Practicing STD-Free Sex (STD Briefs Book 7)

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Where race, sexual orientation and gender were reported, African Americans and heterosexual persons were most likely to be a majority or plurality, but participants were drawn from across the spectrum of these constructs. More studies enrolled only women than only men, but overall proportions by gender were close to even. Of the 13 papers included in Table 1 , 4 found statistically significant reductions in STD at follow-up in the behavioral counseling group compared to the control group. The remaining 8 studies measured and found no differences between intervention and control groups in STD infection gonorrhea, chlamydial infection, HIV, except for bacterial vaginosis in one study In some circumstances, infections in the intervention and control groups both declined over the course of the studies.

The 5 studies with significant intervention effects on STD rates had similar characteristics to the other 8 studies in most respects. Studies in both categories took place in STD and other clinic settings, used mostly 6-month or greater follow-up periods 9 of 13 studies , and addressed variation in age, gender and sexual orientation. Seven of 10 studies measuring behavior changes found at least one significant behavior change by condition, although this includes two studies that had inconsistent findings by either the behavior measured or the follow-up period.

Moreover, there was greater consistency for behavior change effects among the studies with significant STD effects 5 of 5 versus 2 of 5. Five studies 6 articles had active control groups: For studies with positive findings on STD at follow-up, outcomes such as proportion of sex acts with a condom or amount of sex without condoms favored the intervention groups.

Boekeloo 19 found protective intervention effects on condom use at 3 months, but not at 9 months. In terms of behavioral self-reported outcomes, Crosby 26 measured condom use during the last act of penetrative sex, number of sexual partners in the past 3 months, and proficiency of using condoms as measured via direct observation on a life-sized rubber penile model. Jemmott 24 investigated the self-reported proportion of protected sexual intercourse, frequency of unprotected sexual intercourse, and condom use during most recent intercourse.

Two studies produced antagonistic effects for male subsets of participants. The participants in efficacious short behavioral counseling interventions were at high-risk for acquiring new STD, either through design or empirically. Kamb 18 sampled HIV negative heterosexual men and women aged 14 and older; about one-third reported a previous STD at enrollment. Bolu 21 used the same sample of participants as Kamb, but looked specifically at the sub-population which reported a history of intravenous drug use, history of exchanging sex for money or drugs, reported a STD diagnosis at enrollment, or a previous HIV test at enrollment.


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Boekeloo 19 sampled young adolescents 12 — 15 years ; these were sexually active and thus high-risk by definition at those ages. Three of the 5 studies 18 , 21 , 24 examined outcomes after a month follow-up period, the longest time frame examined in any of the investigations. Boekeloo 19 went to 9 months; Crosby 26 reviewed STD outcomes at 6 months and behaviors at 3 months post-intervention. The shortest follow-up was 2 months in a brief counseling study in an adolescent health clinic.

Crosby 26 used lay health advisors to administer the intervention, with the over-arching conceptualization that the most effective facilitators are those from the community, most like those for whom the intervention is intended. Specifically, Crosby and colleagues recruited a young African-American male who grew up and resided in the targeted community. Jemmott 24 prioritized similar factors and selected African-American women from the study catchment area. Kamb and Bolu 18 , 21 do not discuss their facilitator characteristics within their studies, but do note that behavioral counseling was conducted with a trained HIV counselor or clinician.

Cost data were not identified explicitly in most studies. Another study provided the average costs dollars per patient counseled in intervention and control arms: All studies except one 27 recruited participants in the context of an existing clinic visit for care. Nine studies delivered the intervention through existing staff 2 physicians, 2 nurses, 5 counselors , two used research staff, and one other used a lay health advisor model.

In a minute one-time intervention, Jemmott 24 used social cognitive theory as the underpinnings for Sister-to-Sister and strove to present behavioral counseling in a culturally-sensitive and gender appropriate frame, delivered over the course of a routine medical visit. Prioritizing empowering and educating woman through the teaching of behavioral skills, this intervention was designed to increase condom use skills, including practice with an anatomical model.

The intervention also utilized role playing as a tactic to increase self-efficacy and negotiation of condom use with partner. The facilitators emphasized condom skill acquisition and initiating condom use in a one-time, 45 to 50 minute session. RESPECT 18 , 21 was an individual-level, client-focused intervention, consisting of two brief, minute interactive counseling sessions — the 2-session version was as efficacious as the 4-session version. Most studies, whether efficacious or not, were based on principles of social cognitive theory. We reviewed studies to find interventions that were both efficacious and feasible in time-constrained clinical settings, delivered principally by existing staff under existing patient care conditions.

Thus, we reviewed interventions that could be implemented within 60 minutes total contact time in a one-on-one interaction within a clinic setting. We found 13 analyses that fit our criteria, with 5 showing evidence of efficacy with respect to STD infection rates at follow-up. There was more consistency with respect to behavior change, and behavior changes were associated with lower STD incidence in all 5 studies showing an effect on STD at follow-up. This low proportion of efficacious studies, however, is somewhat at odds with other reviews, and we emphasize that the discussion pertains to a select group of interventions, not to all behavioral counseling.

In the remainder of this discussion, we focus upon key factors of behavioral counseling interventions, consider approaches that may improve feasibility, and comment on potential future action. In some respects, the sample characteristics of interventions varied little according to the success of the intervention. The populations were typically high-risk in comparison to the general population in that most were either STD-infected or had been previously diagnosed with STD but not HIV.

They were not especially high-risk compared to STD clinic attendees in general. More salient is that nearly all participants were heterosexual males and females including adolescents , and that effects were generally strongest for these populations.

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Matching the facilitator at least by race and gender appeared consistently helpful, although the effect of this moderator was not empirically measured. Finally, the composition of control groups should not be overlooked: RCTs with active controls were far less likely to be efficacious sometimes active controls were chosen for good reason, because that condition represented the standard of care. If we restrict conclusions to studies with minimal interventions in control groups, conclusions are far more favorable to behavioral counseling.

In sum, a short behavioral counseling intervention for heterosexual clinic patients with known risk behaviors, perhaps facilitated by those who can establish ready rapport with clients through similarity 24 , 26 or training RESPECT studies , 18 , 21 and using a behavioral skills approach and interactive and personalized discussions on how to decrease risk, has the best potential to result in sexual risk reduction and decreased rates of reinfection.

Some of these points are reflected in other areas of STD prevention in program settings. For example, a review of interventions with African American men named male facilitators as reinforcers of effectiveness, 32 and the value of interactive counseling has been established with partner notification across several studies. The first consideration is cost, whether measured directly or in terms of resource allocation.

Most efficacious studies used existing staff and visits, although one required hiring a lay health advisor. Although these conditions minimize hiring and outreach costs, the interventions still require training and take time. Efficacious interventions were spread across clinical settings, so community prevalence around intervention venues could vary. Three related logistic considerations relevant to STD programs appear to play a significant role in counseling effectiveness: These are theoretically-based and empirically confirmed features of successful counseling across numerous topic areas.

Delivery, however, does require specialized training and the ability to move beyond didactic instruction. The second issue is repeat contact e. Repeat contact provides an opportunity to reinforce content and commitment, maintain interaction and rapport, and adjust behavior change plans — in the short term. Retesting is another opportunity, but this typically occurs more than 10 days after initial treatment.

Third, there is the issue of HIV testing, which has changed over the time period of this review. A case for targeting behavioral interventions is thus made more complex as one of the most vulnerable populations, MSM, appear to receive the least benefit in terms of STD incidence.

We hypothesize that many MSM in STD clinics know they are at high risk, know generally why this is so a combination of behaviors, community prevalence and effects of stigma , and have been at risk for some time. Clinically-based behavioral counseling is a difficult avenue for successful intervention under these circumstances, especially as the magnitude of change required to affect incidence increases with high community prevalence.

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The Role of Behavioral Counseling in STD Prevention Program Settings

The evidence suggests many of these factors also apply to heterosexual men in STD clinics, although we found evidence that social cognitive interventions that used lay counselors who are representative of the affected communities remain effective for heterosexual men. Moreover, the bulk of counseling interventions and the recommendations on which they are based, are specific to a subset of prevention behaviors — condom use, reductions in numbers of partners, and, less often, partner selection criteria e. These are not necessarily attractive options as intervention targets.

More promising, however, is the advent of PrEP; 35 a different behavioral outcome from those in this review, but certainly emerging as a component of prevention program action with substantial behavioral counseling ramifications. Interestingly, a recent pilot of doxycycline prophylaxis for HIV-infected MSM engaging in risky sexual behavior showed promise for reducing STD among this select population, 36 although there remain significant practical and ethical considerations. To augment the efficacy of behavioral counseling interventions, health departments may consider integrating behavioral counseling with other prevention efforts.

Integration serves multiple purposes and thereby increases cost efficiency as well as overall prevention effectiveness. For example, a second behavioral counseling session combined with a re-test reminder and check on partner treatment, is testable in many program settings in an experimental or a quality improvement framework.

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There is more reason for research and development: Finally, there are behavioral counseling examples that diverge from sexual behavior as a topic, but that still affect STD at follow-up. For one example, an evaluation of counseling to prevent alcohol-exposed pregnancies in two clinics had effects on sexual behavior, although it did not measure STD. Finally, there is a potential role for STD programs in indirect action on behavioral counseling. Programs may take a role in providing guidance or technical assistance for STD prevention counseling in settings outside STD clinics.

Many of the people for whom interventions appeared most efficacious are seen outside STD clinic settings. DSTDP is also attempting to develop a successful mechanism by which behavioral counseling meets reimbursement requirements, thus furthering the opportunity for sustainable behavioral counseling. Short behavioral counseling interventions are appropriate for many STD clinic populations and for primary care settings serving vulnerable populations e. They require, however, attention and resources to sustain and may be most efficiently managed if they are combined with other prevention activities.

Such activities require research or evaluation, as those combinations have not been clearly analyzed to date — some combinations are visible in studies, but not formally evaluated. High-risk MSM do not appear to benefit from behavioral counseling as currently construed. That noted, behavioral counseling topics extend beyond condom use and numbers of partners, so there is clearly scope for continued efforts to find the best interventions to use for reducing STD incidence. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the U.

Centers for Disease Control and Prevention. National Center for Biotechnology Information , U. Author manuscript; available in PMC Aug 1. Brookmeyer , Matthew Hogben , and Jennine Kinsey.


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The publisher's final edited version of this article is available at Sex Transm Dis. Abstract Background Behavioral counseling for STD prevention is recommended for persons at risk, and the body of evidence yields numerous interventions that have STD preventive efficacy. Methods We reviewed existing systematic reviews of the literature and abstracted from them studies that fit the following criteria in that the interventions: Results From 6 reviews published — covering 91 studies, we found 13 analyses representing 11 intervention studies that fit the selection criteria.

Constraints on Behavioral Counseling in Clinical Settings Rates of repeat infections in STD clinics and of incident STD infections in HIV care settings illustrate that there is a potential benefit for behavioral counseling in these and similar settings serving high-risk populations. Methods We reviewed existing review articles published since that focused upon behavioral counseling interventions.

Table 1 Elements of behavioral counseling interventions included in review. January — April, Adolescents with at least one STD unspecified. Counseling session to discuss perceived susceptibility to HIV as well as standard counseling 20 minutes. No significant differences between intervention and control group in terms of condom frequency of use, number of newly diagnosed STDs, number of partners per month.

Control activities plus condom use skills practice, intervention designed to increase perceived susceptibility to STD and decrease perceived barriers to condom use, and role play 10 — 20 minutes. Control Active Individual discussion with nurse about STD partner notification and condom use plus information 10 — 20 minutes.

Intervention 2 or 4 sessions Interactive counseling to change perceived efficacy, norms and attitudes about condom use. Risk reduction planning at final session 20 minutes per session in 2-session arm; 20 minutes first session 60 minutes for others in 4-session arm. Information and brief encouragement to use condoms 5 minutes per session. STD risk assessment and theoretically tailored education about safe sexual behavior abstinence and condom use.

No significant differences between hierarchical messaging and single messaging groups in terms of reinfection rates. Note — study data drawn from Kamb Note — intervention design is a 2 HIV test type: No significant differences in STD incidence in rapid vs. Results were similar across sample sex and orientation. Note — the 6 study arms were formed from a 2 brief vs.

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IMB model factorial design. All 6 conditions including info-only condition yielded significant declines in infection rates over time, but not between conditions — reductions in new infections observed only relative to baseline and not between conditions. Nurse-based advice and condom provision per control plus a single session with a lay health advisor using a motivational interviewing approach based on the Information, Motivation, Behavior model 45—50 minutes. Motivational interviewing based on principles of Health Belief Model perceived benefits and barriers to action; perceived susceptibility to and severity of the STD.

Open in a separate window. Results Of the 13 papers included in Table 1 , 4 found statistically significant reductions in STD at follow-up in the behavioral counseling group compared to the control group. Outcomes Crosby et al. Target Populations and Follow-up The participants in efficacious short behavioral counseling interventions were at high-risk for acquiring new STD, either through design or empirically.

Facilitator Characteristics and Costs Crosby 26 used lay health advisors to administer the intervention, with the over-arching conceptualization that the most effective facilitators are those from the community, most like those for whom the intervention is intended.

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