Jemmott III JB, Sweet Jemmott L, Fong GT. Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American AdolescentsA Randomized Controlled Trial. JAMA. 1998;279(19):1529-1536. doi:10.1001/jama.279.19.1529
From the Department of Psychology, Princeton University, Princeton, NJ (Dr J. B. Jemmott); the School of Nursing, University of Pennsylvania, Philadelphia (Dr L. S. Jemmott); and the Department of Psychology, University of Waterloo, Waterloo, Ontario (Dr Fong).
Context.— African American adolescents are at high risk of contracting sexually
transmitted infection with human immunodeficiency virus (HIV), but which behavioral
interventions to reduce risk are most effective and who should conduct them
is not known.
Objective.— To evaluate the effects of abstinence and safer-sex HIV risk-reduction
interventions on young inner-city African American adolescents' HIV sexual
risk behaviors when implemented by adult facilitators as compared with peer
Design.— Randomized controlled trial with 3-, 6-, and 12-month follow-up.
Setting.— Three middle schools serving low-income African American communities
in Philadelphia, Pa.
Participants.— A total of 659 African American adolescents recruited for a Saturday
Interventions.— Based on cognitive-behavioral theories and elicitation research, interventions
involved 8 1-hour modules implemented by adult facilitators or peer cofacilitators.
Abstinence intervention stressed delaying sexual intercourse or reducing its
frequency; safer-sex intervention stressed condom use; control intervention
concerned health issues unrelated to sexual behavior.
Main Outcome Measures.— Self-reported sexual intercourse, condom use, and unprotected sexual
Results.— Mean age of the enrollees was 11.8 years; 53% were female and 92.6%
were still enrolled at 12 months. Abstinence intervention participants were
less likely to report having sexual intercourse in the 3 months after intervention
than were control group participants (12.5% vs 21.5%, P=.02), but not at 6- or 12-month follow-up (17.2% vs 22.7%, P=.14; 20.0% vs 23.1%, P=.42, respectively).
Safer-sex intervention participants reported significantly more consistent
condom use than did control group participants at 3 months (odds ratio [OR]=3.38;
95% confidence interval [CI], 1.25-9.16) and higher frequency of condom use
at all follow-ups. Among adolescents who reported sexual experience at baseline,
the safer-sex intervention group reported less sexual intercourse in the previous
3 months at 6- and 12-month follow-up than did control and abstinence intervention
(adjusted mean days over prior 3 months, 1.34 vs 3.77 and 3.03, respectively; P≤.01 at 12-month follow-up) and less unprotected intercourse
at all follow-ups than did control group (adjusted mean days, 0.04 vs 1.85,
respectively, P<.001, at 12-month follow-up).
There were no differences in intervention effects with adult facilitators
as compared with peer cofacilitators.
Conclusion.— Both abstinence and safer-sex interventions can reduce HIV sexual risk
behaviors, but safer-sex interventions may be especially effective with sexually
experienced adolescents and may have longer-lasting effects.
IT IS WELL documented1,2
that African American adolescents are at high risk of sexually transmitted
infection with human immunodefiency virus (HIV), which causes acquired immunodeficiency
syndrome (AIDS). Although a growing amount of literature3,4
suggests that behavioral interventions can reduce adolescents' self-reported
HIV risk-associated sexual behavior, several questions remain unanswered:
Which behavioral intervention strategies are most appropriate and efficacious?
Which types of individuals are likely to be the most effective facilitators
of HIV-behavioral interventions for adolescents?
Sexual transmission of HIV is tied to unprotected sexual intercourse—that
is, sexual intercourse without the use of a latex condom.5
To reduce the risk of sexually transmitted HIV infection, a behavioral intervention
must reduce the frequency of unprotected sexual intercourse. This can be achieved
in 2 ways: (1) the abstinence strategy, which focuses on reducing the frequency
of sexual intercourse, and (2) the safer-sex strategy, which focuses on increasing
the frequency of condom use. Whether abstinence or safer sex should be the
focus of intervention efforts has been vigorously debated among public health
experts, educators, parents, and other advocates for youth.
The abstinence approach has appeal because adolescents, particularly
young adolescents, may lack the knowledge and judgment to make informed choices
to protect themselves from pregnancy and sexually transmitted diseases (STDs)
or to grapple with these adverse consequences of unprotected sexual intercourse.
However, evidence for the efficacy of abstinence interventions is meager.
Two studies6,7 that found significant
effects of abstinence interventions were not randomized controlled trials,
and other studies8- 11
have found that abstinence interventions did not reduce sexual behavior. The
rationale for the safer-sex approach is that interventions that try to prevent,
eliminate, or even reduce sexual intercourse among adolescents are unrealistic;
hence, prevention programs should instead attempt to increase condom use.
Several studies12- 18
have indicated that safer-sex interventions can increase adolescents' condom
use. No randomized controlled trial, however, has considered the efficacy
of both intervention approaches.
Although it is often asserted that interventions for adolescents may
be especially efficacious if peers implement them,6,19- 21
several studies have documented effects of HIV risk-reduction interventions
implemented by adults.13- 15,17,18,22
However, no randomized controlled trial has considered the effects on sexual
behavior of peer-led and adult-led HIV interventions.
This randomized controlled trial tested the effects of theory-based
abstinence and safer-sex interventions on young inner-city African American
adolescents. We hypothesized that, compared with the control group, adolescents
who received the abstinence intervention would report less sexual intercourse
and adolescents who received the safer-sex intervention would report more
condom use. We hypothesized that the abstinence intervention would have the
strongest impact on theoretical mediators of abstinence, whereas the safer-sex
intervention would have the strongest impact on theoretical mediators of condom
use. Finally, we tested whether the effects of the interventions differed
with adult facilitators as compared with peer cofacilitators.
The participants were 659 African American adolescents (mean age, 11.8
years) recruited from sixth and seventh grade classes of 3 middle schools
serving low-income African American communities in Philadelphia, Pa, via announcements
in assemblies, classrooms, and cafeterias and letters to parents or guardians.
They volunteered for the "Spruce Adolescent Health Promotion Project" designed
to reduce the chances that teenagers will develop devastating health problems,
including cardiovascular diseases, cancer, and AIDS. About 53.0% were female
and 26.8% lived with both of their parents. On the preintervention questionnaire,
25.2% of respondents reported ever having sexual intercourse and 15.4% of
respondents reported having sexual intercourse in the previous 3 months. Few
respondents (1.6%) reported having same-gender sexual relationships. The adolescents
were offered $100 for participating: $40 at the end of the 2-session intervention
and an additional $20 for each of the 3 follow-ups.
The study was approved by the Institutional Review Panel of Princeton
University. African American adolescents from the 3 middle schools who had
signed parent or guardian consent forms were eligible to participate. The
study was a randomized controlled trial. The adolescents were stratified by
gender and age, and based on computer-generated random number sequences, were
randomly assigned to 1 of 3 interventions: an abstinence HIV intervention,
a safer-sex HIV intervention, or a health promotion intervention that served
as the control group. They were also randomized into groups of 6 to 8 adolescents
led by (1) 1 male or female adult facilitator or (2) 2 male, 2 female, or
1 male and 1 female peer cofacilitators. (The results did not differ as a
function of facilitator gender or matching facilitator gender with participant
gender.) One researcher conducted the computer-generated random assignment
and others executed the assignments. Adolescents were enrolled in the study
in 3 cycles or replications, 1 at each school. Figure 1 shows the number of adolescents randomized to each group.
The sample sizes are smaller in some analyses because of attrition or participants'
failure to respond to questions.
Each intervention was pilot tested on African American adolescents from
the study population by both adult and peer facilitators. Each intervention
consisted of 8 1-hour modules divided equally over 2 consecutive Saturdays.
Each intervention was highly structured and was implemented by facilitators
who used intervention manuals. Designed to be educational, but entertaining
and culture sensitive, each intervention involved group discussions, videos,
games, brainstorming, experiential exercises, and skill-building activities.
Many of the activities had been used successfully in previous studies13,22- 24 with
inner-city African American adolescents. Each intervention incorporated the
"Be proud! Be responsible!" theme25 that encouraged
the participants to be proud of themselves and their community, to behave
responsibly for the sake of themselves and their community, and to consider
their goals for the future and how unhealthful behavior might thwart the attainment
of their goals. The 2 HIV risk-reduction interventions were based on social
cognitive theory,26- 28
the theory of reasoned action,29,30
its extension, the theory of planned behavior,31,32
and information gathered from elicitation research and focus groups with adolescents
from the study population.
The abstinence intervention acknowledged that condoms can reduce risks
but emphasized abstinence to eliminate the risk of pregnancy and STDs, including
HIV. It was designed to (1) increase knowledge of HIV and STDs, (2) strengthen
behavioral beliefs supporting abstinence, including the belief that abstinence
can prevent pregnancy, STDs, and HIV, and the belief that abstinence can foster
attainment of future goals, and (3) increase self-efficacy and skills regarding
the ability to resist pressure to have sexual intercourse and the ability
to negotiate abstinence.
The safer-sex intervention indicated that abstinence is the best choice
but emphasized the importance of using condoms to reduce the risk of pregnancy
and STDs, including HIV, if participants were to have sex. It was designed
to (1) increase HIV/STD knowledge and the specific belief that using condoms
could prevent pregnancy, STDs, and HIV, (2) enhance hedonistic beliefs to
allay participants' fears regarding adverse effects of condoms on sexual enjoyment,
and (3) increase skills and self-efficacy regarding their ability to use condoms,
including confidence that they could negotiate condom use with sexual partners.
To control for "Hawthorne effects" to reduce the likelihood that effects
of the HIV interventions could be attributed to nonspecific features,33 including group interaction and special attention,
the participants in the control group received a health promotion intervention
designed to be as valuable and enjoyable as the HIV interventions. It focused
not on AIDS or sexual behavior, but on behaviors associated with risk of cardiovascular
disease, stroke, and certain cancers—health problems that are among
the 7 leading causes of premature death among African Americans.34- 36
It was designed to increase knowledge and motivation regarding healthful dietary
practices, aerobic exercise, and breast and testicular self-examination, and
to discourage cigarette smoking.
The adult facilitators were 25 (10 men and 15 women) African Americans
(mean age, 39.5 years). Their median level of education was a master's degree.
They had a median of 8 years of experience working with African American adolescents.
We began with adults who had the skills to implement any of the 3 interventions.
After stratifying them by age and gender, we randomly assigned them to receive
2.5 days of training to implement 1 of the 3 interventions.
The peer facilitators were 45 Philadelphia high school students (mean
age, 15.6 years). We selected them based on letters of recommendation and
interviews; about 56% were female. They participated in a 3-day intensive
leadership training retreat on the basic skills of small-group facilitation.
They were then stratified by age and gender and randomly assigned to receive
4 days of training to implement 1 of the 3 interventions.
The adult and peer intervention training stressed the importance of
implementation fidelity. Implementation fidelity was also emphasized before
each intervention session when the facilitators met with their facilitator
trainers to review the modules to be implemented. Several procedures were
used to monitor the interventions. The facilitator trainers continually, and
unobtrusively, monitored how each facilitator delivered the intervention.
Facilitators recorded any intervention activities they did not cover and reported
their reactions and participants' reactions to the intervention. In addition,
we recorded the number of sessions participants attended and collected participants'
confidential evaluative ratings of the interventions.
Participants in all 3 groups completed confidential questionnaires before
intervention, immediately after intervention, and at 3-, 6-, and 12-month
follow-ups. All questions had been pilot tested to ensure that they were clear
and that the phrasing of all items was appropriate for the study population.
The preintervention and follow-up questionnaires assessed sexual behavior,
demographic variables, and mediator variables. The postintervention questionnaire
assessed mediator variables and participants' evaluative ratings of the interventions.
The primary outcomes were self-reported sexual behaviors in the previous
3 months, including sexual intercourse, condom use, and unprotected sexual
intercourse. Frequency of sexual intercourse was the number of days on which
the participants had sexual intercourse. Frequency of condom use was rated
on a scale from 1 (indicating never) to 5 (indicating always). Consistent
condom use was defined as using a condom during every instance of sexual intercourse.
Frequency of unprotected sexual intercourse was the number of days on which
the participants had sexual intercourse without using a condom.
We took several steps to increase the validity of self-reported sexual
behavior. To reduce potential memory problems, we asked adolescents to report
their behaviors over a relatively brief period (ie, 3 months),37
wrote the dates constituting the period on the blackboard in the questionnaire
administration room, and gave participants calendars on which the period was
demarcated. To reduce the likelihood of demand from giving their responses
to the same individuals from whom they received an intervention, the data
were collected by proctors who were blind to the participants' intervention
group. Proctors emphasized to participants the importance of responding honestly.
For instance, they informed them that their responses would be used to develop
programs for other African American adolescents in Philadelphia and that the
programs would be successful only if they answered the questions truthfully.
In this sense, we attempted to arouse the "social responsibility motive" to
counteract any possible social desirability motive. The proctors also assured
the participants that their responses were confidential and that code numbers
rather than names would be used on the questionnaires. Participants signed
an agreement pledging to answer the questions honestly, a procedure that has
been shown38 to yield more valid self-reports
on sensitive issues.
The secondary outcomes included potential mediators of the effects of
interventions on HIV risk-associated sexual behavior. Several variables from
the theory of reasoned action,30 the theory
of planned behavior,31,32 and
social cognitive theory26- 28
were measured with 5-point Likert scales. We measured 2 behavioral beliefs
regarding condoms identified in previous research23,24:
(1) condom-use prevention beliefs (5 items concerning the belief that condoms
prevent pregnancy, STDs, and AIDS; Cronbach α=.76) and (2) condom-use
hedonistic beliefs (7 items concerning the belief that condoms do not interfere
with sexual enjoyment; α=.74). Five items measured condom availability
beliefs (participants' confidence that they could have access to condoms when
they needed them; α=.75). Three items measured condom-use technical
skills beliefs (participants' confidence that they could use condoms skillfully; α=.76).
Three items measured condom-use impulse control beliefs (participants' confidence
that they could control themselves enough to use condoms; α=.73). Three
items measured condom-use negotiation beliefs (α=.77). One item measured
condom-use self-efficacy, "I am sure that I can use a condom if I have sex."
Three items measured intention to use condoms if they have sex in the next
3 months (α=.75). Knowledge specific to condom use was assessed with
6 true-false items (α=.53).
We assessed 2 behavioral beliefs regarding abstinence: abstinence prevention
beliefs (2 items concerning the belief that abstinence can prevent pregnancy
and AIDS; α=.57) and goal attainment beliefs (2 items concerning the
belief that abstinence can foster attainment of career goals; α=.80).
One item measured attitude toward having sexual intercourse in the next 3
months. One item measured intention to have sexual intercourse in the next
HIV risk-reduction knowledge was measured with 34 items regarding the
transmission and consequences of AIDS and STDs (α=.87). So that all
participants were asked questions pertaining to their intervention, all participants
also completed measures of health knowledge and attitude and intention regarding
health-promoting behaviors to assess effects of the control group. However,
analyses on these measures are not presented in this article.
On the postintervention questionnaire, a 10-item scale measured how
much participants liked the intervention (α=.84). One item measured
how much they liked their facilitator. A 3-item scale measured how much they
thought they learned from the intervention (α=.80). One item measured
the extent to which they would recommend the program to other adolescents.
The Marlowe-Crowne Social Desirability Scale39
included in the preintervention questionnaire assessed the tendency of participants
to describe themselves in favorable, socially desirable terms. The scale has
been used extensively in studies of adolescents,40- 42
including African American adolescents.13,22,43,44
With α=.05, 2-tailed, a total sample size of 550 participants
completing the trial was projected to provide power of 80% to detect a 0.25-SD
difference in self-reported sexual behavior between the HIV intervention groups
and the control group. We conducted a series of analyses of variance and χ2 tests on baseline measures to determine whether the randomization
procedures were successful. We performed χ2 and t tests to analyze attrition. Hypotheses regarding conceptual variables
and frequency of sexual behaviors were tested with analyses of covariance,
controlling for baseline scores, and planned contrasts45
of prespecified hypotheses. To test the effects of the abstinence intervention,
1 contrast compared the abstinence group with the control group and another
compared the abstinence group with the safer-sex group. To test the effects
of the safer-sex intervention, 1 contrast compared the safer-sex group with
the control group and another compared the safer-sex group with the abstinence
group. Hypotheses regarding sexual behaviors measured with dichotomous variables
were tested with logistic regression analyses, controlling for baseline sexual
activity. However, baseline scores were not used as a covariate for hypotheses
regarding condom use because of the small number of participants who reported
sexual intercourse at both baseline and follow-up. Analyses on skewed sexual
intercourse frequency and unprotected sexual intercourse frequency were performed
after subjecting the data to log (x+1) transformation.46 However, we present the untransformed frequency of
sexual intercourse and unprotected sexual intercourse in Table 1, Table 2, and Table 3. All interactions were tested hierarchically,
that is, controlling for the main effects of all variables involved in the
interaction.47,48 Tests of intervention
effects used an intention-to-treat approach in which participants were analyzed
in their original randomized groups regardless of the number of intervention
sessions they attended.
The analyses of variance revealed a significant difference among groups
in preintervention condom-use knowledge (P=.05).
Contrasts indicated that preintervention condom-use knowledge was greater
in the safer-sex group than in the control group (P=.02).
No other differences among groups on preintervention measures of conceptual
variables, sexual behavior, or demographic variables were significant. Multiple
regression revealed that preintervention condom-use knowledge predicted only
3 outcome variables: postintervention attitude toward sexual intercourse (P=.002), intention to have sexual intercourse (P=.005), and HIV risk-reduction knowledge (P=.02),
controlling for preintervention measures. Accordingly, preintervention condom-use
knowledge was used as a covariate in analyses of these 3 outcome variables.
The percentage of intervention activities that the facilitators reported
implementing ranged from 89% to 100%, with a mean of 99%. The percentage of
activities implemented did not differ among the 3 intervention groups. About
98.2% of adolescents attended both intervention sessions, and attendance did
not differ by intervention group.
Participants' evaluations of the interventions were very favorable (means
greater than 4.0 on 5-point scales) and did not differ among the 3 interventions.
However, there were 2 significant effects of facilitator type. Participants
who had peer cofacilitators liked their interventions (means, 4.22 vs 4.01; P=.007) and their facilitators (means, 4.32 vs 4.03; P< .001) more than did those who had an adult facilitator.
As shown in Figure 1, there
was little attrition. About 96.5% of the original participants attended the
3-month follow-up, 94.4% attended the 6-month follow-up, and 92.6% attended
the 12-month follow-up. χ2 Tests indicated that the intervention
groups did not differ significantly in the percentage of participants retained
at 3-month follow-up (P=.27), 6-month follow-up (P=.16), or 12-month follow-up (P=.51).
There were only 3 significant differences between returnees (ie, adolescents
who attended the follow-up) and nonreturnees (ie, adolescents who failed to
attend the follow-up) on key preintervention variables. Returnees at the 3-month
follow-up scored higher in condom prevention beliefs than did nonreturnees
(means, 3.67 vs 3.26; P=.05). Returnees at the 6-month
follow-up scored higher in abstinence prevention beliefs than did nonreturnees
(means, 3.30 vs 2.75; P=.004). Returnees at the 6-month
follow-up scored lower in condom-use knowledge than did nonreturnees (means,
1.68 vs 2.15; P=.02). The generalizability of findings
would be limited if a variable related to attrition interacted with the interventions
to affect outcome measures. However, hierarchical multiple regression analyses
revealed no such interaction on any self-reported sexual behavior outcome
at any follow-up.
Table 1, Table 2, and Table 3
present the effects of the interventions on self-reported sexual behavior
at the 3 follow-ups. As hypothesized, adolescents in the abstinence group
were significantly less likely to report having sexual intercourse in the
3 months after the intervention than were those in the control group, (odds
ratio [OR], 0.45; 95% confidence interval [CI], 0.23-0.86) and marginally
less likely to report such behavior than were those in the safer-sex group
(OR, 0.54; 95% CI, 0.28-1.07). Adolescents in the safer-sex intervention were
more likely to report consistent condom use at the 3-month follow-up than
were those in the control group (OR, 3.38; 95 % CI, 1.25-9.16) or the abstinence
group (OR, 3.10; 95% CI, 0.99-9.73). Self-reported frequency of condom use
was also significantly higher in the safer-sex group than in the control group.
Adolescents in the safer-sex group were less likely to report having unprotected
sexual intercourse in the previous 3 months than were those in the control
group (OR, 0.35; 95% CI, 0.13-0.95). Adolescents in the safer-sex group also
reported fewer days on which they had unprotected sexual intercourse than
did those in the control group.
The interaction between intervention group and preintervention sexual
experience on self-reported abstinence was nonsignificant (P>.28), indicating that the effects of the interventions on abstinence
did not differ between adolescents who were sexually experienced at preintervention
(ie, those who reported having had sexual intercourse at least once before
the intervention) and those who were sexually inexperienced at preintervention.
Among adolescents who reported no preintervention sexual experience, those
in the abstinence intervention were less likely to report having sexual intercourse
at the 3-month follow-up than were their counterparts in the control group
(OR, 0.26; 95% CI, 0.08-0.83) and marginally less than those in the safer-sex
group, (OR, 0.32; 95% CI, 0.10-1.04). The group and sexual experience interaction
was significant on unprotected sexual intercourse (P=.002).
Among sexually inexperienced adolescents, there were no significant effects
of the interventions on unprotected sexual intercourse. In contrast, among
sexually experienced adolescents, those who received the safer-sex intervention
reported less unprotected sexual intercourse than did those in the control
group or the abstinence group.
At the 6-month follow-up, the abstinence intervention did not reduce
self-reported sexual behavior compared with the other interventions. However,
adolescents in the safer-sex group reported marginally fewer days on which
they had sexual intercourse and significantly more frequent condom use than
did those in the control group. There were also group and sexual experience
interactions on frequency of intercourse (P=.009)
and unprotected intercourse (P=.06). Among participants
who reported preintervention sexual experience, the safer-sex intervention
caused less self-reported sexual intercourse than did the control or abstinence
intervention and less self-reported unprotected sexual intercourse than did
the control group. Among the sexually inexperienced participants, the differences
At the 12-month follow-up, the abstinence intervention did not reduce
self-reported sexual behavior compared with the other interventions. However,
adolescents in the safer sex and abstinence interventions reported more frequent
condom use than did those in the control group. There were also significant
group and sexual experience interactions on frequency of intercourse (P=.007) and frequency of unprotected intercourse (P=.002). Among adolescents with preintervention sexual
experience, the safer-sex intervention caused lower reported frequency of
sexual intercourse and unprotected sexual intercourse than did the control
or abstinence intervention. Among sexually inexperienced adolescents, there
were no differences. (More detailed tables on primary and secondary outcome
analyses are available from the authors.)
As shown in Table 4, immediately
after the intervention, the adolescents in the abstinence group believed more
strongly that practicing abstinence would prevent pregnancy and AIDS, expressed
less favorable attitudes toward sexual intercourse, and reported weaker intentions
of having sexual intercourse in the next 3 months than did those in the control
group or the safer-sex group. Adolescents in the abstinence group also believed
more strongly that practicing abstinence would help them achieve their career
goals than did those in the control group, but did not differ from those in
the safer-sex group.
Immediately after the intervention, the adolescents in the safer-sex
group scored significantly higher in condom-use knowledge; believed more strongly
that condoms can prevent pregnancy, STDs, and HIV; believed more strongly
that using condoms would not interfere with sexual enjoyment; and expressed
greater confidence that they could have condoms available when they needed
them than did those in the control group or the abstinence group. Adolescents
in the safer-sex group reported greater confidence that they could exercise
sufficient impulse control to use condoms and greater self-efficacy for using
condoms than did those in the control group, but not more than those in the
abstinence group. Adolescents in the safer-sex group did not differ from those
in the other 2 groups in technical skills belief, negotiation skills belief,
or condom-use intentions.
Adolescents in both HIV-prevention groups scored significantly higher
in HIV risk-reduction knowledge than did those in the control group. In addition,
adolescents in the safer-sex group scored significantly higher than did those
in the abstinence group.
The group and type of facilitator interactions on the primary outcome
measures and the mediators were nonsignificant, indicating that the intervention
effects did not differ depending on whether the groups were implemented by
an adult vs peer cofacilitators. Hierarchical multiple regression analyses
revealed that Marlowe-Crowne Social Desirability Scale39
scores did not interact with intervention group to influence sexual behavior
reported at any of the follow-ups. Analyses on the subsample of adolescents
in the 2 HIV interventions also revealed that social desirability scores were
unrelated to self-reported sexual behavior at the follow-ups.
The results demonstrate that culture-sensitive cognitive-behavioral
interventions stressing abstinence or condom use can reduce HIV risk-associated
sexual behavior among young African American adolescents. The abstinence intervention
caused positive changes on theory-based mediators of abstinence at the immediate
postintervention assessment and increased self-reported abstinence at the
3-month follow-up. The safer-sex intervention increased mediators of condom
use postintervention and self-reported condom use at 3-month follow-up. Although
each intervention had the predicted positive impact on its targeted outcome,
only the safer-sex intervention significantly reduced unprotected sexual intercourse—the
outcome most closely linked to the risk of exposure to HIV and other STDs.
This is the first randomized controlled trial of an abstinence intervention.
We based our abstinence intervention on cognitive-behavioral theory and information
gathered during formative research with adolescents from the study population.
Our intervention is not vulnerable to many of the criticisms49
leveled against abstinence programs. It provided accurate information, did
not portray sex in a negative light, and was not moralistic. Although the
abstinence intervention was effective in the short term, its effects diminished
with longer-term follow-up. Future research must seek to increase the longevity
of these promising effects.
The safer-sex intervention's effects on condom use were sustained 6
and 12 months after intervention. Its efficacy in reducing unprotected sexual
intercourse varied depending on the adolescents' preintervention sexual experience.
At the 3-month follow-up, the safer-sex intervention was significantly more
effective in reducing unprotected sexual intercourse among adolescents who
were sexually experienced before the intervention than among those not sexually
experienced before the intervention. At the 6- and 12-month follow-up, the
safer-sex intervention still had significant effects on unprotected sexual
intercourse among adolescents who reported preintervention sexual experience.
This is the first randomized controlled trial to examine whether adults
or peers are more effective facilitators of HIV risk-reduction interventions
for adolescents. Although the participants who had peer facilitators evaluated
the interventions and their facilitators more favorably, this did not translate
into stronger intervention effects for any of the interventions. In this respect,
our results affirm the value of both peer and adult facilitators of HIV interventions.
It is commonly believed that matching the gender of the facilitator
and the gender of the participants may enhance the effects of HIV interventions.
However, consistent with a recent randomized trial,22
we found no support for this matching hypothesis (data not shown).
This is also the first randomized controlled trial on any population
in any setting to evaluate the long-term effects of HIV-prevention interventions
using a control group that received an intervention of comparable duration
to the experimental group. All previous studies of the long-term effects of
HIV-prevention interventions have used no-treatment or wait-list control groups
or control groups that received substantially shorter interventions than the
experimental group. Our intervention effects cannot be explained as a simple
result of Hawthorne effects or social interaction and special attention received
by adolescents in any particular intervention.
One common argument against AIDS education programs that emphasize condom
use has been that they encourage adolescents to engage in sexual activity.
In the present study, however, the adolescents who received the safer-sex
intervention, which emphasized condom use, were not more likely to report
having sexual intercourse at the follow-ups than were adolescents in the control
group. Indeed, among adolescents who reported preintervention sexual experience,
those in the safer-sex group reported less frequent sexual intercourse than
did those in the control group at the 6-month and 12-month follow-ups, thus
providing evidence contrary to the common belief that sex education increases
sexual activity. Moreover, safer-sex intervention participants who did report
having sexual intercourse reported using condoms more frequently than did
their counterparts in the control group at all 3 follow-ups.
A limitation of this study is that the primary outcome was measured
with participants' self-reports, which might have been unintentionally or
intentionally inaccurate.50 Although we cannot
definitely rule out this possibility, several aspects of our methods and findings
make inaccurate self-reports a less likely explanation for our results. We
used several strategies, described above, to increase participants' ability
to recall and to motivate them to respond honestly. Moreover, if participants'
self-reports were biased, the intervention effects should be strongest among
those participants with the greatest tendency to give socially desirable responses.
Contrary to this, self-reported sexual behavior and changes in self-reported
sexual behavior were unrelated to a standard measure of social desirability
response bias, a finding that dovetails with those reported in at least 2
other recent studies.13,22
It should be noted that the present findings may not generalize to all
young inner-city African American adolescents. Also unclear is whether the
present intervention effects would be observed in other populations, for instance,
older African American adolescents or suburban white adolescents.
Our study supports several conclusions. Intensive theory-based culture-sensitive
interventions designed to influence mediators of risk behavior, including
HIV knowledge, behavioral beliefs, self-efficacy, and skills, whether implemented
by adult facilitators or peer cofacilitators, can reduce the HIV risk-associated
sexual behavior of young inner-city African American adolescents. By using
theory-based interventions, 2 important goals of HIV prevention—decreased
sexual behavior and increased condom use—can be achieved. Our finding
that the safer-sex intervention curbed unprotected sexual intercourse, whereas
the abstinence intervention did not, suggests that if the goal is reduction
of unprotected sexual intercourse, the safer-sex strategy may hold the most
promise, particularly with those adolescents who are already sexually experienced.
Moreover, safer-sex interventions may have longer-lasting effects than abstinence
interventions. These results must be replicated in other adolescent populations
and settings. By conducting such research, it may be possible to reduce the
risk of sexually transmitted HIV infection that adolescents may face as they
prepare for adulthood.