Project STYLE: a multisite RCT for HIV prevention among youths in mental health treatment

Cluster analysis of caregiver and adolescent emotion regulation and its relation to sexual health and dating communication

OBJECTIVE

Adolescent emotion regulation (ER) has been positively linked to caregiver-adolescent sexual communication. With ER becoming increasingly conceptualized as an interpersonal process, it is likely that both adolescent and caregiver ER impact communication patterns to some extent; thus, each must be accounted for in scientific inquiry and intervention approaches. We aimed to identify distinct profiles of caregiver and adolescent ER and examine how each profile is differentially related to caregiver-adolescent communication about sexual health and relationships.

METHODS

Participants included adolescent males (n = 117; Mage = 13.06; SD = 0.72) and their caregivers (Mage = 42.33; SD = 0.72) who were recruited as part of a dyadic, web-based dating violence prevention intervention trial for middle school boys.

RESULTS

Using a self-report measure, three clusters were identified: families with Moderate ER strategy use (by both parents and adolescents), families with Low ER strategy use (by both parents and adolescents), and families with Mixed ER strategy use (moderate adolescent but low caregiver ER strategy use). Caregivers in the Moderate ER strategy use cluster reported discussing the greatest total number of sexual health and relationship topics. Adolescents in the Mixed ER strategy use cluster indicated the greatest perceived caregiver openness during discussions.

CONCLUSIONS

Findings suggest that adolescent ER may more strongly influence positive patterns of communication regarding sexual health and relationships than parent ER. Future research should compare the efficacy of adolescent sexual health and dating interventions with adolescents alone versus dyadic interventions to determine whether there is a clinically significant additive effect of including caregivers or if adolescent engagement alone may suffice.

Adapting a sexual and reproductive health program for Latina teens and their female caregivers: a qualitative study

Background

Adaptation is widely recognized as important when interventions are to be delivered in new settings or with new populations. However, there are gaps in the literature on how adaptations are carried out and documented. IMARA is a 12-h evidence-based sexual health intervention for Black teens and their mothers, designed for delivery over two days. We present our systematic process of adapting IMARA for Latinas to produce the Floreciendo ("Blooming") program for Latina teens (14-18 years old) and their female caregivers (e.g., mothers, sisters).

Methods

Using a community-based participatory research (CBPR) approach, we carried out a qualitative study that included 7 focus groups: 4 with staff from community partner organizations (n = 29), 2 with Latina teens (14-18 years) (n = 11), and 1 with female caregivers (n = 5). We also conducted seven key informant interviews with experts in sexual health and Latina health. We used Escoffery's recommended steps to guide our adaptation process. Data were thematically coded and adaptations documented using the FRAME for reporting modifications to evidence-based interventions.

Results

Informed by the data, we grouped IMARA content into four sessions for Floreciendo, each with unique curricular content and designed to be delivered in two hours (eight hours total): (1) Foundations in Sexual Risk Prevention; (2) Condoms and Contraception; (3) Family Strengthening; and (4) Gender and Relationships. We documented adaptations made for each session. For example, participants emphasized unplanned pregnancy as an important issue facing Latina teens. In response, we added an activity providing hands-on experience with contraceptive methods. Participants also highlighted how gender norms and family expectations in Latine culture shape Latina teens' sexual and reproductive health practices. We therefore developed activities and opportunities for discussion addressing these cultural influences. We removed IMARA activities considered of lower priority (e.g., portrayal of women in the media).

Conclusion

This study addresses gaps in the literature by reporting in detail the adaptations we made to an evidence-based intervention using qualitative methods. The four curriculum sessions we generated through our adaptation process will form the basis of the intervention components we will test in future work using the multiphase optimization strategy (MOST) framework.

Feasibility and Acceptability of a Family-Based Telehealth Intervention for Families Impacted by the Child Welfare System: Formative Mixed Methods Evaluation

BACKGROUND

Despite elevated rates of trauma exposure, substance misuse, mental health problems, and suicide, systems-impacted teens and their caregivers have limited access to empirically supported behavioral health services. Family-based interventions are the most effective for improving mental health, education, substance use, and delinquency outcomes, yet the familial and placement disruption that occurs during child welfare involvement can interfere with the delivery of family-based interventions.

OBJECTIVE

To address this gap in access to services, we adapted an in-person, empirically supported, family-based affect management intervention using a trauma-informed lens to be delivered via telehealth to families impacted by the child welfare system (Family Telehealth Project). We describe the intervention adaptation process and an open trial to evaluate its feasibility, acceptability, and impact.

METHODS

Adaptations to the in-person, family-based affect management intervention were conducted iteratively with input from youth, caregivers, and systems partners. Through focus groups and collaborative meetings with systems partners, a caregiver-only version of the intervention was also developed. An open trial of the intervention was conducted to assess family perspectives of its acceptability and feasibility and inform further refinements prior to a larger-scale evaluation. Participants included English-speaking families involved in the child welfare system in the past 12 months with teens (aged 12-18 years). Caregivers were eligible to participate either individually (caregivers of origin, kinship caregivers, or foster parents; n=7) or with their teen (caregiver of origin only; n=6 dyads). Participants completed session feedback forms and surveys at pretreatment, posttreatment, and 3-month posttreatment time points. Qualitative exit interviews were conducted with a subset of participants (12/19, 63%) to further understand their experiences with the intervention.

RESULTS

Session attendance was high, and both caregivers and teens reported high acceptability of clinicians and sessions on feedback forms. Families were comfortable with video technology, with very few (<5%) sessions having reported technology problems. Thematic analysis of exit interview transcripts indicated that families used effective communication and affect management skills taught during the intervention. Regarding challenges and barriers, some caregiver-only participants expressed a desire to have their teen also participate in the intervention. All interview participants reported that they would recommend the intervention to others and perceptions of the intervention were overwhelmingly positive. Quantitative surveys revealed differential responses to the intervention regarding affect management and communication.

CONCLUSIONS

An open trial of the Family Telehealth Project, a skills-based telehealth intervention for families impacted by the child welfare system, suggests high levels of intervention feasibility and acceptability. Participants noted improvements in areas often hindered by the impacts of trauma and family separation: communication and affect management. Perceptions of the intervention were positive overall for both teens and caregivers. The Family Telehealth Project shows promise in addressing the gaps in behavioral health access for systems-impacted families.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04488523; https://clinicaltrials.gov/study/NCT04488523.

Evaluation of a Brief Online Sexual Health Program for Adolescents: A Randomized Controlled Trial

Adolescents are at increased risk of acquiring sexually transmitted infections (STIs) and experiencing unintended pregnancy. In particular, adolescents from marginalized communities experience significant sexual health disparities compared to their more advantaged peers. Digital sexual health programs, such as HEART (Health Education and Relationship Training), may be effective in reducing these risks and addressing these disparities. HEART is a web-based intervention focused on the promotion of positive sexual health outcomes, such as sexual decision-making skills, sexual communication skills, sexual health knowledge, and sexual norms and attitudes. The current study evaluates the efficacy of HEART, and examines whether effects were moderated by gender, socioeconomic status (SES), race, English as a second language, and sexual orientation to ensure the program is effective for diverse groups of adolescents. Participants were 457 high school students (Meanage=15.06, 59% girls, 35% White, 78% heterosexual, 54% receive free or reduced-price lunch). Students were randomized to HEART or an attention matched control and assessed at pretest and immediate posttest. HEART was effective in increasing sexual assertiveness, sexual communication intentions, HIV/STI knowledge, condom attitudes, and safer sex self-efficacy compared to the control condition. There were no significant interactions by gender, SES, race, English as a second language, or sexual orientation, suggesting the program worked equally well for all groups of youth. The findings of this study suggest that HEART may be a promising avenue for the promotion of positive sexual health outcomes for diverse groups of youth.

Adolescent Preferences for a Pediatric Primary Care-based Sexually Transmitted Infection and HIV Prevention Intervention

PURPOSE

We sought to elicit perspectives on HIV and sexually transmitted infection (STI) prevention among adolescents with recent STIs in primary care to optimize acceptability and effectiveness in designing a novel HIV/STI prevention intervention.

METHODS

We enrolled 13-19 year-olds with recent gonorrhea, chlamydia, trichomonas, and/or syphilis in a multimethods cross-sectional study at two primary care clinics. Participants completed surveys and interviews. We used an integrated analytic approach deductively coding data using the Integrated Behavioral Model, then inductively coding to identify themes not represented in the Integrated Behavioral Model.

RESULTS

Participants (n = 35) were 85% cisgender female, 14% cisgender male, 1% transgender female; 25% identified as lesbian, bisexual, or queer. Most (97%) identified as non-Latinx Black. None used condoms consistently, 26% were aware of pre-exposure prophylaxis (PrEP), and 31% were never HIV tested. Five key themes emerged. 1) Mental health was central to HIV prevention behavior uptake and coping with STI diagnosis. 2) Youth desired prevention counseling that allowed decisional autonomy and individualized goal setting. 3) Negative social norms around condoms and absent norms around HIV testing and PrEP limited method uptake. 4) Both confidence and concrete skills were needed to initiate prevention methods. 5) Youth desired education at the time of STI diagnosis to improve subsequent prevention decision making.

DISCUSSION

Key intervention design considerations included 1) integrating mental health assessment and referral to services, 2) promoting individualized goal setting, 4) building communication skills, 4) providing navigation and material support for PrEP uptake and HIV testing, and 5) augmenting comprehensive STI and HIV prevention education.

Family-based interventions in youth to prevent HIV/AIDS: A systematic review

Parents are primary sex educators of their teenagers and also function as resources for advice and information about sexual decision-making and partner selection. So far, various family-based programs were carried out to prevent HIV infection in young people; however, their findings are contradictory and inconclusive. Therefore, we carried out the current systematic review to critically review the available literature regarding the role of family-based interventions among young people to prevent HIV infection. The available online databases including ISI Web of Science, Scopus, and PubMed were searched systematically up to November 2022. The risk of bias in the eligible studies was examined by two independent authors using the Cochrane Collaboration Risk of Bias tool. A total of 7 studies including 4952 participants were enrolled in the current study. They were conducted between 2006 and 2020. On the basis of the available literature, family-based HIV prevention interventions seem to be effective in terms of improving HIV/AIDS knowledge and also parent-youth communication. It seems that family-based interventions in youth to prevent HIV/AIDS are effective; however, further well-designed studies are needed to help the researchers reach a firm conclusion on this issue. The current systematic review may be used by investigators for future studies in terms of settings and the selection of educational approaches. Moreover, it strongly suggested that further studies investigating the role of family-based education in the prevention of HIV/AIDS utilize more sample size and also a more robust educational framework.

The Role of Family Factors in the Outcomes of Court-Involved Youth

Court-involved youth (CIY) comprise a significant portion of the U.S. population and have a high prevalence of psychiatric illness and substance use. Youth delinquency has also been associated with family variables and parenting practices. However, it is not known which family factors are most relevant to behavioral outcomes in CIY mandated to outpatient mental health treatment. Self-report measures from 163 CIY (M = 15.19 years; 58.3% male) starting psychiatric care in two U.S. cities were utilized in a cross-sectional analysis to examine the association of parental monitoring and family functioning with the severity and variety of delinquent acts. Results demonstrate that parental monitoring is significantly associated with the delinquent behavior of CIY in mental health treatment, beyond that of psychiatric symptoms and substance use. Improved understanding of influential family factors can enhance tailoring of existing interventions to ensure that they are relevant to the needs of CIY, especially those in psychiatric treatment.

Cultural interventions addressing disparities in the HIV prevention and treatment cascade among Black/African Americans: a scoping review

Culture is an important determinant of HIV risk and protective behaviors; yet, we know little about how it is integrated in HIV interventions. This scoping review characterizes the integration of culture in HIV prevention and treatment interventions focused on Black/African Americans. We searched MEDLINE, PsycINFO, CINAHL, and Google Scholar for peer-reviewed manuscripts published between July 1, 2011, and June 28, 2021. Twenty-five interventions were identified, with 96% focused on prevention. Most (40%) targeted men who have sex with men or transgender women. Only three were grounded in cultural theory. Although all interventions were labeled "culturally based," only two explicitly defined culture. Moreover, there was much diversity regarding the ways in which interventions integrated cultural elements, with some conflating race/ethnicity with culture. To improve uptake and HIV-related outcomes, interventions integrating culture are greatly needed. Additionally, HIV interventions purporting to be "culturally based" must include basic information to support rigor and reproducibility.

Sexual self-efficacy and sexual communication among adolescent girls: moderated mediation results from a randomized controlled trial

OBJECTIVE

Guided by the Operating Conditions Framework, the goal of this study was to identify how and for whom an online sexual health program called Health Education and Relationship Training (HEART) worked.

DESIGN

Data come from a randomized controlled trial among 198 U.S. high school girls who completed HEART or an attention-matched control. We conducted mediation and moderated mediation models to determine if sexual self-efficacy was a mediator and if program acceptability and sexual activity status were moderators of HEART efficacy.

MAIN OUTCOME MEASURE

Sexual communication skills were assessed with a behavioral role-play task.

RESULTS

HEART significantly improved sexual communication skills. These effects were fully mediated through sexual self-efficacy. Specifically, HEART improved sexual self-efficacy which in turn increased sexual communication skills. Also, when participants liked the program more, the effect of HEART on sexual self-efficacy was stronger. Further, among girls who had engaged in sexual activity, sexual self-efficacy was significantly associated with sexual communication skills.

CONCLUSION

This study provides insights into the mechanisms of behavior change underlying HEART. Results highlight the need to further 'unpack' the effects of other sexual health programs, as we showed that programs may work better under certain conditions.

An Ecodevelopmental Framework for Engaging Diverse Youth in Foster Care and Their Families Into Technology-Based Family Intervention Research Trials

Family-based interventions delivered via telehealth are a promising mode for overcoming barriers to behavioral health treatment among youth in foster care and their families. There is a dearth of research, however, regarding effectiveness of these interventions for youth in foster care, who commonly exhibit complex behavioral health treatment needs. Clinical research in this area directly relates to equity in service access and quality for these youth and families, with numerous barriers and enabling factors to consider in order to improve engagement in clinical trials and bolster the evidence base. We present a framework to better understand the multi-systemic factors impacting youth and family engagement in clinical research on family-based telehealth interventions, drawing on relevant theory, including the bioecological model and ecodevelopmental theory. We also draw on our experiences conducting technology-based clinical research through the Family Telehealth Project, an evaluation of a brief family-based affect management intervention designed specifically for youth in foster care and their families, as a case example. Recommendations for promoting engagement in clinical research on family-based telehealth interventions with diverse youth in foster care and their families are provided.

Causally Interpretable Meta-analysis: Application in Adolescent HIV Prevention

Endowing meta-analytic results with a causal interpretation is challenging when there are differences in the distribution of effect modifiers among the populations underlying the included trials and the target population where the results of the meta-analysis will be applied. Recent work on transportability methods has described identifiability conditions under which the collection of randomized trials in a meta-analysis can be used to draw causal inferences about the target population. When the conditions hold, the methods enable estimation of causal quantities such as the average treatment effect and conditional average treatment effect in target populations that differ from the populations underlying the trial samples. The methods also facilitate comparison of treatments not directly compared in a head-to-head trial and assessment of comparative effectiveness within subgroups of the target population. We briefly describe these methods and present a worked example using individual participant data from three HIV prevention trials among adolescents in mental health care. We describe practical challenges in defining the target population, obtaining individual participant data from included trials and a sample of the target population, and addressing systematic missing data across datasets. When fully realized, methods for causally interpretable meta-analysis can provide decision-makers valid estimates of how treatments will work in target populations of substantive interest as well as in subgroups of these populations.

Investigating Longitudinal Associations Between Racial Microaggressions, Coping, Racial/Ethnic Identity, and Mental Health in Black Girls and Women

Racial microaggressions pose significant risk to health and well-being among Black adolescents and adults. Yet, protective factors (i.e., coping, racial/ethnic identity) can moderate the impact of racial microaggressions over time. Unfortunately, few studies have evaluated the role of these protective factors longitudinally or specifically among Black girls and women. In the current study, we focused on the experiences of Black girls and women and investigated the longitudinal links between racial microaggressions and mental health symptoms over 1 year. We then explored the role of two key protective factors as moderators-coping with racial discrimination and racial/ethnic identity-for mental health. Participants included 199 Black adolescent girls (M_age  = 16.02) and 199 Black women (M_age  = 42.82) who completed measures on two types of racial microaggressions, three types of coping strategies, racial/ethnic identity, and mental health symptomology. Girls and women completed measures at three time points over 1 year. Results indicated both types of microaggressions predicted increased mental health symptoms in Black women. Among Black girls, assumptions of criminality predicted increased externalizing symptoms only when protective factors were included in the model. Analysis of the protective factors indicated a potential direct benefit rather than a moderating role of coping with racial discrimination through positive thinking for mental health in both Black girls and women. Evidence suggests that coping may have had a direct rather than an indirect effect on Black girls' mental health over time. We conclude with future directions for research and considerations for practice.

Feasibility and Acceptability of Technology-supported Sexual Health Education Among Adolescents Receiving Inpatient Psychiatric Care

Mental illness in adolescence is associated with high-risk sexual behaviors including multiple sex partners, infrequent or inconsistent condom use, and nonuse of contraception. Inpatient psychiatric care represents a promising setting to provide sexual health education. This pilot study investigates the feasibility and acceptability of online sexual health education in this group by assessing usability and impact on short-term psychosocial outcomes. We administered online modules on healthy relationships, pregnancy prevention, condom use, and sexually transmitted infection (STI) prevention to youth. We evaluated outcomes using a single group, pre/post-intervention design. One quality improvement session assessed staff acceptability of the programming. Participants included 51 inpatients (mean age = 15.3; 61% female; 57% Hispanic or Latino; 55% heterosexual). Overall, the program was feasible to administer and highly acceptable to youth (84-89% liked the modules, 98-100% found them easy to use, 96-100% found them credible, 91-98% said information would lead to healthier dating relationships, and 78-87% would refer to a friend). Youth who completed modules demonstrated improvement in several outcomes: attitudes and norms towards violence (p < 0.001), intention to use a method of birth control other than condoms if having sex in the next 3 months (p < 0.001), condom knowledge (p < 0.001), condom use self-efficacy (p < 0.001), condom beliefs (p = 0.04), HIV/STI knowledge (p < 0.001), and perceived susceptibility to STI (p < 0.01). The quality improvement session revealed high acceptability by nursing staff on the unit. This intervention could be useful and efficacious in an inpatient setting and larger studies are warranted to understand its full impact.

A Technology-Based Training Tool for a Health Promotion and Sex Education Program for Justice-Involved Youth: Development and Usability Study

Background

Justice-involved youth are especially vulnerable to mental health distress, substance misuse, and risky sexual activity, amplifying the need for evidence-based programs (EBPs). Yet, uptake of EBPs in the justice system is challenging because staff training is costly in time and effort. Hence, justice-involved youth experience increasing health disparities despite the availability of EBPs.

Objective

To counter these challenges, this study develops and pilot-tests a prototype of a technology-based training tool that teaches juvenile justice staff to deliver a uniquely tailored EBP for justice-involved youth—PHAT (Preventing HIV/AIDS Among Teens) Life. PHAT Life is a comprehensive sex education, mental health, and substance use EBP collaboratively designed and tested with guidance from key stakeholders and community members. The training tool addresses implementation barriers that impede uptake and sustainment of EBPs, including staff training and support and implementation costs.

Methods

Staff (n=11) from two juvenile justice settings pilot-tested the technology-based training tool, which included five modules. Participants completed measures of HIV and sexually transmitted infection (STI) knowledge, sex education confidence, and implementation outcomes such as training satisfaction, adoption, implementation, acceptability, appropriateness, and sustainability. PHAT Life trainers assessed fidelity through two activity role plays participants submitted upon completing the training modules.

Results

Participants demonstrated increases in HIV and STI knowledge (t₁₀=3.07; P=.01), and were very satisfied (mean 4.42, SD 0.36) with the training tool and the PHAT Life curriculum. They believed that the training tool and curriculum could be adopted, implemented, and sustained within their settings as an appropriate and acceptable intervention and training.

Conclusions

Overall, the results from this pilot test demonstrate feasibility and support continuing efforts toward completing the training tool and evaluating it within a fully powered randomized controlled trial. Ultimately, this study will provide a scalable option for disseminating an EBP and offers a more cost-effective and sustainable way to train staff in an EBP.

An individually randomized controlled trial of a mother-daughter HIV/STI prevention program for adolescent girls and young women in South Africa: IMARA-SA study protocol

BACKGROUND

South Africa has the world's largest HIV epidemic, but South African adolescent girls and young women (AGYW) acquire HIV at twice the rate of and seroconvert on average 5-7 years earlier than their male peers. Female caregivers (FC) are an untapped resource for HIV/STI prevention in South Africa and offer a novel opportunity to strengthen AGYW prevention efforts. This study will evaluate the effectiveness and cost-effectiveness of an evidence-based mother-daughter HIV/STI prevention program tested in the United States and adapted for South Africa, Informed Motivated Aware and Responsible Adolescents and Adults (IMARA), to decrease STI incident infections and increase HIV testing and counseling (HTC) and PrEP uptake in AGYW.

METHODS

This is a 2-arm individually randomized controlled trial comparing IMARA to a family-based control program matched in time and intensity with 525 15-19-year-old Black South African AGYW and their FC-dyads in Cape Town's informal communities. AGYW will complete baseline, 6-, and 12-month assessments. Following randomization, AGYW-FC dyads will participate in a 2-day group workshop (total 10 h) that includes joint and separate mother and daughter activities. Primary outcomes are AGYW STI incidence, HTC uptake, and PrEP uptake at 6 months. Secondary outcomes are AGYW STI incidence, HTC uptake, and PrEP uptake at 12 months, sexual behavior (e.g., condom use, number of partners), HIV incidence, and ART/PrEP adherence and intervention cost-effectiveness. AGYW who test positive for a STI will receive free treatment at the study site. HIV positive participants will be referred to ART clinics.

DISCUSSION

Primary prevention remains the most viable strategy to stem new STI and HIV transmissions. HIV and STI disparities go beyond individual level factors, and prevention packages that include supportive relationships (e.g., FC) may produce greater reductions in HIV-risk, improve HTC and PrEP uptake, and increase linkage, retention, and adherence to care. Reducing new HIV and STI infections among South African AGYW is global public health priority.

TRIAL REGISTRATION

ClinicalTrials.gov Number NCT04758390 , accepted 02/16/2021.

Examining the Link Between Sexual Self-Concept and Sexual Communication among Adolescents

The purpose of this study was to move beyond a sexual risk framework to investigate the possible associations among three sex-positive constructs for adolescents: their sexual self-concept (i.e., their positive/negative feelings about themselves as sexual beings), their sexual communication with romantic/sexual partners, and their sexual communication self-efficacy. We also examined differences in these constructs by sexual intercourse experience and gender. Participants were 171 adolescents who had been in a dating or sexual relationship in the past year (M _age=16.32 years; 64.3% girls). Compared to girls, boys had more positive sexual self-concepts but less self-efficacy to communicate with their partners about sex. Adolescents who reported having had sexual intercourse had more positive sexual self-concepts as well as more frequent partner sexual communication compared to adolescents without sexual intercourse experience. Adolescents with a more positive sexual self-concept had higher sexual communication self-efficacy and reported more frequent sexual communication. In addition, sexual communication self-efficacy partially mediated the relationship between sexual self-concept and sexual communication. Results highlight the connection between sexual self-concept and sexual communication and contribute to a growing body of work on the positive aspects of adolescent sexuality.

Improving the Sexual Health of Young People (under 25) in High-Risk Populations: A Systematic Review of Behavioural and Psychosocial Interventions

Background: Ensuring young people experience good sexual health is a key public health concern, yet some vulnerable groups of young people remain at higher risk of poor sexual health. These individuals require additional support to achieve good sexual health but the best way to provide this remains needs to be better understood. Methods: We searched for randomised controlled trials of behavioural and psychosocial interventions aimed at promoting sexual health in high-risk young populations. Outcomes of interest were indicators of sexual health (e.g., condom use, attitudes to contraception, knowledge of risk). Participants were under 25 years old and in one of the following high-risk groups: alcohol and other drug use; ethnic minority; homeless; justice-involved; LGBTQI+; mental ill-health; or out-of-home care. Results: Twenty-eight papers from 26 trials met our inclusion criteria, with all but one conducted in North America. Condom use was the most frequently reported outcome measure along with knowledge and attitudes towards sexual health but considerable differences in measures used made comparisons across studies difficult. Change in knowledge and attitudes did not consistently result in long-term change in behaviours. Conclusions: There remains a dearth of research undertaken outside of North America across all high-risk groups of young people. Future interventions should address sexual health more broadly than just the absence of negative biological outcomes, with LGBTQI+, homeless and mental ill-health populations targeted for such work. An international consensus on outcome measures would support the research field going forward, making future meta-analyses possible.

HIV knowledge, attitudes and practices amongst patients with severe mental illnesses and chronic medical illnesses in Durban, South Africa

BACKGROUND

Studies exploring HIV knowledge, attitudes and practices (KAP) of individuals with severe mental illness (SMI) have suggested their poorer knowledge about HIV. In KwaZulu-Natal (KZN) province, South Africa (SA), the epicentre of the country's HIV epidemic, improving KAP is essential for reduce its incidence amongst individuals with SMI. Comparing the KAP related to HIV between those with SMI and chronic medical illnesses (CMI) such as hypertension and diabetes may expose gaps in KAP related to HIV in the mentally ill who are more vulnerable to HIV.

AIM

This study aimed to compare the KAP related to HIV between people living with SMI and CMI.

SETTING

Outpatient clinics in Durban, SA.

METHODS

A cross-sectional structured questionnaire survey was conducted amongst 214 adult outpatients with SMI and CMI attending two general public sector hospitals in Durban, KZN. The KAP questionnaire consisted of three sections: general information, prevention and transmission of HIV.

RESULTS

Interviews were conducted with 124 patients with SMI and 90 with CMI. Most were female (69.5%), single (57.5%) and unemployed (59.4%). The diagnosis of SMI was associated with poorer general information of HIV (p = 0.02), but not with its prevention and transmission compared with those with CMI. Educational level was associated with poorer performance in all three domains: general information of HIV (p = 0.01), prevention (p = 0.01) and transmission (p = 0.02) amongst all the participants.

CONCLUSION

Gaps in the KAP of HIV amongst individuals with SMI compared with those with CMI suggested a need to provide focused health promotion regarding sexual health and HIV to the mentally ill at psychiatric facilities.

Intervening for HIV prevention and mental health: a review of global literature

INTRODUCTION

Numerous effective HIV prevention options exist, including behaviour change interventions, condom promotion and biomedical interventions, like voluntary medical male circumcision and pre-exposure prophylaxis. However, populations at risk of HIV also face overlapping vulnerabilities to common mental disorders and severe mental illness. Mental health status can affect engagement in HIV risk behaviours and HIV prevention programmes. We conducted a narrative review of the literature on HIV prevention among key populations and other groups vulnerable to HIV infection to understand the relationship between mental health conditions and HIV prevention outcomes and summarize existing evidence on integrated approaches to HIV prevention and mental healthcare.

METHODS

We searched five databases for studies published from January 2015 to August 2020, focused on HIV prevention and mental health conditions among key populations and individuals with serious mental illness. Studies were included if they evaluated an HIV prevention intervention or assessed correlates of HIV risk reduction and included assessment of mental health conditions or a mental health intervention.

RESULTS AND DISCUSSION

We identified 50 studies meeting our inclusion criteria, of which 26 were randomized controlled trials or other experimental designs of an HIV prevention intervention with or without a mental health component. Behaviour change interventions were the most common HIV prevention approach. A majority of studies recruited men who have sex with men and adolescents. Two studies provided distinct approaches to integrated HIV prevention and mental health service delivery. Overall, a majority of included studies showed that symptoms of mental disorder or distress are associated with HIV prevention outcomes (e.g. increased risky sexual behaviour, poor engagement in HIV prevention behaviours). In addition, several studies conducted among groups at high risk of poor mental health found that integrating a mental health component into a behaviour change intervention or linking mental health services to combination prevention activities significantly reduced risk behaviour and mental distress and improved access to mental healthcare.

CONCLUSIONS

Evidence suggests that mental health conditions are associated with poorer HIV prevention outcomes, and tailored integrated approaches are urgently needed to address overlapping vulnerabilities among key populations and other individuals at risk.

Results from Project GOLD: A pilot randomized controlled trial of a psychoeducational HIV/STI prevention intervention for black youth

Black youth face significant disparities in HIV/sexually transmitted infection (STI) disease burden. Mental illness and emotion regulation are ontributors to HIV/STI risk, yet many HIV/STI prevention interventions do not address these factors. Project GOLD was a pilot randomized controlled trial of a psychoeducational HIV/STI prevention intervention designed to address the role of mental illness and emotion regulation in HIV/STI risk among heterosexually active Black youth aged 14-17 (N = 108). Participants were recruited from outpatient mental health treatment programs and general community settings via community partner referrals, face-to-face encounters, flyers and social media. Assessments were conducted pretest, immediate posttest, and at 3-, 6-, and 12-month follow-up. Although there were no statistically significant differences in behavior change from baseline, there were practically significant effect sizes among HIV condition participants when compared to the general health condition (e.g., fewer sexual partners at 6 months). An increase in theoretical mediators (e.g., condom use negotiation beliefs) was sustained at 12 months. HIV condition participants also reported lower depressive symptom severity, with statistical significance noted at immediate post and at 3 months. The findings highlight the importance and challenges of engaging Black youth in culturally and contextually relevant, developmentally and psychologically appropriate HIV/STI prevention interventions.

A Review of Parent- and Family-based Prevention Efforts for Adolescent Dating Violence

Prevention efforts for adolescent dating violence (ADV) have largely focused on adolescent-based interventions with little emphasis on parent- and family-based interventions, despite the integral role parents serve in adolescent relationship development. This literature review provides an overview of the existing parent- and family-based intervention efforts for ADV. This review highlights that some programs are geared toward a universal audience, whereas others are more targeted towards populations believed to be at greater risk for ADV. Some programs primarily target parents, whereas others integrate parent-based components into primarily adolescent-focused or comprehensive programs. Aspects to consider when selecting a program are discussed, as well as future directions. Suggested future directions involve broadening existing parent- and family-based programming for ADV to include a focus on secondary and tertiary prevention, gender differences, and gender and sexual minorities. This review also highlights the need for existing programs to expand their evaluation of behavioral outcomes and comparison of programs to one another.

Social self-efficacy and sexual communication among adolescents in the United States: a cross-sectional study

Background Sexual communication between partners is associated with safer sex behaviours, including condom use among adolescents. Several studies have found a relationship between negative psychological constructs (e.g. depression, anxiety) and poor sexual communication; however, scant research exists regarding positive psychological constructs and their potential to promote effective sexual communication among adolescents. This study examined the association between a positive construct, social self-efficacy - a person's belief in their ability to successfully manage social relationships - and three components of sexual communication: sexual assertiveness, self-efficacy for communication, and frequency of sexual communication with dating partners.

METHODS

Data were collected in a cross-sectional survey from 222 high school girls in a rural school district in the south-eastern United States (Mage = 15.2; 38% White, 29% Latina, 24% Black; 50% were in a dating relationship in the past 3 months). Variables were measured with Likert-type scales. Bivariate correlation and regression analyses were conducted.

RESULTS

Social self-efficacy was significantly positively associated with sexual assertiveness and sexual communication self-efficacy for all girls, and there was a positive trend in the relationship between social self-efficacy and communication frequency among the subsample of girls who had a dating partner. The significant relationship with sexual assertiveness (β = 0.22, s.e. = 0.07, P = 0.001) and sexual communication self-efficacy (β = 0.17, s.e. = 0.04, P = 0.013) remained when controlling for sexual activity status.

CONCLUSIONS

Strengthening social self-efficacy may enhance girls' sexual communication and assertiveness skills. Future studies are needed to confirm the causal and temporal nature of these associations.

Latino STYLE: Preliminary Findings From an HIV Prevention RCT Among Latino Youth

OBJECTIVE

Latino STYLE is a family-centered, HIV-focused intervention (HIV) emphasizing cultural factors and parent-adolescent communication. We hypothesized that, compared with a general health promotion (HP) intervention, the HIV arm would improve caregiver and adolescent HIV knowledge, attitudes, parental monitoring, sexual communication, and family relationships after a 3-month postintervention period. This article reports on the short-term findings of the longer trial.

METHODS

A single-site, two-arm, parallel, family-based, randomized, controlled trial was conducted; eligible participants were Latino adolescents aged 14-17 and their primary caregiver. The study was conducted at the University of South Florida with 227 adolescent-caregiver dyads allocated to the HIV (n = 117) or HP (n = 110) intervention after completing a baseline assessment. Interim measures at 3-month follow-up included demographics, HIV knowledge, self-efficacy, parental monitoring, sexual communication, family relationships, and adolescent sexual behavior.

RESULTS

Adolescents in the HIV group reported small effects in parental permissiveness and the HP group reported small effects for family support. Caregivers in both groups reported decreases in all outcomes. Incidence of past 90-day sexual intercourse decreased in both treatment arms. Among those who were sexually active over the past 90 days, the number of sex acts decreased from baseline, particularly in the HIV group. The percentage of condom-protected sex acts increased in the HIV group and decreased in the HP group, but did not reach statistical significance.

CONCLUSIONS

The HIV Latino STYLE intervention was not efficacious in improving hypothesized outcomes over a 3-month period. However, exploratory analyses revealed moderate effects for decreases in adolescent sexual risk behavior, particularly in the HIV group.

A systematic review of early adoption of implementation science for HIV prevention or treatment in the United States

OBJECTIVE

To provide the first systematic review of the early adoption of implementation science for HIV prevention or treatment in the United States. We identified primary research studies that addressed implementation of HIV prevention or treatment in the United States and qualitatively assessed the reporting of implementation outcomes and intervention descriptions.

METHODS

We searched PubMed, PsycInfo, and CINAHL databases for evaluations of HIV prevention or treatment interventions that at least reported one implementation outcome and were published between 2014 and 2018. We used the 12-item Template for Intervention Description and Replication to assess study interventions.

RESULTS

A total of 2275 articles were identified. Thirty-nine studies met inclusion criteria. Of these, 84.6% used quantitative methods with 5% being hybrid effectiveness-implementation studies and 15% used qualitative methods. No studies cited a formal theoretical framework for implementation science. Acceptability and feasibility were the most frequently reported implementation outcomes. Eligible studies were diverse with regard to demographic categories. Most interventions focused on HIV prevention, particularly risk-reduction strategies. HIV treatment interventions targeted linkage to care and adherence to medications. Key implementation outcome findings indicated that these interventions are feasible and acceptable in the real world.

CONCLUSION

HIV implementation science could support dissemination of HIV prevention or treatment in the United States, although HIV treatment interventions are limited. Theoretical frameworks and key implementation outcomes like fidelity, penetration, and appropriateness could promote the rigor of future HIV treatment implementation research, helping the field deliver the promise of HIV prevention or treatment efforts in the United States.

IMARA: A mother-daughter group randomized controlled trial to reduce sexually transmitted infections in Black/African-American adolescents

Black/African-American girls are infected with sexually transmitted infections (STIs) at higher rates than their White counterparts. This study tested the efficacy of IMARA, a mother-daughter psychosocial STI/HIV prevention program, on adolescent Black/African-American girls’ incident STIs at 12 months in a 2-arm group randomized controlled trial. Black/African-American girls 14–18 years old and their primary female caregiver were eligible for the study. Girls provided urine samples to test for N. gonorrhoeae, C. trachomatis, and T. vaginalis infection at baseline and 12-months. Mother-daughter dyads were randomly assigned to IMARA (n = 118) or a time-matched health promotion control program (n = 81). Retention at 12-months was 86% with no difference across arms. Both interventions were delivered over two consecutive Saturdays totaling 12 hours. Girls who received IMARA were 43% less likely to contract a new STI in the 12-month post-intervention period compared with those in the health promotion control program (p = .011). A secondary follow-up intent-to-treat analysis provided additional support for the protective effect of IMARA, albeit with a similar magnitude of 37% (p = .014). Findings provide early evidence for IMARA’s efficacy, such that IMARA protected against STIs at 12-months among adolescent Black/African-American girls. Future research should examine the mechanisms associated with reduced STIs.

The Behavioral Health Needs of First-Time Offending Justice-Involved Youth: Substance Use, Sexual Risk and Mental Health

This study examines substance use, emotional/behavioral symptoms and sexual risk among first-time offending, court-involved, non-incarcerated (FTO-CINI) youth. Youth and caregivers (N=423) completed tablet-based assessments. By time of first justice contact (average 14.5 years old), 49% used substances, 40% were sexually active and 33% reported both. Youth with co-occurring substance use and sexual risk had more emotional/behavioral symptoms; youth with delinquent offenses and females had greater co-occurring risk. Time of first offense is a critical period to intervene upon high rates of mental health need for those with co-occurring substance use and sexual risk to prevent poor health and legal outcomes.

Changes in externalizing and internalizing symptoms among African American female adolescents over 1 year following a mother-daughter sexual health intervention

OBJECTIVE

African American female adolescents face disparities compared with White peers in the interrelated areas of mental health symptoms and sexually transmitted infection (STI) acquisition. IMARA (Informed, Motivated, Aware and Responsible about AIDS) is a group-based mother-daughter intervention addressing these factors among African American teenagers. Previous work demonstrated that female adolescents who received IMARA were 43% less likely than controls to evidence a new STI at 1 year. This report aimed to provide the 1st test of IMARA on externalizing and internalizing symptoms and an exploratory analysis of whether symptom improvements were associated with the protective effect of treatment against future STIs.

METHOD

Female African Americans aged 14-18 years (M = 16; N = 199) were randomly assigned to IMARA or a health promotion control group matched for time and structure. They completed the Youth Self-Report of externalizing and internalizing symptoms at baseline and at 6 and 12 months and were tested for STIs at baseline and 12 months; positive cases were treated. Hierarchical linear modeling tested symptom change over time, including the moderating effects of baseline symptoms.

RESULTS

Among participants who entered with high versus lower externalizing symptoms, those who received IMARA showed a slightly greater decrease in externalizing scores relative to the control (p = .035). For these youth, symptom improvements appeared to be associated with IMARA's protective effect against new STIs. Treatment was not associated with internalizing symptom change (p > .05).

CONCLUSION

IMARA shows promise in modestly reducing self-reported externalizing symptoms, although only for participants with high scores at baseline. The possibility that externalizing symptom improvement is linked with reduced STI acquisition warrants future examination. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Evaluation of an Online Sexual Health Program among Adolescent Girls with Emotional and Behavioral Difficulties

OBJECTIVES

Adolescent girls with emotional and behavioral difficulties (EBDs) have a heightened risk of negative sexual health, including HIV, other sexually transmitted infections (STIs), and unplanned pregnancy. Few evidence-based sexual health interventions are available for adolescent girls with EBDs. This study tested the feasibility, acceptability, and efficacy of a brief, online sexual health program called HEART (Health Education and Relationship Training).

METHODS

Forty-seven participants (M-age = 15.79; SD = 1.71; 62% Black, 23% Hispanic) recruited from community-based organizations in the southeastern U.S. were compared to a non-equivalent comparison group who received an attention-matched intervention.

RESULTS

Findings support the feasibility of participant recruitment and program administration in community-based settings. Participants completed HEART in 44 minutes and experienced few technological difficulties. HEART was highly acceptable: most participants liked, learned from, and were engaged with the program. Further, 92% would recommend HEART to a friend and 98% would use what they learned in the future. At posttest, intervention participants had significantly higher communication intentions, communication skills, STI/HIV knowledge, sexual self-efficacy, condom attitudes, and condom norms than the comparison group (ps < .003; effect size ds = .38-1.65). Significant improvement in condom intentions was observed when comparing pretest to posttest scores among intervention participants only, t(46) = -3.21, d = 0.47.

CONCLUSIONS

Findings support the feasibility, acceptability, and efficacy of HEART among adolescent girls with EBDs in community-based settings. This study also addresses the growing need for research into the transferability of sexual health interventions to facilitate evidence-based decision-making about program dissemination and implementation.

Parent Psychological Distress: A Moderator of Behavioral Health Intervention Outcomes among Justice-Involved Adolescents

We examined whether pre-existing parent psychological distress moderated juvenile offenders' substance use, sexual risk, and mental health outcomes in a randomized trial. Forty-seven parent-adolescent dyads received either Family-based Affect Management Intervention (FAMI) for adolescent substance use and HIV prevention or adolescent-only Health Promotion Intervention (HPI). Parents' self-reported distress at baseline significantly moderated adolescents' self-reported marijuana use and alcohol use but not other outcomes at 3 months postintervention, producing crossover interactions. FAMI outperformed HPI when parents reported high-level distress, whereas HPI outperformed FAMI when parents reported low-level distress. This finding that the relative efficacy of interventions depends on the severity of parent psychological distress could inform efforts to match substance-using, justice-involved adolescents with the intervention most likely to benefit them.

Association of Adolescent- and Parent-Reported Relationship Functioning with HIV Sexual Risk Among Adolescents in Botswana

Globally, adolescents in sub-Saharan Africa are the youth most affected by HIV. Parent-adolescent relationships can be protective in child and adolescent development and may be implicated in lowered adolescent HIV sexual risk. However, the importance of parental and adolescent perceptions of their relationship and assessing the implications of family functioning in adolescents' risk for HIV or other sexually transmitted infections are not well established in the research literature. This dyadic study simultaneously assessed both parents' and adolescents' perceptions of family functioning and their relationships with adolescent sexual behaviors in Botswana. Seventy-two parent-adolescent dyads completed audio computer-assisted self-interview surveys. Surveys, independently completed by parents and their adolescent, assessed multiple indicators of their relationship and is the first such study in Botswana to collect the perspectives of both the parents and their adolescents. The results highlight significantly discrepant views of their relationships and revealed that the magnitude of those discrepancies was associated with greater adolescent HIV sexual risk behavior across multiple measures of family relationships. Parents' inaccurate perceptions of their adolescents' sexual activity were also associated with greater adolescent sexual risk. These findings elucidate the importance of improving parent-adolescent communications and relationships, which may subsequently assist in lowering adolescents' sexual risk for HIV and other negative sexual health outcomes.

Feasibility, Acceptability, and Preliminary Efficacy of a Brief Online Sexual Health Program for Adolescents

This study evaluated the feasibility, acceptability, and preliminary efficacy of a 45-minute interactive, online sexual health program for adolescents, called Health Education and Relationship Training (HEART). The program was originally developed and evaluated among adolescent girls (HEART for Girls); the current project describes and evaluates a new version of the program that was adapted for boys and girls. Participants were 226 high school students (mean age = 16.3; 58% girls; 46% White; 79% heterosexual). Students were randomized to HEART or an attention-matched control and assessed at pre-test and immediate post-test. Overall, the program was feasible to administer in a school setting and youth found the program highly acceptable (83% liked the program, 87% learned new things, and 93% would use program content in the future). At post-test, students who completed HEART demonstrated improvements on every outcome we examined: sexual communication intentions, condom use intentions, HIV/STD knowledge, condom attitudes, condom norms, self-efficacy to practice safer sex, and sexual assertiveness compared to control participants (effect size ds = .23 to 1.27). Interactions by gender and sexual orientation revealed the program was equally acceptable and worked equally well for boys and girls and for heterosexual and sexual minority youth. We propose several avenues to further adapt and tailor HEART given its promise in promoting adolescent sexual health.

Pathways from witnessing community violence to mental health problems among South African adolescents

BACKGROUND

The intersection of violence exposure and mental health problems is a public health crisis for South African (SA) adolescents. Understanding the impact of community violence on adolescent mental health can inform future interventions.

OBJECTIVES

To assess pathways between community violence exposure and internalising and externalising problems in SA adolescents receiving mental healthcare, and the roles of parent and peer relationships in these associations.

METHODS

Participants (N=120 parent-adolescent pairs) were recruited from four mental health clinics in Western Cape Province to participate in a pilot test of a family-based HIV prevention study. Adolescents reported on their exposure to community violence, parental attachment, peer support of risk behaviour, and mental health. Parents reported on adolescents' internalising and externalising mental health problems. Participants received transport money (ZAR30 = USD3) and a shopping voucher or cash (ZAR50 = USD5) for their time.

RESULTS

Adolescents were 12 - 18 years old (mean (standard deviation) 14.39 (1.82) years), 53% were male, and 67% and 33% reported black African and mixed-race ethnicity, respectively. Parents were 94% female and reported an average monthly income of ZAR3 973 (USD397). Boys reported significantly higher rates of witnessing community violence than girls. Among boys, significant paths emerged from community violence and low parent attachment to externalising symptoms and from community violence to peer support of risky behaviour. For girls, the only significant path was from low parent attachment to peer support of risky behaviour.

CONCLUSIONS

This cross-sectional study sheds new light on the possible pathways from witnessing community violence to mental health problems among SA adolescents. Identifying factors that drive and mitigate psychological distress in the context of persistent community violence is critical to SA's future and can inform the selection and delivery of appropriate and targeted evidence-based interventions.

Publicly Available Internet Content as a HIV/STI Prevention Intervention for Urban Youth

Sexual and racial minority adolescents and young adults account for the most substantial number of new HIV infections in the United States. Numerous publicly available websites and YouTube videos contain HIV/STI prevention information that is culturally tailored to racial and ethnic minorities, and gay and bisexual youth. However, the effect of this easily accessible Internet content on adolescent and young adult HIV/STI related knowledge, attitudes and behaviors is unknown. We assembled a HIV/STI Internet intervention from publicly available online sources, including YouTube and privately and publicly hosted websites. We tested the preliminary efficacy of this internet intervention by means of a randomized controlled pilot study with 60 diverse adolescents and young adults recruited in Providence, RI (mean age 18.6 years, 62% male, 52% Black/African American, 36% Hispanic, 47% non-heterosexual). Youth who received links to publicly accessible online prevention content by email had a significant improvement in HIV self-efficacy (p < .05) and a significant reduction in unprotected vaginal or anal sex (12.5 vs. 47.6%, AOR = 7.77, p < .05), as compared to a control group who did not receive the internet content by email. If these preliminary findings can be confirmed by future research, free online content could be inexpensively distributed to at risk youth in underserved communities and could hold promise as an inexpensive method of HIV/STI prevention.

Making a Case for Integrating Evidence-Based Sexual Risk Reduction and Mental Health Interventions for Adolescent Girls

Recently identified as the top concern of teens, mental health issues now compete with sexual health risks as major threats to the well-being of adolescent females. Depression and anxiety can lead to or compound the negative repercussions of sexual behavior choices that result in disproportionately high rates of sexually-transmitted infections (STIs), hetero-sexually acquired HIV, and unplanned pregnancy rates in girls ages 15-19. There are a limited number of CDC- and DHHS-recognized HIV/STI and teen pregnancy evidence-based interventions (EBIs) targeted to adolescent girls of diverse races/ethnicities and none that simultaneously address common mental health disorders. The Health Improvement Project for Teens (HIPTeens), a manualized gender-specific sexual risk reduction intervention, and the Creating Opportunities for Personal Empowerment (COPE) Program, a manualized cognitive-behavioral skills intervention that reduces depression and anxiety, are recognized by national agencies as strong EBIs that have successfully improved their targeted outcomes. Baseline data from the HIPTeens clinical trial revealed that a substantial portion of the more than 700 girls enrolled had moderate to high levels of depressive symptoms as well as other mental health challenges (e.g., binge drinking and eating, cannabis use). Thus, there is an urgent need to combine EBIs, such as HIPTeens and COPE, to curtail these leading public health problems confronting today's adolescents.

Assessment of Parent-Based Interventions for Adolescent Sexual Health: A Systematic Review and Meta-analysis

IMPORTANCE

Parent-based sexual health interventions have received considerable attention as one factor that can increase safer sexual behavior among youth; however, to our knowledge, the evidence linking parent-based interventions to youth sexual behaviors has not been empirically synthesized.

OBJECTIVE

To examine the association of parent-based sexual health interventions with 3 primary youth outcomes-delayed sexual activity, condom use, and parent-child sexual communication-as well as several secondary outcomes. We also explored potential moderators of intervention effectiveness.

DATA SOURCES

A systematic search was conducted of studies published through March 2018 using MEDLINE, PsycINFO, Communication Source, and CINAHL databases and relevant review articles.

STUDY SELECTION

Studies were included if they: (1) sampled adolescents (mean age, ≤18 years), (2) included parents in a key intervention component, (3) evaluated program effects with experimental/quasi-experimental designs, (4) included an adolescent-reported behavioral outcome, (5) consisted of a US-based sample, and (6) were published in English.

DATA EXTRACTION AND SYNTHESIS

Standardized mean difference (d) and 95% confidence intervals were computed from studies and meta-analyzed using random-effects models. A secondary analysis evaluated potential moderating variables.

MAIN OUTCOMES AND MEASURES

The primary outcomes were delayed sexual activity, condom use, and sexual communication.

RESULTS

Independent findings from 31 articles reporting on 12 464 adolescents (mean age = 12.3 years) were synthesized. Across studies, there was a significant association of parent-based interventions with improved condom use (d = 0.32; 95% CI, 0.13-0.51; P = .001) and parent-child sexual communication (d = 0.27; 95% CI, 0.19-0.35; P = .001). No significant differences between parent-based interventions and control programs were found for delaying sexual activity (d = -0.06; 95% CI, -0.14 to 0.02; P = .16). The associations for condom use were heterogeneous. Moderation analyses revealed larger associations for interventions that focused on younger, compared with older, adolescents; targeted black or Hispanic youth compared with mixed race/ethnicity samples; targeted parents and teens equally compared with emphasizing parents only; and included a program dose of 10 hours or more compared with a lower dose.

CONCLUSIONS AND RELEVANCE

Parent-based sexual health programs can promote safer sex behavior and cognitions in adolescents, although the findings in this analysis were generally modest. Moderation analyses indicated several areas where future programs could place additional attention to improve potential effectiveness.

Evaluating the Role of Family Context Within a Randomized Adolescent HIV-Risk Prevention Trial

Project STYLE is a multi-site 3-arm RCT comparing family-based, adolescent-only, and general health promotion interventions with 721 adolescents in mental health treatment. This study reports 12-month outcomes for family context and sexual risk behaviors, and explores the role of baseline family context in modifying treatment response. Using the full sample, there were sustained benefits for parent-reported sexual communication (d = 0.28), and adolescent-reported parental monitoring (d = 0.24), with minimal differences in risk behaviors. Latent profile analysis identified four family context classes: struggling (n = 177), authoritative (n = 183), authoritarian (n = 175), and permissive (n = 181). The authoritarian and permissive classes were also distinguished by disagreement between parent and adolescent report of family context. Classes differed in terms of baseline mental health burden and baseline sexual risk behavior. Classes showed different patterns of treatment effects, with the struggling class showing consistent benefit for both family context and sexual risk. In contrast, the authoritarian class showed a mixed response for family context and increased sexual risk.

Sexual risk among African American girls seeking psychiatric care: A social-personal framework

OBJECTIVE

This study examined individual and social factors associated with sexual risk behavior among African American girls seeking outpatient mental health services across 2 years and key developmental transitions.

METHOD

African American females 12-16 years old (M = 14.5; SD = 1.15; n = 266) were recruited from eight outpatient mental health clinics and completed interviewer-administered and computer-assisted measures at baseline, 12, and 24 months. Analyses tested individual attributes (externalizing and internalizing problems) and family context (maternal acceptance-rejection, mother-daughter communication about sex) at baseline, peer influences (peer support of substance use, girlfriend dating behavior) and partner relationship characteristics (rejection sensitivity, partner risk communication frequency and openness) at 12 months, and girls' sexual behavior at 24 months.

RESULTS

At baseline, 32% of girls reported having had vaginal/anal sex compared with 60% at 24 months. Data analyses revealed robust associations between externalizing problems and maternal acceptance-rejection and mother-daughter risk communication during early adolescence, peer support of substance use and girlfriend dating behavior 1 year later, and girls' sexual risk taking 2 years later.

CONCLUSION

Findings support a social-personal framework (SPF) of sexual risk for African American girls seeking mental health care, underscoring the potential benefits of early intervention to reduce externalizing problems while strengthening mother-daughter communication and relationships to prevent subsequent sexual risk and associated negative outcomes. (PsycINFO Database Record

Project GOLD: A pilot randomized controlled trial of a novel psychoeducational HIV/STI prevention intervention for heterosexually-active black youth

Black youth account for the largest number of new HIV infections among heterosexual youth. Mental illness and difficulties in emotion regulation contribute to increased reports of HIV/sexually transmitted infection (STI) risk-related sexual behaviors in this group. Yet limited interventions exist to address this affective component of the sexual decision-making process. The purpose of this paper was to describe the trial design, research challenges, and baseline characteristics from a study designed to fill this gap. Project GOLD was a pilot randomized controlled trial of a psychoeducational HIV/STI prevention intervention designed to address the role of mental illness and emotion regulation in HIV/STI risk among heterosexually-active Black youth aged 14 to 17 (N = 108). Challenges encountered in the research process warrant further attention in future research (e.g., disagreement among the regulatory bodies on parental permission requirements). The most common mental health diagnoses were Recurrent Major Depressive Disorder (15.7%) and current substance abuse (7.4%). Participants reported higher levels of emotional suppression, and adaptive methods of emotion management, than culturally inappropriate expressions of anger or sadness. They also reported a mean age of 13.6 at first vaginal sex, used condoms 66% of the time for vaginal sex, and had an average of three sexual partners in the past 6 months. More than one-quarter (26.9%) had sex with more than one person in the same day. These findings indicate intervention is crucial for this population. The forthcoming trial evaluation will indicate the promise of such interventions in reducing HIV/STI infections in this key population.

The development of an innovative, theory-driven, psychoeducational HIV/STI prevention intervention for heterosexually active black adolescents with mental illnesses

Sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), continue to disproportionately affect Black adolescents. Those experiencing the psychological sequelae of mental illnesses are at increased risk. Here, we outline the development of an HIV/STI prevention intervention for heterosexually-active Black adolescents with mental illnesses. This research was guided by a psychosocial expansion of the Theory of Planned Behavior, nested within a broader social determinants of health framework. A youth community advisory board provided study oversight. Heterosexually-active Black adolescents aged 14 to 17 were recruited from community-based outpatient mental health providers for focus groups, surveys and two "dress rehearsals" of the intervention protocol (N = 68). The qualitative and quantitative findings indicated that knowledge, attitudes and skills related to consistent condom use, reduced number of sexual partners, routine HIV/STI testing, abstinence and emotion regulation were important areas to target. These elicitation data provided insight on the context of HIV/STI risk for the study population, and were used to develop the intervention content. "Project GOLD: We are Kings and Queens" was designed to be delivered over two days (three hours per day), with eight, 45-minute modules. The activities address behaviors, as well as cognitive, emotional, psychological and social processes associated with HIV/STI risk. Alongside evidence-based HIV/STI prevention strategies (e.g., sexual partner communication skills), the intervention activities are rooted in principles of Cognitive Behavioral Therapy. Dress rehearsal participants were in favor of the intervention and provided feedback on activity length, gender and cultural relevance, and strategies to sustain attention; this information was used to finalize the curriculum. In partnership with the community, we developed a theoretically-driven, gender and culturally relevant, developmentally and psychologically appropriate HIV/STI prevention program. Our ultimate goal is to standardize sexual health assessment and intervention in outpatient mental health treatment settings to meet sexual health needs in this underserved population.

Enhancing health among youth living with HIV using an iPhone game

BACKGROUND

Despite promising outcomes of antiretroviral therapy (ART), challenges to improving adherence among youth living with HIV (YLWH) exist. Mobile games are popular among youth and may improve skills related to resilience, coping, and ART adherence. This study examines the preliminary effects of an iPhone game/app on ART adherence, viral load, and relevant knowledge and attitudes among YLWH in Jackson, MS.

METHODS

A RCT with 61 YLWH tested the impact of BattleViro, an ART-related iPhone game, over 16 weeks. Participants, ages 14-26, were recruited from HIV clinics and randomly assigned to receive BattleViro or a non-HIV-related game. All participants received a medication monitoring device. Chi-square and t-test analyses examined baseline differences between conditions. Continuous outcomes were examined using analyses of covariance (ANCOVAs) controlling for baseline scores. Cohen's d effect size differences (ESD) between groups were calculated.

RESULTS

The sample was 79% male, 97% Black, and 74% non-heterosexual, with a mean age of 22 years. A third had started ART in the past 3 months. There were no demographic differences between conditions. Examination of ESDs revealed that BattleViro demonstrated promising, but nonsignificant, improvements in HIV knowledge (ESD = 0.50), ART knowledge (ESD = 0.42) and social support (ESD = 0.62). Exploratory moderation analyses revealed interactions between BattleViro and newly starting ART. Those newly starting ART in the BattleViro condition, compared to those in the control, experienced a 0.96 log greater decrease in viral load (ESD=-2.21, F = 4.33, p = 0.04), better adherence (71% vs. 48%; ESD = 1.15, F = 3.90, p = 0.05), more HIV knowledge (ESD = 0.90), and more ART knowledge (ESD = 0.72).

CONCLUSION

BattleViro showed promising improvements in HIV knowledge, ART knowledge and social support. Also, there was improved adherence and viral load outcomes specifically among those newly starting ART. ART initiation may be an opportunity to empower and motivate YLWH to build healthy skills.

The longitudinal impact of a family-based communication intervention on observational and self-reports of sexual communication

Parents can play a vital role in shaping teenagers' sexual attitudes, behavior, and contraceptive use through communication, however, less is known about how to modify parent-adolescent communication among youth with mental health problems. The impact of a family-based sexual risk prevention intervention on both observational and self-report of parent adolescent sexual communication was examined at 12-months among adolescents with mental health problems. Of the 721 parent- adolescent dyads recruited for the study, 167 videotapes of sexual discussions between parents and adolescent were coded for the family-based intervention and 191 videotapes for the active comparison. Longitudinal analyses examined differences between conditions (family-based vs. comparison) in self-reported and observed parent-adolescent sexual discussions and also examined the impact of gender on intervention response. More parent I-statements, healthier parent Body-Language, and fewer adolescent Negative Vocalizations were detected for family-based intervention participants 12 months after participating in the brief intervention (11 hours of total intervention time) relative to those in the comparison condition. Parents in the family-based intervention also self-reported better sexual communication at 12-months. The current study provides supporting evidence that a relatively brief family-based intervention was successful at addressing parent-adolescent sexual communication among a mental health sample.

"Where Did This [PrEP] Come From?" African American Mother/Daughter Perceptions Related to Adolescent Preexposure Prophylaxis (PrEP) Utilization and Clinical Trial Participation

Despite the demonstrated effectiveness of preexposure prophylaxis (PrEP) to reduce incident HIV infections, PrEP's potential as an HIV prevention strategy for adolescent populations is unknown. This study assessed perceptions of adolescent PrEP use and clinical trial participation among African American women and their adolescent daughters. We conducted focus group discussions with 15 African American mother/daughter pairs ( N = 30). Findings suggest a general lack of PrEP awareness, favorable attitudes toward adolescent PrEP use, altruistic attitudes regarding research participation among daughters, and less favorable attitudes toward adolescent clinical trial participation among mothers. Study findings have the potential to inform strategies that provide equitable access to HIV scientific advances among African American women and girls and promote informed parent-child research decision making.

HIV-risk reduction intervention for juvenile offenders on probation: The PHAT Life group randomized controlled trial

OBJECTIVE

Juvenile offenders report high rates of sexual risk taking, increasing the possibility of HIV. This 2-arm group randomized controlled trial tested the efficacy of PHAT Life, a sexual risk reduction program, compared with a time-matched health promotion program for youth on probation.

METHOD

Male and female 13- to 17-year-olds (M = 16.08; SD = 1.09) recently arrested and placed on probation at an Evening Reporting Center were eligible for the study. Youth were 66% male, and 90% African American. Teens self-reported their sexual behavior (condom use, number of sexual partners) at baseline and 6 months. Retention was 85%.

RESULTS

Youth were randomized to PHAT Life (n = 163) or a health promotion program (n = 147). Among youth reporting the highest risk at baseline (a composite measure of multiple partners and inconsistent condom use), those who received PHAT Life were over 4 times more likely than the control group to report a lower level of risk (i.e., no sex or one partner plus consistent condom use) by 6 months, OR = 4.28 with 95% CI [1.37, 13.38], SE = 0.58, p = .01. Among sexually active teens who reported sexual debut before 12-years-old, those who received PHAT Life reported significantly fewer sexual partners at 6-months than controls, partial eta squared = .32, p = .002.

CONCLUSIONS

Findings support PHAT Life's efficacy to reduce sexual risk for juvenile offenders on probation. Future research should examine how best to disseminate PHAT Life to ensure that it is self-sustaining within the juvenile justice system. (PsycINFO Database Record

Sexual Assertiveness Skills and Sexual Decision-Making in Adolescent Girls: Randomized Controlled Trial of an Online Program

OBJECTIVES

To evaluate the efficacy of an interactive, Web-based sexual health program (Health Education and Relationship Training [HEART]) for developing sexual assertiveness skills and enhancing sexual decision-making in adolescent girls.

METHODS

Participants were 222 tenth-grade girls (mean age = 15.2; 38% White, 29% Hispanic, 25% Black) in the Southeastern United States who were randomized in fall 2015 to the HEART intervention or an attention-matched control. We assessed participants at pretest, immediate posttest, and 4-month follow-up.

RESULTS

Both groups had similar demographic and sexual behavior characteristics at pretest. At immediate posttest, girls who completed the HEART program demonstrated better sexual assertiveness skills measured with a behavioral task, higher self-reported assertiveness, intentions to communicate about sexual health, knowledge regarding HIV and other sexually transmitted diseases (STDs), safer sex norms and attitudes, and condom self-efficacy compared with the control condition. At 4-month follow-up, group differences remained in knowledge regarding HIV and other STDs, condom attitudes, and condom self-efficacy.

CONCLUSIONS

This brief online sexual health program can improve short-term outcomes among adolescent girls and offers an exciting new option in the growing array of digital health interventions available to youths.

TRIAL REGISTRATION NUMBER

NCT02579135.

Challenges to conducting adolescent HIV prevention services research with court-involved youth

Multiple assessment studies demonstrate that juvenile offenders are at increased risk for contracting HIV and other STIs relative to their non-offending counterparts. Such data are used to support the implementation of adolescent HIV prevention interventions within the juvenile justice system. Despite the compelling data related to high rates of unprotected sexual activity, pregnancy, STIs, substance use and psychiatric symptoms, there are very few empirically supported HIV prevention interventions for this adolescent subgroup. Using our experience conducting HIV prevention research studies with court-involved, non-incarcerated (CINI) youth we identify salient and unique challenges to consider when conducting HIV prevention intervention research with this population. Obstacles to consider include lack of "buy-in" and engagement from justice staff and families about the need for youth sexual health promotion and HIV prevention services and logistical barriers (time, transportation, space) related to conducting intervention research with a community-based sample of justice-involved youth. We consider these various challenges and provide recommendations for researchers on how to overcome barriers to continue to develop evidence-based HIV prevention services for communities of youth in need.

Feasibility and acceptability of a web-based HIV/STD prevention program for adolescent girls targeting sexual communication skills

Adolescent girls are at substantial risk of sexually transmitted diseases including HIV. To reduce these risks, we developed Health Education And Relationship Training (HEART), a web-based intervention focused on developing sexual assertiveness skills and enhancing sexual decision-making. This study assessed the feasibility and acceptability of this new program and examined if perceived acceptability varied according to participant ethnicity, sexual orientation or sexual activity status. Participants were part of a randomized controlled trial of 222 10th-grade girls (Mage = 15.26). The current analyses included those in the intervention condition (n = 107; 36% white, 27% black and 29% Hispanic). HEART took approximately 45 min to complete and was feasible to administer in a school-based setting. Participants found the program highly acceptable: 95% liked the program and learned from the program, 88% would recommend the program to a friend and 94% plan to use what they learned in the future. The primary acceptability results did not vary by the ethnicity, sexual orientation or sexual activity status of participants, suggesting broad appeal. Results indicate that this new online program is a promising method to reach and engage adolescents in sexual health education.

Alcohol Use and Sexual Risk Behaviors among Adolescents with Psychiatric Disorders: A Systematic Review and Meta-Analysis

Adolescents with psychiatric disorders appear to be at increased risk for acquiring HIV and other sexually transmitted infections; however, little is known about the prevalence of behavioral risk factors in this population. This meta-analysis aimed to assess the prevalence of alcohol use and sexual risk behaviors among adolescents with psychiatric disorders. Electronic database searches identified studies sampling adolescents diagnosed with psychiatric disorders and assessing both alcohol and sexual risk behaviors. Fourteen studies sampling 3,029 adolescents with psychiatric disorders were included. The majority of adolescents with psychiatric disorders report alcohol use and sexual risk behaviors. Risk reduction interventions targeting these two behaviors are needed.

The Role of Affect Management for HIV Risk Reduction for Youth in Alternative Schools

OBJECTIVE

Adolescents in alternative schools for behavioral and emotional problems have an earlier sexual onset and higher rates of sexual risk than their peers. They also often have difficulty managing strong emotions, which can impair sexual decision making. Human immunodeficiency virus (HIV) prevention programs for these adolescents may be most effective if skills for coping with strong emotions during sexual situations are included.

METHOD

This article reports the 6-month outcomes of a three-arm randomized controlled trial comparing an HIV prevention intervention with affect management (AM) to a standard, skills-based HIV prevention intervention (SB), and a general health promotion intervention (HP). HP was similar to a general health class, and SB was based on previous effective HIV prevention programs used with community adolescents, whereas AM included affect management skills in addition to effective HIV prevention skills. Youth (N = 377) in two US cities were 13 to 19 years of age and attending alternative schools for behavioral and emotional problems.

RESULTS

Multiple logistic regression analyses, adjusted for the baseline scores, age, and gender, found that adolescents in AM were significantly less likely to report being sexually active at follow-up (80% versus 91%, adjusted odds ratio = 0.28, 95% CI = 0.08-0.96) and more consistently using condoms than those in HP at follow-up (62%, versus 39%, adjusted odds ratio = 3.42, CI = 1.10-10.63).

CONCLUSION

Affect management techniques tested in this project, focused on sexual situations, are similar to those that are used in dialectical behavioral therapy (DBT) and in clinical practice. These data suggest that these techniques might decrease risk behaviors and improve the health of adolescents with emotional/behavioral problems. Clinical trial registration information-Therapeutic Schools: Affect Management and HIV Prevention; http://clinicaltrials.gov/; NCT00500487.

Outcomes of a family-based HIV prevention intervention for substance using juvenile offenders

Approximately 80% of all arrested youth are diverted from detention and supervised in the community through probation, specialty courts and other community-based diversion efforts. Justice-involved youth have greater psychiatric impairment, substance use and sexual risk behaviors than their non-justice-involved peers. Family-based interventions to address mental health, substance use and recidivism have been successful in improving these youth outcomes; but the lack of integration of HIV/STI prevention is notable given the co-occurrence of substance use, delinquency and sexual risk-taking behaviors among justice-involved youth. Moreover, emotion dysregulation may be an important and understudied underlying construct of these co-occurring risk behaviors for justice-involved youth. Study participants were 47 caregiver-youth dyads enrolled in a juvenile drug court program. As part of a pilot efficacy trial, dyads were randomized to a 5-session family-based integrated substance use and HIV/STI prevention intervention that relied on affect management strategies for risk reduction or an adolescent-only psychoeducation condition matched for time and attention. Data collected at baseline and 3months post-intervention suggest that a family-based integrated affect management substance use and HIV prevention pilot intervention may lead to justice-involved youths' enhanced motivation to change their marijuana use, decreased marijuana use and decreased risky sexual behavior over time. Future research is required to replicate these pilot trial findings and should also examine family-level mediators and moderators of treatment response, particularly with respect to HIV prevention efforts for these youth.