 to 0.63). In one study among people with syphilis, contract referral elicited treatment of more partners than provider referral (MD 2.2, 95% CI 1.95 to 2.45), but the number of partners receiving treatment was the same in both groups. Where measured, there was no statistical evidence of differences in the incidence of adverse effects between PN strategies.

AUTHORS' CONCLUSIONS

The evidence assessed in this review does not identify a single optimal strategy for PN for any particular STI. When combining trials of STI causing urethritis or cervicitis, expedited partner therapy was more successful than simple patient referral for preventing re-infection of the index patient but was not superior to enhanced patient referral. Expedited partner therapy interventions should include all components that were part of the trial intervention package. There was insufficient evidence to determine the most effective components of an enhanced patient referral strategy. There are too few trials to allow consistent conclusions about the relative effects of provider, contract or other patient referral methods for different STIs. More high-quality RCTs of PN strategies for HIV and syphilis, using biological outcomes, are needed.

Voices from the trenches: facilitators' perspectives on HIV risk reduction interventions

Experienced HIV prevention group facilitators have a unique perspective on sexual risk reduction interventions; however, their views are rarely reported in the research literature. To address this gap, the authors solicited input from four men and four women who served as facilitators in a randomized controlled trial of HIV risk reduction interventions. During focus groups or individual interviews, these facilitators commented on issues related to facilitation training and supervision, key facilitator characteristics, and challenges associated with intervention delivery. Facilitators reported that they valued training that was specific to the HIV context, the opportunity to observe workshops and to facilitate a mock workshop before facilitating themselves, and ongoing peer supervision. They recognized several important facilitator characteristics, including being open and nonjudgemental, being flexible, and being culturally competent. Finally, facilitators mentioned that facilitating workshops was made more difficult by the many psychosocial problems many low-income participants experienced, and that facilitating workshops with men was more difficult than with women. Observations such as these, provided by experienced facilitators, can help to improve intervention training and delivery, and may increase the likelihood that interventions will be adopted in community settings.

Results of a randomized controlled trial of a peer mentor HIV/STI prevention intervention for women over an 18 month follow-up

Despite numerous behavioral interventions designed for women, rates of HIV and STIs are increasing. Interventions are needed that reach a large number of at-risk individuals. This study was a randomized clinical trial of a HIV/STI behavioral intervention conducted in Baltimore, MD, USA. Heterosexual women (n = 169) completed a baseline and three semiannual follow-up visits. Participants were randomized into a standard of care comparison condition or a Peer Mentor condition. At the 6-month follow-up, Peer Mentors were less likely to have multiple sex partners [AOR: 0.28 (95% CI: 0.13, 0.63)]. At the 18 month follow-up assessment, Peer Mentors increased their condom use during vaginal [AOR: 0.47 (95% CI: 0.25, 0.87)] and anal sex [AOR: 0.24 (95% CI: 0.09, 0.68)] as well as with main [AOR: 0.41 (95% CI: 0.21, 0.77)] and non-main partners [AOR: 0.33 (95% CI: 0.14, 0.79)]. Peer education is a sustainable approach to change risky sexual behaviors.

A brief intervention for prevention of sexually transmitted infection among battered women

OBJECTIVE

To test the feasibility and acceptability of a combined brief nursing intervention (BNI) to prevent sexually transmitted infections (STIs) and intimate partner violence (IPV) among rural women attending a family planning clinic. The primary outcomes of interest were frequency and severity of IPV, the number of safety behaviors implemented by women, and the number of safer sex strategies used at 3 months postintervention.

DESIGN

A one-group pretest/posttest design.

SETTING

Rural health department family planning clinics.

PARTICIPANTS

Eighty-eight women were screened for IPV. Nineteen (21.4%) screened positive for past-year history of IPV, and 18 completed the intervention and data collection (baseline and 3 months).

METHODS

Women who screened positive for IPV were given a BNI addressing IPV and STI prevention. Severity and frequency of violence, IPV safety behaviors, and safer sex behaviors were measured at baseline and 3 months.

RESULTS

The frequency of physical (p = .02) and sexual (p = .05) violence decreased from baseline to 3-month follow-up. Although not statistically significant the number of safer sex behaviors reported increased from baseline to follow-up.

CONCLUSIONS

This BNI shows promise, though findings must be interpreted with caution due to small sample, lack of a control group, and no randomization. It was feasible to deliver the intervention in clinic settings.

Comparison of a theory-based (AIDS Risk Reduction Model) cognitive behavioral intervention versus enhanced counseling for abused ethnic minority adolescent women on infection with sexually transmitted infection: results of a randomized controlled trial

BACKGROUND

Ethnic minority adolescent women with a history of sexual or physical abuse and sexually transmitted infections represent a vulnerable population at risk for HIV. Community-based interventions for behavior modification and subsequent risk reduction have not been effective among these women.

OBJECTIVES

To evaluate the effects of a theory-based (AIDS Risk Reduction Model) cognitive behavioral intervention model versus enhanced counseling for abused ethnic minority adolescent women on infection with sexually transmitted infection at 6 and 12 months follow-up.

DESIGN

Controlled randomized trial with longitudinal follow-up.

SETTINGS

Southwestern United States, Metropolitan community-based clinic.

PARTICIPANTS

Mexican-and-African American adolescent women aged 14-18 years with a history of abuse or sexually transmitted infection seeking sexual health care.

METHODS

Extensive preliminary study for intervention development was conducted including individual interviews, focus groups, secondary data analysis, pre-testing and feasibility testing for modification of an evidence-based intervention prior to testing in the randomized controlled trial. Following informed consents for participation in the trial, detailed interviews concerning demographics, abuse history, sexual risk behavior, sexual health and physical exams were obtained. Randomization into either control or intervention groups was conducted. Intervention participants received workshop, support group and individual counseling sessions. Control participants received abuse and enhanced clinical counseling. Follow-up including detailed interview and physical exam was conducted at 6 and 12 months following study entry to assess for infection. Intention to treat analysis was conducted to assess intervention effects using chi-square and multiple regression models.

RESULTS

409 Mexican-(n=342) and African-(n=67) American adolescent women with abuse and sexually transmitted infection histories were enrolled; 90% intervention group attendance; longitudinal follow-up at 6 (93%) and 12 (94%) months. Intervention (n=199) versus control (n=210) group participants experienced fewer infections at 0-6 (0% versus 6.6%, p=.001), 6-12 (3.6% versus 7.8%, p=.005, CI 95% lower-upper .001-.386) and 0-12 (4.8% versus 13.2%, p=.002, CI 95% lower-upper, .002-.531) month intervals.

CONCLUSIONS

A cognitive behavioral intervention specifically designed for ethnic minority adolescent women with a history of abuse and sexually transmitted infection was effective for prevention of infection. These results provide evidence for development of evidence-based interventions for sexually transmitted infection/HIV. Implications include translation to community-clinic-based settings for prevention of adverse outcomes regarding sexual health of adolescent women.

Randomized clinical trial of brief risk reduction counseling for sexually transmitted infection clinic patients in Cape Town, South Africa

OBJECTIVES

We examined the effects of a brief counseling intervention designed to reduce HIV risk behaviors and sexually transmitted infections (STIs) among patients receiving STI services in Cape Town, South Africa.

METHODS

After randomization to either a 60-minute risk reduction counseling session or a 20-minute HIV-STI educational session, patients completed computerized sexual behavior assessments. More than 85% of the participants were retained at the 12-month follow-up.

RESULTS

There were 24% fewer incident STIs and significant reductions in unprotected vaginal and anal intercourse among participants who received risk reduction counseling relative to members of the control condition. Moderator analyses showed shorter lived outcomes for heavy alcohol drinkers than for lighter drinkers. The results were not moderated by gender.

CONCLUSIONS

Brief single-session HIV prevention counseling delivered to STI clinic patients has the potential to reduce HIV infections. Counseling should be enhanced for heavier drinkers, and sustained outcomes will require relapse prevention techniques. Disseminating effective, brief, and feasible behavioral interventions to those at highest risk for HIV infection should remain a public health priority.

Characteristics of women reporting multiple recent sex partners presenting to a sexually transmitted disease clinic for care

BACKGROUND

Sexually transmitted disease (STD) clinic attendees are considered to be at higher risk of sexually transmitted infections (STIs) than the general population. However, little is known about STD clinic subpopulations and their unique risks for STI's. The goal of this project was to begin to characterize an important STD clinic subpopulation, the small proportion of women reporting a recent history of multiple sex partners.

METHODS

Screening of electronic medical records from 2007 identified 347 (7%) women with ≥4 partners in the last 12 months. Records for women with ≥4 sex partners were matched with women reporting 1 sex partner in the last 12 months. Demographic, sexual history, STI history, and laboratory diagnosis(es) were extracted from the electronic medical record and compared using a case-control study design.

RESULTS

Approximately 5000 women presented to our STD clinic in 2007; 7.0% reported≥4 sex partners. Women with ≥4 sex partners were less often black and on average younger than women with single partners (Median age, 24 vs. 29). They reported more nonvaginal sex, more same-sex contacts, but more consistent condom use than women with single partners. Dyspareunia, genital lesions, abdominal pain, and skin findings were more commonly reported by women with ≥4 sex partners. Women with multiple partners were also more likely to report ever having had ≥3 STI's and were more likely to report a history of gonorrhea or syphilis. They were also more likely to be diagnosed at presentation with chlamydia, gonorrhea, or syphilis.

CONCLUSION

Women reporting multiple sex partners are an important minority among STD clinic attendees. Understanding the antecedents to high risk sexual behavior as determined by partner number is an important step in reducing STI's in this group.

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.

The path to intervention: community partnerships and development of a cognitive behavioral intervention for ethnic minority adolescent females

Reproductive health needs for ethnic minority adolescents are a national priority given the population growth of minority adolescents in the United States. United States census reports predict minority adolescents will comprise one-third of all young persons less than 20 years of age early in the twenty-first century. Developing culturally sensitive interventions for minority adolescents includes ecological assessments of cultural priorities, community resources, disease burden, and socioeconomic conditions. These assessments must be accomplished in partnership with the local community. Understanding reproductive health needs necessarily includes an evaluation of the absence of reproductive health, namely, the prevalence of sexually transmitted infection (STI), sexual or physical abuse, unplanned pregnancy, and the risk factors that contribute to such adverse outcomes. This article describes the methodological processes utilized to conduct an ecological assessment of a community including the health, economic, and psychosocial status of, and resources available to, a target population prior to the implementation of a community-based, cognitive behavioral intervention to reduce STI, abuse, and unplanned pregnancy.

A genome-wide profiling of the humoral immune response to Chlamydia trachomatis infection reveals vaccine candidate antigens expressed in humans

A whole genome scale proteome array consisting of 908 open reading frames encoded in Chlamydia trachomatis genome and plasmid was used to profile anti-chlamydial Ab responses. A total of 719 chlamydial proteins was recognized by one or more antisera from 99 women urogenitally infected with C. trachomatis. Revealing such a large C. trachomatis ANTIGENome in humans might partially be attributed to the significantly improved detection sensitivity of the whole genome scale proteome array assay because both linear and conformation-dependent Abs were detected by the array assay. Twenty-seven of the 719 Ags were recognized by >or=50% antisera, thus designated as immunodominant Ags. Comparison of Ag profiles recognized by live chlamydial organism-infected versus dead organism-immunized hosts led to the identification of infection-dependent or in vivo expressed Ags. The infection-dependent Ags induced Abs only in live organism-infected, but not in dead organism-immunized hosts. Many of these Ags were highly expressed during replication, but only minimally packaged into the infectious elementary bodies. Because inactivated whole chlamydial organism-based vaccines failed to induce protection in humans, identification of the infection-dependent or in vivo expressed immunodominant Ags in humans should greatly facilitate the selection of promising chlamydial subunit vaccine candidates for further evaluation. This approach may also be applicable to other pathogens.

Randomized controlled trials of interventions to prevent sexually transmitted infections: learning from the past to plan for the future

Globally, sexually transmitted infections (STIs) represent a significant source of morbidity and disproportionately impact the health of women and children. The number of randomized controlled trials testing interventions to prevent STIs has dramatically increased over time. To assess their impact, the authors conducted a systematic review of interventions to prevent sexual transmission or acquisition of STIs other than human immunodeficiency virus, published in the English-language, peer-reviewed literature through December 2009. Ninety-three papers reporting data from 74 randomized controlled trials evaluating 75 STI prevention interventions were identified. Eight intervention modalities were used: behavioral interventions (36% of interventions), vaginal microbicides (16%), vaccines (16%), treatment (11%), partner services (9%), physical barriers (5%), male circumcision (5%), and multicomponent (1%). Overall, 59% of interventions demonstrated efficacy in preventing infection with at least 1 STI. Treatment interventions and vaccines for viral STIs showed the most consistently positive effects. Male circumcision protected against viral STIs and possibly trichomoniasis. Almost two-thirds of behavioral interventions were effective, but the magnitude of effects ranged broadly. Partner services yielded similarly mixed results. In contrast, vaginal microbicides and physical barrier methods demonstrated few positive effects. Future STI prevention efforts should focus on enhancing adherence within interventions, integrating new technologies, ensuring sustainable behavior change, and conducting implementation research.

Circle of life: rationale, design, and baseline results of an HIV prevention intervention among young American Indian adolescents of the Northern Plains

In spite of significant disparities in sexual health outcomes for American Indian youth, no studies exist examining the effectiveness of HIV-prevention interventions. Circle of Life is an HIV-prevention intervention specifically developed for American Indian middle-school youth. We describe the rationale, methodology, and baseline results of a longitudinal randomized trial of Circle of Life conducted among American Indian youth aged 11-15 in a reservation community. The innovative design includes two pre-intervention waves to determine patterns of behavior prior to the intervention that might be associated with a differential impact of the intervention on sexual risk. We used one-way analysis of variance and chi-square tests to test for significant differences between randomized group assignment at each baseline wave and generalized estimating equations (GEE) to test significant differences in the rate of change in outcomes by group longitudinally. We present the collaborative and adaptive strategies for consenting, assenting, and data collection methodology in this community. Achieved response rates are comparable to other similar studies. Results from the two baseline waves indicate that few outcomes significantly varied by randomized intervention assignment. Ten percent of youth reported having had sex at Wave 1, rising to 15% at Wave 2. Among those who had had sex, the majority (>70%) reported using a condom at last sex. The project is well positioned to carry out the longitudinal assessments of the intervention to determine the overall impact of the Circle of Life and the differential impact by pre-intervention patterns of behavior across youth.

The male sexual partners of adult versus teen women with sexually transmitted infections

OBJECTIVES

We compared the male sexual partners of teen girls of age 15 to 19 years, currently infected with a sexually transmitted infection (STI) versus the male partners of adult women of age 20 to 41 years, with an STI to determine risk factors in these high-risk sexual dyads related to the male partner.

STUDY DESIGN

Interview of 514 men who were partnered with 152 teen girls and 362 adult women, enrolled in Project Sexual Awareness for Everyone, a randomized controlled trial of behavioral intervention to reduce recurrent STIs.

RESULTS

Compared to the male partners of adult women, male partners of teen girls were significantly more likely (P < 0.05) to be infected with any STI at intake. Men partnered with teens were younger and had significantly more sexual partners per year sexually active, shorter relationship length, and shorter length of monogamy with the index girls. They were more likely to report that it was "really important" for the teen to have their baby (P = 0.04) and were slightly more likely to be the father of her children (P = 0.17). Young age independently predicted STI infection in men.

CONCLUSIONS

Although all women had an STI at intake, important differences were noted among the male partners of teens versus adults. Clinicians with similar populations may use this data to understand the characteristics of male partners of teens with STIs, in order to more effectively counsel adult and teen women on partner notification, treatment and STI prevention.

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.

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 Well Woman Program: a community-based randomized trial to prevent sexually transmitted infections in low-income African American women

In this sexually transmitted infection (STI) prevention study, we compared the efficacy of the Well Woman Program (WWP), a nurse practitioner-directed, culturally specific, intensive intervention, to minimal intervention (MI), brief lecture, and referral to usual care, in a community-based randomized controlled trial. African American women having past STIs and residing in high-risk communities were randomly assigned to the two groups. STI outcome was measured at baseline and three later points. A random effects logistic longitudinal regression model showed that, at baseline, approximately 75% of participants tested positive for an STI, predominantly trichomoniasis. At month 15, the estimated probability of a WWP participant having an STI was 20% less than an MI participant. Better STI outcomes were due to the intensive individualized intervention.

Theory-based interventions for contraception

BACKGROUND

The explicit use of theory in research helps expand the knowledge base. Theories and models have been used extensively in HIV-prevention research and in interventions for preventing sexually transmitted infections (STIs). The health behavior field uses many theories or models of change. However, educational interventions addressing contraception often have no stated theoretical base.

OBJECTIVES

Review randomized controlled trials that tested a theoretical approach to inform contraceptive choice; encourage contraceptive use; or promote adherence to, or continuation of, a contraceptive regimen.

SEARCH STRATEGY

We searched computerized databases for trials that tested a theory-based intervention for improving contraceptive use (MEDLINE, POPLINE, CENTRAL, PsycINFO, EMBASE, ClinicalTrials.gov, and ICTRP). We also wrote to researchers to find other trials.

SELECTION CRITERIA

Trials tested a theory-based intervention for improving contraceptive use. We excluded trials focused on high-risk groups. Interventions addressed the use of one or more contraceptive methods. The reports provided evidence that the intervention was based on a specific theory or model. The primary outcomes were pregnancy, contraceptive choice, initiating or changing contraceptive use, contraceptive regimen adherence, and contraception continuation.

DATA COLLECTION AND ANALYSIS

The primary author evaluated abstracts for eligibility. Two authors extracted data from included studies. We calculated the odds ratio for dichotomous outcomes and the mean difference for continuous data. No meta-analysis was conducted due to intervention differences.

MAIN RESULTS

Of 26 trials, 12 interventions addressed contraception (other than condoms), while 14 focused on condom use for preventing HIV or STIs. In 2 of 10 trials with pregnancy or birth data, a theory-based group showed better results. Four of nine trials with contraceptive use (other than condoms) showed better outcomes in an experimental group. For condom use, a theory-based group had favorable results in 14 of 20 trials, but the number was halved in a subgroup analysis. Social Cognitive Theory was the main theoretical basis for 12 trials, and 10 showed positive results. Of the other 14 trials, favorable results were shown for other social cognition models (N=2), motivational interviewing (N=5), and the AIDS Risk Reduction Model (N=2). No major patterns were detected by type of theory, intervention, or target population.

AUTHORS' CONCLUSIONS

Family planning researchers and practitioners could apply the relevant theories and effective interventions from HIV and STI prevention. More thorough use of single theories would help inform the field about what works. Better reporting is needed on research design and intervention implementation.

Prevention of sexually transmitted infections in women

Because the acquisition of sexually transmitted infections (STIs) is based on individual sexual behaviors, the most successful STI prevention initiatives have been behavioral interventions seeking to change individual risk behaviors. This article explores systematic and community-based prevention initiatives and the steps in development and validation of behavioral interventions to reduce STIs. Key interventions and the trials in which they were proven effective are discussed in detail. It is hoped that a greater understanding of the development and validation of behavioral interventions for STI prevention will encourage physicians to accept these interventions as additional tools to prevent disease and suffering.

Partner notification of sexually transmitted infections among pregnant women

The object of this study was to determine the factors associated with partner notification (PN) of sexually transmitted infection (STI) exposure among pregnant, low income, Mexican-American (MA) and African-American (AA) women and their male sexual partners. We used a cross-sectional analysis of 166 pregnant women with an STI, enrolled in a randomized controlled trial of behavioural intervention to prevent recurrent STIs. The primary outcome, PN, is notification of, or intent to notify male sexual partner(s) of STI exposure. Pregnant women with one (n = 136) versus multiple (n = 30) partners reported PN for 88.2% and 54.5% of male partners, respectively (P < 0.001). Multivariate logistic regression demonstrated three variables that independently predicted PN: a steady relationship, with one male sexual partner and recent (<30 days) intercourse with the partner. Among the low income, pregnant MA and AA women, the three relationship variables predicted 81.6% of PN and correctly classified 78.5% of males notified and 65.7% of males not notified.

Sexually transmitted infections in adolescent women

Adolescent women possess physiologic and, frequently, behavioral characteristics that place them at an increased risk for contracting sexually transmitted infections. Diagnosis and prompt treatment of sexually transmitted infections is of paramount importance for an adolescent's future fertility and prevention of transmission to future partners. Diagnosis and treatment is often hindered by lack of symptoms, concern for screening and treatment confidentiality, and lack of knowledge about community medical resources.

Partner Notification of Sexually Transmitted Infections: A Large Cohort of Mexican American and African American Women

OBJECTIVES

To determine factors associated with partner notification (PN) of sexually transmitted infection (STI) exposure among low-income Mexican American and African American women and their male sexual partners.

GOAL

To identify women most likely to notify their partners about an STI exposure.

STUDY DESIGN

Cross-sectional analysis of 775 women with a nonviral STI. The primary outcome, PN, is notification of, or intent to notify male sexual partner(s) of STI exposure. A comprehensive intake interview was used to obtain sociodemographic, psychosocial, communication, and relationship information for the patients and each male sexual partner. Chi square analysis and multivariate logistic regression analysis were used to determine factors independently associated with PN.

RESULTS

The 775 women identified 1122 male sexual partners. Of women with 1, 2, and 3 or more partners, 87.9%, 41.4%, and 25.0% reported PN for all partners respectively. Logistic regression demonstrated that 5 variables independently predicted PN: a "steady" relationship (OR: 5.25; CI: 2.82-4.91), 1 partner (OR: 2.10; CI: 1.71-2.56), recent intercourse (OR: 1.37; CI: 1.21-1.54), anticipated ongoing sexual activity (OR: 1.48; CI: 1.04-2.10), and/or desire for pregnancy with that partner (OR: 1.68; CI: 1.10-2.58). Patient and partner sociodemographic variables were not significantly associated with PN. Responses to specific relationship and communication variables, although significant, did not remain independent in the final logistic regression model.

CONCLUSION

Among low-income Mexican American and African American women, the perception that a relationship with individual partner(s) was committed was predictive of PN.

Designing and delivering a prevention project within an HIV treatment setting: lessons learned from a specialist model

This paper presents lessons learned from an intervention designed to provide HIV prevention counseling within a hospital-based, multidisciplinary HIV clinic. The model, Positive Prevention, used Master's-level social workers (MSWs) as intervention specialists to minimize burden on primary care providers and to offer a replicable way to provide prevention in a similar setting. The intervention goal was to reduce risk behaviors through Motivational Interviewing, a patient-centered counseling approach with proven success impacting behavioral change. Implementation experiences offer insight into the challenges of using MSWs as prevention specialists. Particular challenges were related to patient engagement and retention. Experiences early in the implementation process were informative and allowed for adaptations to facilitate a more viable program; however even after executing new strategies, many of the program issues remained. Thus, the Positive Prevention model is not recommended as a best HIV prevention model for replication in similar high-volume, hospital-based, multidisciplinary HIV clinic settings.

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.

Brief Cognitive Counseling With HIV Testing To Reduce Sexual Risk Among Men Who Have Sex With Men

OBJECTIVES

To test the efficacy and acceptability of a single-session personalized cognitive counseling (PCC) intervention delivered by paraprofessionals during HIV voluntary counseling and testing.

METHODS

HIV-negative men who have sex with men (MSM; n = 336) were randomly allocated to PCC or usual counseling (UC) between October 2002 and September 2004. The primary outcome was the number of episodes of unprotected anal intercourse (UAI) with any nonprimary partner of nonconcordant HIV serostatus in the preceding 90 days, measured at baseline, 6 months, and 12 months. Impact was assessed as "intent to treat" by random-intercept Poisson regression analysis. Acceptability was assessed by a standardized client satisfaction survey.

RESULTS

Men receiving PCC and UC reported comparable levels of HIV nonconcordant UAI at baseline (mean episodes: 4.2 vs. 4.8, respectively; P = 0.151). UAI decreased by more than 60% to 1.9 episodes at 6 months in the PCC arm (P < 0.001 vs. baseline) but was unchanged at 4.3 episodes for the UC arm (P = 0.069 vs. baseline). At 6 months, men receiving PCC reported significantly less risk than those receiving UC (P = 0.029 for difference to PCC). Risk reduction in the PCC arm was sustained from 6 to 12 months at 1.9 (P = 0.181), whereas risk significantly decreased in the UC arm to 2.2 during this interval (P < 0.001 vs. 6 months; P = 0.756 vs. PCC at 12 months). Significantly more PCC participants were "very satisfied" with the counseling experience (78.2%) versus UC participants (59.2%) (P = 0.002).

CONCLUSIONS

Both interventions were effective in reducing high-risk sexual behavior among MSM repeat testers. PCC participants demonstrated significant behavioral change more swiftly and reported a more satisfying counseling experience than UC participants.