Context African American adolescent girls are at high risk for human immunodeficiency
virus (HIV) infection, but interventions specifically designed for this population
have not reduced HIV risk behaviors.
Objective To evaluate the efficacy of an intervention to reduce sexual risk behaviors,
sexually transmitted diseases (STDs), and pregnancy and enhance mediators
of HIV-preventive behaviors.
Design, Setting, and Participants Randomized controlled trial of 522 sexually experienced African American
girls aged 14 to 18 years screened from December 1996 through April 1999 at
4 community health agencies. Participants completed a self-administered questionnaire
and an interview, demonstrated condom application skills, and provided specimens
for STD testing. Outcome assessments were made at 6- and 12-month follow-up.
Intervention All participants received four 4-hour group sessions. The intervention
emphasized ethnic and gender pride, HIV knowledge, communication, condom use
skills, and healthy relationships. The comparison condition emphasized exercise
and nutrition.
Main Outcome Measures The primary outcome measure was consistent condom use, defined as condom
use during every episode of vaginal intercourse; other outcome measures were
sexual behaviors, observed condom application skills, incident STD infection,
self-reported pregnancy, and mediators of HIV-preventive behaviors.
Results Relative to the comparison condition, participants in the intervention
reported using condoms more consistently in the 30 days preceding the 6-month
assessment (unadjusted analysis, intervention, 75.3% vs comparison, 58.2%)
and the 12-month assessment (unadjusted analysis, intervention, 73.3% vs comparison,
56.5%) and over the entire 12-month period (adjusted odds ratio, 2.01; 95%
confidence interval [CI], 1.28-3.17; P = .003). Participants
in the intervention reported using condoms more consistently in the 6 months
preceding the 6-month assessment (unadjusted analysis, intervention, 61.3%
vs comparison, 42.6%), at the 12-month assessment (unadjusted analysis, intervention,
58.1% vs comparison, 45.3%), and over the entire 12-month period (adjusted
odds ratio, 2.30; 95% CI, 1.51-3.50; P<.001).
Using generalized estimating equation analyses over the 12-month follow-up,
adolescents in the intervention were more likely to use a condom at last intercourse,
less likely to have a new vaginal sex partner in the past 30 days, and more
likely to apply condoms to sex partners and had better condom application
skills, a higher percentage of condom-protected sex acts, fewer unprotected
vaginal sex acts, and higher scores on measures of mediators. Promising effects
were also observed for chlamydia infections and self-reported pregnancy.
Conclusion Interventions for African American adolescent girls that are gender-tailored
and culturally congruent can enhance HIV-preventive behaviors, skills, and
mediators and may reduce pregnancy and chlamydia infection.
Adolescents are acknowledged as a population at increased risk of human
immunodeficiency virus (HIV) infection.1-5 Among
adolescents, African American girls are a subgroup at particularly high risk
of HIV infection. A seroepidemiologic study of Job Corps applicants reported
that HIV prevalence among African American adolescent girls was significantly
higher than among their white or Hispanic female peers (4.9 vs 0.7 and 0.6
per 1000, respectively) and exceeds that of white, Hispanic, and African American
male adolescents (0.8, 1.5, and 3.2 per 1000, respectively). African American
adolescent girls in the South had the highest prevalence (6.4 per 1000) relative
to adolescents from other geographic regions.6
Recent meta-analyses and reviews indicate that theoretically derived
and empirically based HIV interventions can successfully promote the adoption
of protective sexual behaviors among adolescents.7-14 While
encouraging, many studies are limited by the range of outcomes assessed and
the magnitude and consistency of intervention effects observed.15 Moreover,
caution is warranted in generalizing intervention effects from HIV prevention
studies with lower-risk and mixed racial/ethnic groups to sexually experienced
African American adolescents, particularly African American girls. Overall,
while African American adolescent girls are disproportionately affected by
the HIV epidemic, no intervention designed specifically for this population
has demonstrated efficacy in reducing HIV-associated risk behaviors.12,16
To address this health disparity, we evaluated the efficacy of an HIV
prevention intervention in reducing risky sexual behaviors and sexually transmitted
diseases and enhancing skills and mediators of HIV-preventive behaviors among
sexually experienced African American adolescent girls residing in the southern
United States.
The study was conducted from September 1995 to August 2002. The University
of Alabama at Birmingham Institutional Review Board (IRB) approved the study
protocol prior to implementation. From December 1996 through April 1999, recruiters
screened 1130 self-identified African American adolescent girls seeking services
at 4 community health agencies. Of these, 609 (53.9%) met eligibility criteria.
Eligibility criteria included being African American, female, and 14 to 18
years of age; reporting vaginal intercourse in the preceding 6 months; and
providing written informed consent. Parental consent was waived by the IRB.
Of those not eligible, nearly 93% were not sexually experienced. Thus, 522
adolescents agreed to participate in the study, completed baseline assessments,
and were randomized to study conditions (Figure 1). Participants were compensated $25 for travel and child
care to attend intervention sessions and complete assessments.
The study was a randomized controlled trial. Assignment to study conditions
was conducted subsequent to baseline assessment using concealment of allocation
procedures, defined by protocol and compliant with published recommendations.17-19 Prior to enrollment,
an investigator used a random-numbers table to generate the allocation sequence.
As participants completed baseline assessments, sealed opaque envelopes were
used to execute the assignments. Participants were randomly assigned to either
the HIV intervention or a general health promotion condition.
The research team collaborated with African American adolescent girls
in the community to develop the study conditions. The HIV intervention consisted
of four 4-hour interactive group sessions implemented on consecutive Saturdays
at a family medicine clinic. Each session had an average of 10 to 12 participants
and was implemented by a trained African American female health educator and
2 African American female peer educators. Peer educators were instrumental
in modeling skills and creating group norms supportive of HIV prevention.
To reduce the likelihood that the effects of the HIV prevention intervention
could be attributed to group interaction or Hawthorne effects, participants
randomized to the general health promotion condition also received four 4-hour
interactive group sessions, 2 sessions emphasizing nutrition and 2 sessions
emphasizing exercise, administered on consecutive Saturdays. Prior to implementing
the main trial, both conditions were field tested with adolescents from the
study population.
Social cognitive theory20 and the theory
of gender and power21,22 were
complementary theoretical frameworks guiding the design and implementation
of the HIV intervention. Session 1 emphasized ethnic and gender pride by discussing
the joys and challenges of being an African American adolescent female, acknowledging
the accomplishments of African American women, reading poetry written by African
American women, and framing artwork created by African American women artists.
Session 2 enhanced awareness of HIV risk-reduction strategies such as abstaining
from sex, using condoms consistently, and having fewer sex partners. Session
3, through role-play and cognitive rehearsal, enhanced adolescents' confidence
in initiating safer-sex conversations, negotiating safer sex, and refusing
unsafe sexual encounters. Additionally, peer educators discussed the importance
of abstinence and proper and consistent condom use and modeled condom skills.
Session 4 emphasized the importance of healthy relationships. Health educators
described how unhealthy relationships could make it difficult to practice
safer sex.
Data collection occurred at baseline and at 6- and 12-month follow-up.
At each assessment, data were obtained from 4 sources. First, participants
completed a self-administered questionnaire assessing sociodemographics and
psychosocial mediators of HIV-preventive behaviors. Subsequently, a trained
African American female interviewer administered an interview assessing sexual
behaviors. Next, the interviewer assessed participants' ability to correctly
apply condoms using a direct observation of skills assessment protocol. Finally,
participants provided 2 self-collected vaginal swab specimens that were analyzed
for sexually transmitted diseases.
Self-reported consistent condom use, the primary outcome, was defined
as use of a condom during every episode of vaginal intercourse. Consistent
condom use was assessed for the 30 days and the 6 months prior to baseline
and at the 6- and 12-month assessments. This outcome was calculated by dividing
the total number of episodes of vaginal intercourse by the total number of
times a male condom was used, with a score of 1 representing consistent condom
use. Consistent condom use was selected as a primary outcome based on demonstrated
evidence of effectiveness in reducing sexually transmitted HIV infection.23-25
Self-reported Sexual Behaviors. Other self-reported
behavioral outcomes included (1) condom use at last vaginal intercourse; (2)
percentage of condom-protected vaginal intercourse acts in the 30 days preceding
assessment; (3) percentage of condom-protected vaginal intercourse acts in
the 6 months preceding assessment; (4) number of unprotected vaginal intercourse
acts in the 30 days preceding assessment; (5) number of unprotected vaginal
intercourse acts in the 6 months preceding assessment; (6) whether participants
had a new vaginal sex partner in the 30 days preceding assessment; and (7)
self-reported pregnancy. Additionally, a single item assessed the frequency
with which participants applied condoms on their sex partners in the past
6 months. Responses ranged from 1 ("never") to 5 ("every time"). These measures
of condom use were included to permit comparison with previous HIV interventions
conducted among adolescents.7,8,12,26,27 Preliminary
research and our pilot study indicated that anal and oral sex are extremely
low-prevalence behaviors in this population and therefore were not assessed
as outcomes.
Several techniques were used to enhance the validity of participants'
self-reported sexual behaviors. Participants were asked to report their behaviors
over relatively brief time intervals to enhance accurate recall28 and
were provided calendars specifying the reporting intervals of interest. To
enhance confidentiality, interviewers assured participants that codes rather
than names would be used on records.29 To minimize
potential interviewer bias, interviewers were blinded to participants' condition
assignments.
STD Status. Sexually transmitted disease (STD)
incidence was defined as a positive laboratory test result for a new chlamydia,
gonorrhea, or trichomonas infection at either the 6-month assessment or the
12-month assessment. Given the small sample size and limited power to detect
differences in STD incidence for each assessment interval, incidence for each
STD was determined only for the entire 12-month follow-up period. Given the
expected low incidence of HIV during the 12-month follow-up, HIV testing was
not conducted.
Specimens were collected after all other assessment procedures were
completed. Participants provided 2 vaginal swabs at each of the 3 assessments.30 One swab was evaluated for Neisseria
gonorrhoeae and Chlamydia trachomatis using
the Abbott LCx Probe System (Abbott Labs, Abbott Park, Ill).31 A
second swab was tested for Trichomonas vaginalis using
the InPouch TV test from BioMed Diagnostics Inc (San Jose, Calif).32 All assays were conducted at the University of Alabama,
Birmingham, Division of Infectious Diseases STD Research Laboratory. Adolescents
testing positive for an STD were provided directly observable single-dose
treatment, received appropriate risk-reduction counseling per Centers for
Disease Control and Prevention recommendations, and were encouraged to refer
sex partners for treatment. The county health department was notified of reportable
STDs.
Psychosocial Mediators of Sexual Behavior. Psychosocial
mediators were derived from the underlying theoretical frameworks and a review
of the empirical literature. Constructs were assessed using scales with satisfactory
psychometric properties previously used among African American adolescents.27,33 HIV prevention knowledge was measured
using a 16-item scale (α = .68). Perceived partner-related barriers
to condom use were measured using a 6-item scale that assessed attitudes that
impede participants' ability to effectively use condoms (α = .82). Attitudes
toward using condoms were measured using an 8-item scale (α = .68).
Frequency of sexual communication was measured using a 5-item scale assessing
the frequency with which participants discussed HIV-preventive practices with
sex partners (α = .80). Condom use self-efficacy was measured using
a 9-item scale that assessed participants' confidence in their ability to
properly use condoms (α = .88). Participants' condom application skills
were rated by interviewers using a structured scoring protocol that ranged
from 0 to 6, with higher ratings reflecting greater proficiency at applying
condoms.
Sample size calculations for the primary behavioral outcome were conducted
based on previous research in this population identifying approximately 25%
consistent condom use. We projected a clinically meaningful effect size of
a 50% increase in consistent condom use in the HIV intervention condition.
Estimating 20% attrition over the 12-month follow-up period and setting the
type I error rate at .05 for a 2-tailed test with power = 0.80 required enrolling
250 participants in each study condition to detect the specified effect size.
Analyses were performed only on prespecified hypotheses using an intention-to-treat
protocol in which participants were analyzed in their original assigned study
conditions irrespective of the number of sessions attended.34,35 At
baseline, descriptive statistics were calculated to summarize sociodemographic
variables, psychosocial mediators, sexual behaviors, and STD prevalence between
study conditions. Differences between conditions were assessed using t tests for continuous variables and χ2 analyses
for categorical variables.36 Variables in which
differences between study conditions approached statistical significance or
that were theoretically or empirically identified as potential confounders
were included as covariates in the models.
The effectiveness of the HIV intervention was analyzed over the entire
12-month period (from baseline to the 12-month assessment). Effectiveness
was also investigated for the two 6-month periods from baseline to the 6-month
assessment and from the 6-month to the 12-month assessment. The HIV intervention
effects analysis for each of the two 6-month assessment periods used logistic
regression to compute adjusted odd ratios (ORs) for dichotomous outcomes37 and used linear regression38 to
compute adjusted means and mean differences for continuous outcomes. Each
of these approaches included the corresponding baseline measure for the specific
outcome as a covariate in the analysis.
To assess HIV intervention effects for the entire 12-month follow-up
period, logistic and linear generalized estimating equation (GEE) regression
models were designed specifically to control for repeated within-subject measurements.
This technique allows for a differential number of observations on study participants
over the longitudinal course of observation. These models included a time-independent
variable (study condition) as well as time-dependent variables (covariates
and outcomes). The models were adjusted for the corresponding baseline measure
for each outcome and other covariates to obtain adjusted ORs to assess the
effect of the intervention on dichotomous outcomes and adjusted mean differences
to assess the effect of the intervention on continuous outcomes. Additionally,
an indicator for the time period was included in the model to capture any
unaccounted temporal effects.39,40 An
indicator for cohort was also included in the model to adjust for clustering.
Fitted GEE parameters can be interpreted as the odds (in logistic models)
or mean difference (in linear regression models) over the entire 12-month
period for an "average" participant. The 95% confidence intervals (CIs) around
the adjusted ORs and adjusted mean differences and the corresponding P values were also computed. To obtain adjusted means and
mean differences, models were repeatedly estimated from the bootstrap samples
where samples were drawn with replacement at the level of the participant.
For each model, adjusted means were calculated and standard errors were then
calculated from the collection of bootstrap results.41 Percentage
of relative change for continuous variables was computed as the difference
between the adjusted means for each condition divided by the adjusted mean
for the comparison condition. Percentage of relative change provides a common
measure of the magnitude of change across different scale measures relative
to the baseline measure. Analyses were performed using STATA statistical software,
version 8 (Stata Corp, College Station, Tex), and SAS, version 8 (SAS Institute
Inc, Cary, NC).
Of the 522 participants randomized, 251 were allocated to the HIV intervention
and 271 to the general health promotion condition. At baseline, significant
differences were observed for several variables associated with HIV sexual
behaviors and were included as covariates in subsequent analyses.7,42-46 No
differences were observed for sociodemographic characteristics, the primary
outcome measure, or other outcome measures (Table 1).
Trained monitors attended all study sessions and rated the fidelity
of implementation to assess quality assurance.47 Nearly
98% of the activities in each study condition were implemented with fidelity.
Participants' attendance in each condition was high; 95.2% (n = 239) completed
all 4 intervention sessions and 94.5% (n = 256) completed all 4 general health
promotion sessions. Additionally, participants' confidential ratings of their
satisfaction with the delivery and content of each session, assessed using
a 5-point scale, indicated comparably high ratings between the HIV intervention
(mean [SD], 4.82 [0.11]) and the general health promotion comparison (mean
[SD], 4.76 [0.09]).
Of the 251 participants allocated to the HIV intervention, 226 (90%)
completed the 6-month assessment and 219 (87.3%) completed the 12-month assessment.
Of the 271 participants allocated to the general health promotion condition,
243 (89.7%) completed the 6-month assessment and 241 (88.9%) completed the
12-month assessment (Figure 1).
No differences in attrition were observed between study conditions at either
the 6-month (P = .89) or 12-month (P = .56) assessment. Additionally, no differences between study conditions
for sociodemographic characteristics were observed at either the 6- or 12-month
assessment. Finally, no differences were observed in baseline variables for
either study condition in participants retained in the trial compared with
those unavailable for follow-up.
Effects of the HIV Intervention
Effects of the intervention on the primary outcome, consistent condom
use, and other dichotomous outcomes are presented in Table 2. These analyses were performed separately at the 6-month
assessment (baseline to 6-month assessment), at the 12-month assessment (6-
to 12-month assessment), and over the entire 12-month period (baseline to
12-month assessment). Relative to participants in the general health promotion
condition, participants in the HIV intervention were more likely to report
using condoms consistently in the 30 days preceding the 6-month assessment
(unadjusted analysis, intervention, 75.3% vs comparison, 58.2%; adjusted OR,
1.77; 95% CI, 0.97-3.20; P = .06) and the 12-month
assessment (unadjusted analysis, intervention, 73.3% vs comparison, 56.5%;
adjusted OR, 2.23; 95% CI, 1.17-4.27; P = .02) and
over the entire 12-month period (adjusted OR, 2.01; 95% CI, 1.28-3.17; P = .003). Likewise, participants in the HIV intervention
were more likely to report using condoms consistently during the 6 months
prior to the 6-month assessment (unadjusted analysis, intervention, 61.3%
vs comparison, 42.6%; adjusted OR, 2.48; 95% CI, 1.44-4.26; P = .001) and the 12-month assessment (unadjusted analysis, intervention,
58.1% vs comparison, 45.3%; adjusted OR, 2.14; 95% CI, 1.20-3.84; P = .01) and over the entire 12-month period (adjusted OR, 2.30; 95%
CI, 1.51-3.50; P<.001). Additionally, participants
in the HIV intervention were more likely to report using a condom at last
vaginal sexual intercourse, less likely to self-report a pregnancy, and less
likely to report having a new vaginal sex partner in the 30 days prior to
assessments.
The effects of the HIV intervention on other measures of self-reported
sexual behavior are presented in Table 3 and Table 4. Participants
in the HIV intervention were more likely to report a significantly higher
percentage of condom-protected sex acts in the 30 days and in the 6 months
preceding the 6- and the 12-month assessments and over the entire 12-month
period. Additionally, participants in the HIV intervention reported significantly
fewer unprotected vaginal intercourse episodes in the 30 days and in the 6
months preceding the 6- and the 12-month assessments and over the entire 12-month
period. Furthermore, participants in the HIV intervention reported a higher
frequency of putting condoms on their partners at the 6- and 12-month assessments
and over the entire 12-month period.
Effects of the HIV intervention on incident STDs were also assessed.
The crude STD incidence, by condition, was calculated for chlamydia (intervention,
2.1 vs comparison, 2.0 per 100 person-months), trichomonas (intervention,
0.9 vs comparison, 1.2 per 100 person-months), and gonorrhea (intervention,
0.9 vs comparison, 0.7 per 100 person-months). Results of GEE STD-specific
analyses over the entire 12-month follow-up period, adjusting for the corresponding
baseline variable and covariates, suggest a treatment advantage in reducing
chlamydia infections (OR, 0.17; 95% CI, 0.03-0.92; P =
.04). Intervention effects were not observed for trichomonas (OR, 0.37; 95%
CI, 0.09-1.46; P = .16) or gonorrhea (OR, 0.14; 95%
CI, 0.01-3.02; P = .21). The intervention effects
reflect adjusted analyses. These findings may result from the relatively small
number of incident STDs and missing data for some covariates, which affect
the precision and stability of effect estimates.
The effects of the HIV intervention on empirically and theoretically
derived psychosocial mediators of HIV-preventive behavior are presented in Table 5 and Table 6. In general, participants in the HIV intervention reported
fewer perceived partner-related barriers to condom use, more favorable attitudes
toward using condoms, more frequent discussions with male sex partners about
HIV prevention, higher condom use self-efficacy scores, and higher HIV prevention
knowledge scores; in addition, they demonstrated greater proficiency in using
condoms at the 6- and the 12-month assessments and over the entire 12-month
period.
While other studies have shown that self-reported sexual risk behaviors
can be reduced in adolescents, this is the first trial, to our knowledge,
demonstrating that an HIV intervention can result in substantial reductions
in sexual risk behaviors, including acquisition of a new male sex partner,
and markedly enhance theoretically important mediators and skills associated
with HIV-preventive behaviors among sexually experienced African American
adolescent girls. Promising intervention effects were also observed for self-reported
pregnancy and laboratory-confirmed chlamydia. Because STDs, particularly chlamydia,
are prevalent among adolescents48 and facilitate
HIV transmission,49,50 even small
reductions in incidence could result in considerable reductions in treatment
costs as well as sizable reductions in HIV morbidity51 and
its associated treatment costs.52 Furthermore,
mathematical modeling studies suggest that reductions in incident chlamydia
infections may be one of the most promising surrogate markers for HIV incidence
in prevention trials.53
The efficacy of the HIV intervention may be attributable partly to the
gender-tailored framework that highlighted the underlying social processes,
such as the dyadic nature of sexual interactions, relationship power, and
emotional commitment that may promote and reinforce risk behaviors. Conceptualizing
HIV prevention within the broader context of a healthy relationship also marshaled
new intervention strategies and offered new options for creating behavior
change. Additionally, the thematic focus of the intervention, "Stay Safe for
Yourself and Your Community," was designed to promote a sense of solidarity
and ethnic pride among participants and may have inspired them to modify risk
behaviors for altruistic motives: by enhancing their health, they were also
enhancing the health of the African American community.
The present study has a number of methodological strengths. Foremost
is the use of a randomized controlled trial design that includes a dose-equivalent
comparison condition to minimize Hawthorne effects. Another methodological
strength is the use of STDs and directly observed condom skills to complement
self-reported behavior change.47,54,55 However,
STDs and self-reported behavior change are relatively independent measures
for evaluating the efficacy of HIV interventions, and modifying sexual behavior
may not necessarily result in reductions in STD incidence.56,57 Thus,
rather than solely relying on any single measure, it is the weight of empirical
evidence assessing the magnitude and consistency of intervention effects across
the range of outcomes that is critical for adequately evaluating the efficacy
of HIV interventions.
This study is not without limitations. First, the findings may not be
applicable to African American adolescent girls with different sociodemographic
characteristics or risk profiles. A second methodological concern is the reliability
of self-reported outcome measures. Previous research has, however, established
the validity and reliability of self-reported sexual behavior,58-60 specifically
for young African American women.61,62 Third,
incident STDs as outcomes represent a methodological improvement; however,
the statistical power and precision of the effect estimates may be limited
by small sample sizes, missing data, or number of incident infections. Future
studies using STDs, particularly as the primary outcome, will require larger
samples, longer follow-up, or samples that have a higher incidence of infection
to yield more precise and stable effect estimates.63,64
Overall, the observed magnitude, consistency, and scope of effects strengthen
confidence in the efficacy of the HIV intervention. Collectively, the research
literature indicates that HIV prevention interventions for adolescents can
be efficacious. However, it may be more difficult to change sexual risk behaviors
among sexually experienced adolescents than among samples containing both
sexually experienced and non–sexually experienced youth.12 More
intensive interventions may be necessary to motivate health-promoting behavior
change among those who are sexually experienced. Thus, new and innovative
intervention research is critical to optimizing HIV prevention effectiveness
tailored for diverse adolescent populations, particularly high-risk youth.16,65-69
In response to the growing HIV epidemic among adolescents, there is
a clear, cogent, and compelling urgency to develop and implement prevention
interventions. Ultimately, to be optimally effective, the primary prevention
of HIV among adolescents must emerge from the stigma of a hidden epidemic
and become a public health priority. Only then will prevention research realize
its potential and its promise of reducing the impact of the HIV epidemic among
adolescents.
1.DiClemente RJ. The emergence of adolescents as a risk group for human immunodeficiency
virus infection.
J Adolesc Res.1990;5:7-17.Google Scholar 2.DiClemente RJ. Adolescents at-risk for acquired immune deficiency syndrome: epidemiology
of AIDS, HIV prevalence and HIV incidence. In: Oskamp S, Thompson S, eds. Understanding and
Preventing HIV Risk Behavior. Newbury Park, Calif: Sage Publications;
1996;13-30.
3.Eng TR, Butler WT. The Hidden Epidemic: Confronting Sexually Transmitted
Diseases. Washington, DC: National Academy Press; 1997.
4.National Institutes of Health. Interventions to Prevent HIV Risk Behavior. Washington, DC: National Institutes of Health; 1997.
5.Office of National AIDS Policy. Youth and HIV/AIDS: An American Agenda. Washington, DC: Office of National AIDS Policy; 1996.
6.Valleroy LA, MacKellar DA, Karon JM, Janssen RS, Hayman CR. HIV infection in disadvantaged out-of-school youth: prevalence for
US Job Corps entrants, 1990 through 1996.
J Acquir Immune Defic Syndr Hum Retrovirol.1998;19:67-73.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9732072&dopt=Abstract
Google Scholar 7.DiClemente RJ, Crosby RA. Sexually transmitted diseases among adolescents: risk factors, antecedents,
and prevention strategies. In: Adams GR, Berzonsky M, eds. The Blackwell Handbook
of Adolescence. Oxford, England: Blackwell Publishers Ltd; 2003:573-605.
8.Robin L, Dittus P, Whitaker D.
et al. Behavioral interventions to reduce incidence of HIV, STD, and pregnancy
among adolescents: a decade in review.
J Adolesc Health.2004;34:3-26.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14706401&dopt=Abstract
Google Scholar 9.Rotheram Borus MJ, O'Keefe Z, Kracker R.
et al. Prevention of HIV among adolescents.
Prev Sci.2000;1:15-25.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11507791&dopt=Abstract
Google Scholar 10.Santelli J, DiClemente RJ, Miller K, Kirby D. Sexually transmitted diseases, unintended pregnancy, and adolescent health promotion.
Adolesc Med.1999;10:87-108, vi.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10086168&dopt=Abstract
Google Scholar 11.Marsh KL, Johnson BT, Carey MP. Primary prevention of HIV and other STD infection in adolescents. In: Gullotta TP, Bloom M, eds. Encyclopedia of
Primary Prevention and Health Promotion. New York, NY: Kluwer Academic/Plenum;
2003:541-548.
12.Mullen DP, Ramirez G, Strouse D, Hedges LV, Sogolow E. Meta-analysis of the effects of behavioral HIV prevention interventions
on the sexual behavior of sexually experienced adolescents in controlled studies
in the United States.
J Acquir Immune Defic Syndr.2002;30:S94-S105.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12107363&dopt=Abstract
Google Scholar 13.Peersman GV, Levy JA. Focus and effectiveness of HIV-prevention efforts for young people.
AIDS.1998;12:S191-S196.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9633003&dopt=Abstract
Google Scholar 14.Kim N, Stanton B, Li X, Dickersin K, Galbraith J. Effectiveness of the 40 adolescent AIDS-risk reduction interventions:
a quantitative review.
J Adolesc Health.1997;20:204-215.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9069021&dopt=Abstract
Google Scholar 15.Johnson BT, Carey MP, Marsh KL, Levin KD, Scott-Sheldon LA. Interventions to reduce sexual risk for HIV in adolescents (1985-2000).
Arch Pediatr Adolesc Med.2003;157:381-388.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12695235&dopt=Abstract
Google Scholar 16.Ellen JM. The next generation of HIV prevention for adolescent females in the
United States: linking behavioral and epidemiologic sciences to reduce incidence
of HIV.
J Urban Health.2003;80(4 suppl 3):iii40-iii49.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14713670&dopt=Abstract
Google Scholar 17.Schulz KF. Subverting randomization in controlled trials.
JAMA.1995;274:1456-1458.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7474192&dopt=Abstract
Google Scholar 18.Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias: dimensions of methodological quality associated
with treatment effects in controlled trials.
JAMA.1995;273:408-412.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7823387&dopt=Abstract
Google Scholar 19.Schulz KF, Grimes DA. Blinding in randomized trials: hiding who got what.
Lancet.2002;359:696-700.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11879884&dopt=Abstract
Google Scholar 20.Bandura A. Social cognitive theory and exercise of control over HIV infection. In: DiClemente RJ, Peterson J, eds. Preventing
AIDS: Theories and Methods of Behavioral Interventions. New York, NY:
Plenum Publishing Corp; 1994:25-59.
21.Wingood GM, DiClemente RJ. The theory of gender and power: a social structural theory for guiding
the design and implementation of public health interventions to reduce women's
risk of HIV. In: DiClemente RJ, Crosby RA, Kegler M, eds. Emerging
Theories in Health Promotion Practice and Research: Strategies for Enhancing
Public Health. San Francisco, Calif: Jossey-Bass; 2002;313-347.
22.Wingood GM, DiClemente RJ. Application of the theory of gender and power to examine HIV related
exposures, risk factors and effective interventions for women.
Health Educ Behav.2000;27:539-565.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11009126&dopt=Abstract
Google Scholar 23.Saracco A, Musicco M, Nicolosi A.
et al. Man-to-woman sexual transmission of HIV: longitudinal study of 343
steady partners of infected men.
J Acquir Immune Defic Syndr.1993;6:497-502.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8097789&dopt=Abstract
Google Scholar 24.De Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by
heterosexual partners.
N Engl J Med.1994;331:341-346.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8028613&dopt=Abstract
Google Scholar 25.National Institute of Allergy and Infectious Diseases. Workshop Summary: Scientific Evidence on Condom Effectiveness
for Sexually Transmitted Disease (STD) Prevention. Bethesda, Md: National Institute of Allergy and Infectious Diseases;
July 20, 2001.
26.Kirby D. School-based interventions to prevent unprotected sex and HIV among
adolescents. In: Peterson JL, DiClemente RJ, eds. Handbook of
HIV Prevention. New York, NY: Plenum Press; 2000:83-102.
27.Jemmott III JB, Jemmott LS. HIV behavioral interventions for adolescents in community settings. In: Peterson JL, DiClemente RJ, eds. Handbook of
HIV Prevention. New York, NY: Plenum Press; 2000:103-128.
28.McFarlane M, St Lawrence JS. Adolescents' recall of sexual behavior: consistency of self-report
and the effects of variation in recall duration.
J Adolesc Health.1999;25:199-206.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10475496&dopt=Abstract
Google Scholar 29.Ford CA, Millstein SG, Halpern-Felsher BL, Irwin Jr CE. Influence of physician confidentiality assurances on adolescents' willingness
to disclose information and seek future health care: a randomized controlled
trial.
JAMA.1997;278:1029-1034.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9307357&dopt=Abstract
Google Scholar 30.Smith K, Harrington K, Wingood G.
et al. Self-obtained vaginal swabs for treatable STD diagnosis in adolescent
women.
Arch Pediatr Adolesc Med.2001;155:676-679.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11386956&dopt=Abstract
Google Scholar 31.Hook III EW, Ching SF, Stephens J, Hardy KF, Lee HH. Diagnosis of
Neisseria gonorrhoeae infection
in women by using ligase chain reaction on patient-obtained vaginal swabs.
J Clin Microbiol.1997;35:2129-2132.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9230396&dopt=Abstract
Google Scholar 32.Schwebke JR, Morgan SC, Pinson GB. Validity of self-obtained vaginal specimens for diagnosis of trichomoniasis.
J Clin Microbiol.1997;35:1618-1619.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9163499&dopt=Abstract
Google Scholar 33.Wingood GM, DiClemente RJ. HIV/AIDS in women. In: Wingood GM, DiClemente RJ, eds. Handbook of
Women's Sexual and Reproductive Health. New York, NY: Kluwer/Plenum
Publishing Corp; 2002:281-301.
34.Piantadosi S. Clinical Trials: A Methodologic Perspective. New York, NY: John Wiley & Sons; 1997.
35.Pocock SJ. Clinical Trials. New York, NY: John Wiley & Sons; 1993.
36.Fleiss JL, Levin B, Paik MC. Statistical Methods for Rates and Proportions. 3rd ed. New York, NY: John Wiley & Sons; 2003.
37.Hosmer DW, Lemeshow SL. Applied Logistic Regression. New York, NY: John Wiley & Sons; 1989.
38.Kleinbaum DG, Kupper LL, Muller KE, Nizam A. Applied Regression Analysis and Other Multivariable
Methods. New York, NY: Duxbury Press; 1998.
39.Hardin JW, Hilbe JM. Generalized Estimating Equations. New York, NY: Chapman & Hall/CRC; 2003.
40.Liang K-Y, Zeger SL. Longitudinal data analysis using generalized linear models.
Biometrika.1986;73:13-22.Google Scholar 41.Efron B. Nonparametric estimates of standard error: the jackknife, the bootstrap,
and other methods.
Biometrika.1981;68:589-599.Google Scholar 42.Shrier LA, Harris SK, Beardslee WR. Temporal associations between depressive symptoms and self-reported
sexually transmitted disease among adolescents.
Arch Pediatr Adolesc Med.2002;156:599-606.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12038894&dopt=Abstract
Google Scholar 43.Shrier LA, Harris SK, Sternebrg M, Beardslee WR. Associations of depression, self-esteem, and substance use with sexual
risk among adolescents.
Prev Med.2001;33:179-189.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11522159&dopt=Abstract
Google Scholar 44.Wingood GM, DiClemente RJ, Crosby R, Harrington K, Davies SL, Hook III EW. Gang involvement and the health of African-American female adolescents.
Pediatrics.2002;110:E1-E5.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12093982&dopt=Abstract
Google Scholar 45.DiClemente RJ. Psychosocial determinants of condom use among adolescents. In: DiClemente RJ, ed. Adolescents and AIDS: A
Generation in Jeopardy. Newbury Park, Calif: Sage Publications; 1992:34-51.
46.Oh MK, Funkhouser E, Simpson T, Brown P, Merchant J. Early onset of vaginal douching is associated with false beliefs and
high-risk behavior.
Sex Transm Dis.2003;30:689-693.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12972791&dopt=Abstract
Google Scholar 47.O'Leary A, DiClemente RJ, Aral S. Reflections on the design and reporting of STD/HIV behavioral intervention
research.
AIDS Educ Prev.1997;9(1 suppl):1-14.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9083595&dopt=Abstract
Google Scholar 48.Weinstock H, Berman S, Cates Jr W. Sexually transmitted diseases in American youth: incidence and prevalence
estimates.
Perspect Sex Reprod Health.2004;36:6-10.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14982671&dopt=Abstract
Google Scholar 49.Wasserheit JN. Epidemiological synergy: interrelationships between human immunodeficiency
virus infection and other sexually transmitted diseases.
Sex Transm Dis.1992;19:61-77.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1595015&dopt=Abstract
Google Scholar 50.Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice:
the contribution of other sexually transmitted diseases to sexual transmission
of HIV infection.
Sex Transm Infect.1999;75:3-17.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10448335&dopt=Abstract
Google Scholar 51.Bozzette SA, Joyce G, McCaffrey DF.
et al. Expenditures for the care of HIV-infected patients in the era of highly
active antiretroviral therapy.
N Engl J Med.2001;344:817-23.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11248159&dopt=Abstract
Google Scholar 52.Chesson HW, Blandford JM, Gift TL, Tao G, Irwin KL. The estimated direct medical cost of sexually transmitted diseases
among American youth, 2000.
Perspect Sex Reprod Health.2004;36:11-19.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14982672&dopt=Abstract
Google Scholar 53.Pinkerton SD, Layde PM. Using sexually transmitted disease incidence as a surrogate marker
for HIV incidence in prevention trials.
Sex Transm Dis.2002;29:298-307.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11984448&dopt=Abstract
Google Scholar 54.Stephenson JM. Evaluation of behavioural interventions in HIV/STI prevention.
Sex Transm Infect.1999;75:69-71.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10448349&dopt=Abstract
Google Scholar 55.Cowan FM. Adolescent reproductive health interventions.
Sex Transm Infect.2002;78:315-318.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12407227&dopt=Abstract
Google Scholar 56.Fishbein M, Pequegnat W. Evaluating AIDS prevention interventions using behavioral and biological
outcome measures.
Sex Transm Dis.2000;27:101-110.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10676977&dopt=Abstract
Google Scholar 57.Schachter J, Chow JM. The fallibility of diagnostic tests for sexually transmitted disease:
the impact on behavioral and epidemiologic studies.
Sex Transm Dis.1995;22:191-196.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7652663&dopt=Abstract
Google Scholar 58.Ochs EP, Binik YM. The use of couple data to determine the reliability of self-reported
sexual behavior.
J Sex Res.1999;36:374-384.Google Scholar 59.Miller HG, Turner CF, Moses LE. AIDS: The Second Decade. Washington, DC: National Academy Press; 1990:359-472.
60.Jaccard J, Wan CK. A paradigm for studying the accuracy of self-reports of risk behavior
relevant to AIDS: empirical perspectives on stability, recall bias, and transitory
influences.
J Appl Soc Psychol.1995;25:1831-1858.Google Scholar 61.Plichta SB, Weisman CS, Nathanson CA, Ensminger ME, Robinson JC. Partner-specific condom use among adolescent women clients of a family
planning clinic.
J Adolesc Health.1992;13:506-511.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1390818&dopt=Abstract
Google Scholar 62.Upchurch DM, Weisman CS, Shepherd M.
et al. Interpartner reliability of reporting of recent sexual behaviors.
Am J Epidemiol.1991;134:1159-1165.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1746526&dopt=Abstract
Google Scholar 63.DiClemente RJ. Looking forward: future directions for HIV prevention research. In: Peterson JL, DiClemente RJ, eds. Handbook of
HIV Prevention. New York, NY: Kluwer/Plenum Publishing Corp; 2000:311-324.
64.Kamb ML, Fishbein M, Douglas JM.
et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency
virus and sexually transmitted diseases: a randomized controlled trial.
JAMA.1998;280:1161-1167.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9777816&dopt=Abstract
Google Scholar 65.DiClemente RJ, Wingood GM. HIV prevention for adolescents: windows of opportunity for optimizing
intervention effectiveness.
Arch Pediatr Adolesc Med.2003;157:319-320.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12695223&dopt=Abstract
Google Scholar 66.DiClemente RJ, Wingood GM. Expanding the scope of HIV prevention for adolescents: beyond individual-level
interventions.
J Adolesc Health.2000;26:377-378.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10822177&dopt=Abstract
Google Scholar 67.DiClemente RJ, Wingood GM, Crosby R. A contextual perspective for understanding and preventing STD/HIV among
adolescents. In: Romer D, ed. Reducing Adolescent Risk: Toward
an Integrated Approach. Thousand Oaks, Calif: Sage Publications; 2003:366-373.
68.Jemmott JB, Jemmott LS, Fong GT. Abstinence and safer sex HIV risk-reduction interventions for African
American adolescents: a randomized controlled trial.
JAMA.1998;279:1529-1536.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9605896&dopt=Abstract
Google Scholar 69.DiClemente RJ. Preventing sexually transmitted infections among adolescents.
JAMA.1998;279:1574-1575.http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9605904&dopt=Abstract
Google Scholar