[Skip to Content]
Sign In
Individual Sign In
Create an Account
Institutional Sign In
OpenAthens Shibboleth
Purchase Options:
[Skip to Content Landing]
Figure 1.  Analytical Framework: Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections
Analytical Framework: Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections

Evidence reviews for the US Preventive Services Task Force (USPSTF) use an analytic framework to visually display the key questions that the review will address to allow the USPSTF to evaluate the effectiveness and safety of a preventive service. The questions are depicted by linkages that relate interventions and outcomes. A dashed line indicates a health outcome that immediately follows an intermediate outcome. See the USPSTF Procedure Manual9 for interpretation of the analytical framework.

Figure 2.  Literature Search Flow Diagram: Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections
Literature Search Flow Diagram: Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections

KQ indicates key question.

aRelevance: Study aim not relevant. Design: Not a randomized clinical trial or controlled clinical trial. Not primary data: eg, editorials, narrative reviews. Setting: Excluded on the basis of setting alone (eg, emergency departments, research laboratories, school classrooms, worksites, inpatient/residential departments). Population: limited to populations requiring specialized health care or interventions to address sexually transmitted infection (STI) health risks. Intervention: Not linked to health care (eg, STI testing only, sexual abuse prevention, cash and reward-based incentives, preexposure prophylaxis, or vaccine only). Comparator: Control group received active intervention. Outcomes: No relevant outcomes or self-reported STI. Poor quality: Study was poor quality. Country: Not a country with a very high Human Development Index ranking.

bIncluded studies may appear in more than 1 key question.

Figure 3.  Combined Effects of Interventions on Diagnosed Sexually Transmitted Infections, Stratified by Age Groups
Combined Effects of Interventions on Diagnosed Sexually Transmitted Infections, Stratified by Age Groups

Dashed line indicates the overall measure of effect. Confidence intervals were estimated with the DerSimonian and Laird method. NR indicates not reported.

aTotal intervention contact time categorized as high (>120 minutes), moderate (30 to 120 minutes), and low (<30 minutes).

bStudy participants ranged in age from 12 to 19 years.

cStudy participants ranged in age from 12 to 25 years or study included adolescents and adults with population mean age younger than 25 years.

dStudy participants ranged in age from 18 to 25 years only or study enrolled adults of all ages with population mean age younger than 25 years.

eStudy participants 18 years and older or enrolled broad age-range population with mean age older than 25 years.

Table 1.  Study and Population Characteristics of Included Adolescent Studies, Sorted by Age Group and Author (n = 39)a
Study and Population Characteristics of Included Adolescent Studies, Sorted by Age Group and Author (n = 39)a
Table 2.  Study and Population Characteristics of Included Adolescent and Young Adult Studies, Sorted by Age Group and Authora
Study and Population Characteristics of Included Adolescent and Young Adult Studies, Sorted by Age Group and Authora
Table 3.  Study and Population Characteristics of Included Young Adult Studies, Sorted by Age Group and Authora
Study and Population Characteristics of Included Young Adult Studies, Sorted by Age Group and Authora
Table 4.  Study and Population Characteristics of Included Adult Studies, Sorted by Age Group and Authora,b
Study and Population Characteristics of Included Adult Studies, Sorted by Age Group and Authora,b
Table 5.  Meta-analysis Results: Summary of Behavioral Outcomes
Meta-analysis Results: Summary of Behavioral Outcomes
Table 6.  Summary of Evidence for Behavioral Counseling Interventions to Prevent Sexually Transmitted Infection
Summary of Evidence for Behavioral Counseling Interventions to Prevent Sexually Transmitted Infection
1.
Satterwhite  CL, Torrone  E, Meites  E,  et al.  Sexually transmitted infections among US women and men.   Sex Transm Dis. 2013;40(3):187-193. doi:10.1097/OLQ.0b013e318286bb53 PubMedGoogle ScholarCrossref
2.
Centers for Disease Control and Prevention.  Sexually Transmitted Disease Surveillance 2017. US Department of Health and Human Services; 2018.
3.
Centers for Disease Control and Prevention.  Sexually Transmitted Disease Surveillance 2018. US Department of Health and Human Services; 2019.
4.
Ward  H.  Prevention strategies for sexually transmitted infections.   Sex Transm Infect. 2007;83(suppl 1):i43-i49. doi:10.1136/sti.2006.023598 PubMedGoogle ScholarCrossref
5.
Ford  JV, Ivankovich  MB, Douglas  JM  Jr,  et al.  The need to promote sexual health in America.   Sex Transm Dis. 2017;44(10):579-585. doi:10.1097/OLQ.0000000000000660 PubMedGoogle ScholarCrossref
6.
National Center for HIV/AIDS, Viral Hepatitis, and TB Prevention. A Guide to Taking a Sexual History. Centers for Disease Control and Prevention. Published 2011. Accessed April 24, 2019. https://www.cdc.gov/std/treatment/sexualhistory.pdf
7.
LeFevre  ML; US Preventive Services Task Force.  Behavioral counseling interventions to prevent sexually transmitted infections: U.S. Preventive Services Task Force recommendation statement.   Ann Intern Med. 2014;161(12):894-901. doi:10.7326/M14-1965 PubMedGoogle ScholarCrossref
8.
O’Connor  EA, Lin  JS, Burda  BU, Henderson  JT, Walsh  ES, Whitlock  EP.  Behavioral sexual risk-reduction counseling in primary care to prevent sexually transmitted infections: a systematic review for the U.S. Preventive Services Task Force.   Ann Intern Med. 2014;161(12):874-883. doi:10.7326/M14-0475 PubMedGoogle ScholarCrossref
9.
 U.S. Preventive Services Task Force Procedure Manual. U.S. Preventive Services Task Force; 2015.
10.
Henderson  JT, Henninger  M, Bean  SI, Senger  CA, Redmond  N, O’Connor  EA.  Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections: Updated Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 192. Agency for Healthcare Research and Quality; 2020. AHRQ publication 19-05260-EF-1.
11.
Human Development Report 2016: Human Development for Everyone. United Nations Development Programme. Published 2016. Accessed July 9, 2020. http://hdr.undp.org/sites/default/files/2016_human_development_report.pdf
12.
Egger  M, Davey Smith  G, Schneider  M, Minder  C.  Bias in meta-analysis detected by a simple, graphical test.   BMJ. 1997;315(7109):629-634. doi:10.1136/bmj.315.7109.629 PubMedGoogle ScholarCrossref
13.
Brockwell  SE, Gordon  IR.  A comparison of statistical methods for meta-analysis.   Stat Med. 2001;20(6):825-840. doi:10.1002/sim.650 PubMedGoogle ScholarCrossref
14.
Ehrhardt  AA, Exner  TM, Hoffman  S,  et al.  A gender-specific HIV/STD risk reduction intervention for women in a health care setting.   AIDS Care. 2002;14(2):147-161. doi:10.1080/09540120220104677 PubMedGoogle ScholarCrossref
15.
Billings  DW, Leaf  SL, Spencer  J, Crenshaw  T, Brockington  S, Dalal  RS.  A randomized trial to evaluate the efficacy of a web-based HIV behavioral intervention for high-risk African American women.   AIDS Behav. 2015;19(7):1263-1274. doi:10.1007/s10461-015-0999-9 PubMedGoogle ScholarCrossref
16.
Carey  MP, Senn  TE, Walsh  JL,  et al.  Evaluating a brief, video-based sexual risk reduction intervention and assessment reactivity with STI clinic patients.   AIDS Behav. 2015;19(7):1228-1246. doi:10.1007/s10461-014-0960-3 PubMedGoogle ScholarCrossref
17.
Berenson  AB, Rahman  M.  A randomized controlled study of two educational interventions on adherence with oral contraceptives and condoms.   Contraception. 2012;86(6):716-724. doi:10.1016/j.contraception.2012.06.007 PubMedGoogle ScholarCrossref
18.
Berkman  A, Pilowsky  DJ, Zybert  PA,  et al.  HIV prevention with severely mentally ill men: a randomised controlled trial.   AIDS Care. 2007;19(5):579-588. doi:10.1080/09540120701213989 PubMedGoogle ScholarCrossref
19.
Carey  MP, Carey  KB, Maisto  SA, Gordon  CM, Schroder  KE, Vanable  PA.  Reducing HIV-risk behavior among adults receiving outpatient psychiatric treatment.   J Consult Clin Psychol. 2004;72(2):252-268. doi:10.1037/0022-006X.72.2.252 PubMedGoogle ScholarCrossref
20.
Carey  MP, Senn  TE, Vanable  PA, Coury-Doniger  P, Urban  MA.  Brief and intensive behavioral interventions to promote sexual risk reduction among STD clinic patients.   AIDS Behav. 2010;14(3):504-517. doi:10.1007/s10461-009-9587-1 PubMedGoogle ScholarCrossref
21.
Carey  MP, Vanable  PA, Senn  TE, Coury-Doniger  P, Urban  MA.  Evaluating a two-step approach to sexual risk reduction in a publicly-funded STI clinic: rationale, design, and baseline data from the Health Improvement Project-Rochester (HIP-R).   Contemp Clin Trials. 2008;29(4):569-586. doi:10.1016/j.cct.2008.02.001 PubMedGoogle ScholarCrossref
22.
Champion  JD.  Behavioural interventions and abuse: secondary analysis of reinfection in minority women.   Int J STD AIDS. 2007;18(11):748-753. doi:10.1258/095646207782212180 PubMedGoogle ScholarCrossref
23.
Champion  JD, Collins  JL.  Comparison of a theory-based (AIDS Risk Reduction Model) cognitive behavioral intervention versus enhanced counseling for abused ethnic minority adolescent women on infection with sexually transmitted infection.   Int J Nurs Stud. 2012;49(2):138-150. doi:10.1016/j.ijnurstu.2011.08.010 PubMedGoogle ScholarCrossref
24.
Crosby  R, DiClemente  RJ, Charnigo  R, Snow  G, Troutman  A.  A brief, clinic-based, safer sex intervention for heterosexual African American men newly diagnosed with an STD.   Am J Public Health. 2009;99(suppl 1):S96-S103. doi:10.2105/AJPH.2007.123893 PubMedGoogle ScholarCrossref
25.
DiClemente  RJ, Wingood  GM, Harrington  KF,  et al.  Efficacy of an HIV prevention intervention for African American adolescent girls.   JAMA. 2004;292(2):171-179. doi:10.1001/jama.292.2.171 PubMedGoogle ScholarCrossref
26.
Dworkin  SL, Beckford  ST, Ehrhardt  AA.  Sexual scripts of women: a longitudinal analysis of participants in a gender-specific HIV/STD prevention intervention.   Arch Sex Behav. 2007;36(2):269-279. doi:10.1007/s10508-006-9092-9 PubMedGoogle ScholarCrossref
27.
Enrhardt  AA, Exner  TM, Hoffman  S,  et al.  HIV/STD risk and sexual strategies among women family planning clients in New York: Project FIO.   AIDS Behav. 2002;6(1):1-13. doi:10.1023/A:1014534110868 Google ScholarCrossref
28.
Guilamo-Ramos  V, Bouris  A, Jaccard  J, Gonzalez  B, McCoy  W, Aranda  D.  A parent-based intervention to reduce sexual risk behavior in early adolescence.   J Adolesc Health. 2011;48(2):159-163. doi:10.1016/j.jadohealth.2010.06.007 PubMedGoogle ScholarCrossref
29.
Hoffman  S, Exner  TM, Leu  CS, Ehrhardt  AA, Stein  Z.  Female-condom use in a gender-specific family planning clinic trial.   Am J Public Health. 2003;93(11):1897-1903. doi:10.2105/AJPH.93.11.1897 PubMedGoogle ScholarCrossref
30.
Jemmott  JB  III, Jemmott  LS, Braverman  PK, Fong  GT.  HIV/STD risk reduction interventions for African American and Latino adolescent girls at an adolescent medicine clinic.   Arch Pediatr Adolesc Med. 2005;159(5):440-449. doi:10.1001/archpedi.159.5.440 PubMedGoogle ScholarCrossref
31.
Jemmott  LS, Jemmott  JB  III, O’Leary  A.  Effects on sexual risk behavior and STD rate of brief HIV/STD prevention interventions for African American women in primary care settings.   Am J Public Health. 2007;97(6):1034-1040. doi:10.2105/AJPH.2003.020271 PubMedGoogle ScholarCrossref
32.
Kershaw  TS, Magriples  U, Westdahl  C, Rising  SS, Ickovics  J.  Pregnancy as a window of opportunity for HIV prevention: effects of an HIV intervention delivered within prenatal care.   Am J Public Health. 2009;99(11):2079-2086. doi:10.2105/AJPH.2008.154476 PubMedGoogle ScholarCrossref
33.
Lang  DL, DiClemente  RJ, Hardin  JW,  et al.  Threats of cross-contamination on effects of a sexual risk reduction intervention: fact or fiction.   Prev Sci. 2009;10(3):270-275. doi:10.1007/s11121-009-0127-z PubMedGoogle ScholarCrossref
34.
Marrazzo  JM, Thomas  KK, Agnew  K, Ringwood  K.  Prevalence and risks for bacterial vaginosis in women who have sex with women.   Sex Transm Dis. 2010;37(5):335-339. doi:10.1097/OLQ.0b013e3181ca3cac PubMedGoogle Scholar
35.
Marrazzo  JM, Thomas  KK, Fiedler  TL, Ringwood  K, Fredricks  DN.  Relationship of specific vaginal bacteria and bacterial vaginosis treatment failure in women who have sex with women.   Ann Intern Med. 2008;149(1):20-28. doi:10.7326/0003-4819-149-1-200807010-00006 PubMedGoogle ScholarCrossref
36.
Marrazzo  JM, Thomas  KK, Ringwood  K.  A behavioural intervention to reduce persistence of bacterial vaginosis among women who report sex with women.   Sex Transm Infect. 2011;87(5):399-405. doi:10.1136/sti.2011.049213 PubMedGoogle ScholarCrossref
37.
Melendez  RM, Hoffman  S, Exner  T, Leu  CS, Ehrhardt  AA.  Intimate partner violence and safer sex negotiation: effects of a gender-specific intervention.   Arch Sex Behav. 2003;32(6):499-511. doi:10.1023/A:1026081309709 PubMedGoogle ScholarCrossref
38.
Metsch  LR, Feaster  DJ, Gooden  L,  et al.  Effect of risk-reduction counseling with rapid HIV testing on risk of acquiring sexually transmitted infections: the AWARE randomized clinical trial.   JAMA. 2013;310(16):1701-1710. doi:10.1001/jama.2013.280034 PubMedGoogle ScholarCrossref
39.
Milhausen  RR, DiClemente  RJ, Lang  DL, Spitalnick  JS, Sales  JM, Hardin  JW.  Frequency of sex after an intervention to decrease sexual risk-taking among African-American adolescent girls.   Sex Educ. 2008;8:47-57. doi:10.1080/14681810701811803 Google ScholarCrossref
40.
Miller  S, Exner  TM, Williams  SP, Ehrhardt  AA.  A gender-specific intervention for at-risk women in the USA.   AIDS Care. 2000;12(5):603-612. doi:10.1080/095401200750003789 PubMedGoogle ScholarCrossref
41.
Mittal  M, Senn  TE, Carey  MP.  Mediators of the relation between partner violence and sexual risk behavior among women attending a sexually transmitted disease clinic.   Sex Transm Dis. 2011;38(6):510-515. doi:10.1097/OLQ.0b013e318207f59b PubMedGoogle Scholar
42.
Neumann  MS, O’Donnell  L, Doval  AS,  et al.  Effectiveness of the VOICES/VOCES sexually transmitted disease/human immunodeficiency virus prevention intervention when administered by health department staff: does it work in the “real world”?   Sex Transm Dis. 2011;38(2):133-139. doi:10.1097/OLQ.0b013e3181f0c051 PubMedGoogle ScholarCrossref
43.
O’Leary  A, Jemmott  LS, Jemmott  JB.  Mediation analysis of an effective sexual risk-reduction intervention for women: the importance of self-efficacy.   Health Psychol. 2008;27(2S)(suppl):S180-S184. doi:10.1037/0278-6133.27.2(Suppl.).S180 PubMedGoogle ScholarCrossref
44.
Peipert  J, Redding  CA, Blume  J,  et al.  Design of a stage-matched intervention trial to increase dual method contraceptive use (Project PROTECT).   Contemp Clin Trials. 2007;28(5):626-637. doi:10.1016/j.cct.2007.01.012 PubMedGoogle ScholarCrossref
45.
Peipert  JF, Redding  CA, Blume  JD,  et al.  Tailored intervention to increase dual-contraceptive method use: a randomized trial to reduce unintended pregnancies and sexually transmitted infections.   Am J Obstet Gynecol. 2008;198(6):630.e1-630.e8. doi:10.1016/j.ajog.2008.01.038 PubMedGoogle ScholarCrossref
46.
Petersen  R, Albright  J, Garrett  JM, Curtis  KM.  Pregnancy and STD prevention counseling using an adaptation of motivational interviewing: a randomized controlled trial.   Perspect Sex Reprod Health. 2007;39(1):21-28. doi:10.1363/3902107 PubMedGoogle ScholarCrossref
47.
Proude  EM, D’Este  C, Ward  JE.  Randomized trial in family practice of a brief intervention to reduce STI risk in young adults.   Fam Pract. 2004;21(5):537-544. doi:10.1093/fampra/cmh510 PubMedGoogle ScholarCrossref
48.
Sales  JM, Lang  DL, Hardin  JW, Diclemente  RJ, Wingood  GM.  Efficacy of an HIV prevention program among African American female adolescents reporting high depressive symptomatology.   J Womens Health (Larchmt). 2010;19(2):219-227. doi:10.1089/jwh.2008.1326 PubMedGoogle ScholarCrossref
49.
Scholes  D, McBride  CM, Grothaus  L,  et al.  A tailored minimal self-help intervention to promote condom use in young women.   AIDS. 2003;17(10):1547-1556. doi:10.1097/00002030-200307040-00016 PubMedGoogle ScholarCrossref
50.
Shain  RN, Piper  JM, Holden  AE,  et al.  Prevention of gonorrhea and chlamydia through behavioral intervention.   Sex Transm Dis. 2004;31(7):401-408. doi:10.1097/01.olq.0000135301.97350.84 PubMedGoogle ScholarCrossref
51.
Warner  L, Klausner  JD, Rietmeijer  CA,  et al; Safe in the City Study Group.  Effect of a brief video intervention on incident infection among patients attending sexually transmitted disease clinics.   PLoS Med. 2008;5(6):e135. doi:10.1371/journal.pmed.0050135 PubMedGoogle Scholar
52.
Wingood  GM, DiClemente  RJ, Harrington  KF,  et al.  Efficacy of an HIV prevention program among female adolescents experiencing gender-based violence.   Am J Public Health. 2006;96(6):1085-1090. doi:10.2105/AJPH.2004.053595 PubMedGoogle ScholarCrossref
53.
Wingood  GM, Diclemente  RJ, Robinson-Simpson  L, Lang  DL, Caliendo  A, Hardin  JW.  Efficacy of an HIV intervention in reducing high-risk human papillomavirus, nonviral sexually transmitted infections, and concurrency among African American women: a randomized-controlled trial.   J Acquir Immune Defic Syndr. 2013;63(suppl 1):S36-S43. doi:10.1097/QAI.0b013e3182920031 PubMedGoogle ScholarCrossref
54.
Card  JJ, Benner  TA, eds.  Model Programs for Adolescent Sexual Health: Evidence-based HIV, STI and Pregnancy Prevention Interventions. Springer; 2008:253-260.
55.
Lewis  MA, Rhew  IC, Fairlie  AM, Swanson  A, Anderson  J, Kaysen  D.  Evaluating personalized feedback intervention framing with a randomized controlled trial to reduce young adult alcohol-related sexual risk taking.   Prev Sci. 2019;20(3):310-320. doi:10.1007/s11121-018-0879-4PubMedGoogle ScholarCrossref
56.
Morrison-Beedy  D, Crean  HF, Passmore  D, Carey  MP.  Risk reduction strategies used by urban adolescent girls in an HIV prevention trial.   Curr HIV Res. 2013;11(7):559-569. doi:10.2174/1570162X12666140129110129 PubMedGoogle ScholarCrossref
57.
Mittal  M, Senn  TE, Carey  MP.  Fear of violent consequences and condom use among women attending an STD clinic.   Women Health. 2013;53(8):795-807. doi:10.1080/03630242.2013.847890 PubMedGoogle ScholarCrossref
58.
Morrison-Beedy  D, Jones  SH, Xia  Y, Tu  X, Crean  HF, Carey  MP.  Reducing sexual risk behavior in adolescent girls.   J Adolesc Health. 2013;52(3):314-321. doi:10.1016/j.jadohealth.2012.07.005 PubMedGoogle ScholarCrossref
59.
Sanci  L, Chondros  P, Sawyer  S,  et al.  Responding to young people’s health risks in primary care: a cluster randomised trial of training clinicians in screening and motivational interviewing.   PLoS One. 2015;10(9):e0137581. doi:10.1371/journal.pone.0137581 PubMedGoogle Scholar
60.
Bailey  JV, Webster  R, Hunter  R,  et al.  The Men’s Safer Sex project: intervention development and feasibility randomised controlled trial of an interactive digital intervention to increase condom use in men.   Health Technol Assess. 2016;20(91):1-124. doi:10.3310/hta20910 PubMedGoogle ScholarCrossref
61.
Free  C, McCarthy  O, French  RS,  et al.  Can text messages increase safer sex behaviours in young people? intervention development and pilot randomised controlled trial.   Health Technol Assess. 2016;20(57):1-82. doi:10.3310/hta20570 PubMedGoogle ScholarCrossref
62.
Besera  GT, Cox  S, Malotte  CK,  et al.  Assessing patient exposure to a video-based intervention in STD clinic waiting rooms: findings from the Safe in the City trial.   Health Promot Pract. 2016;17(5):731-738. doi:10.1177/1524839916631537 PubMedGoogle ScholarCrossref
63.
Recto  P, Champion  JD.  Psychological distress and associated factors among Mexican American adolescent females.   Hisp Health Care Int. 2016;14(4):170-176. doi:10.1177/1540415316676224 PubMedGoogle ScholarCrossref
64.
Gallo  MF, Margolis  AD, Malotte  CK,  et al; Safe in the City Study Group.  Sexual abstinence and other behaviours immediately following a new STI diagnosis among STI clinic patients: findings from the Safe in the City trial.   Sex Transm Infect. 2016;92(3):206-210. doi:10.1136/sextrans-2014-051982 PubMedGoogle ScholarCrossref
65.
Gift  TL, OʼDonnell  LN, Rietmeijer  CA,  et al; Safe in the City Study Group.  The program cost of a brief video intervention shown in sexually transmitted disease clinic waiting rooms.   Sex Transm Dis. 2016;43(1):61-64. doi:10.1097/OLQ.0000000000000388 PubMedGoogle ScholarCrossref
66.
Mittal  M, Thevenet-Morrison  K, Landau  J,  et al.  An integrated HIV risk reduction intervention for women with a history of intimate partner violence: pilot test results.   AIDS Behav. 2017;21(8):2219-2232. doi:10.1007/s10461-016-1427-5 PubMedGoogle ScholarCrossref
67.
Ybarra  ML, Prescott  TL, Phillips  GL  II, Bull  SS, Parsons  JT, Mustanski  B.  Pilot RCT results of an mHealth HIV prevention program for sexual minority male adolescents.   Pediatrics. 2017;140(1):e20162999. doi:10.1542/peds.2016-2999 PubMedGoogle Scholar
68.
Costa  EC, McIntyre  T, Trovisqueira  A, Hobfoll  SE.  Comparison of two psycho-educational interventions aimed at preventing HIV and promoting sexual health among Portuguese women.   Int J Sex Health. 2017;29(3):258-272. doi:10.1080/19317611.2017.1307300 Google ScholarCrossref
69.
Tzilos Wernette  G, Plegue  M, Kahler  CW, Sen  A, Zlotnick  C.  A pilot randomized controlled trial of a computer-delivered brief intervention for substance use and risky sex during pregnancy.   J Womens Health (Larchmt). 2018;27(1):83-92. doi:10.1089/jwh.2017.6408 PubMedGoogle ScholarCrossref
70.
Peragallo Montano  N, Cianelli  R, Villegas  N, Gonzalez-Guarda  R, Williams  WO, de Tantillo  L.  Evaluating a culturally tailored HIV risk reduction intervention among Hispanic women delivered in a real-world setting by community agency personnel.   Am J Health Promot. 2019;33(4):566-575. doi:10.1177/0890117118807716 PubMedGoogle ScholarCrossref
71.
Whiteley  LB, Brown  LK, Curtis  V, Ryoo  HJ, Beausoleil  N.  Publicly available internet content as a HIV/STI prevention intervention for urban youth.   J Prim Prev. 2018;39(4):361-370. doi:10.1007/s10935-018-0514-y PubMedGoogle ScholarCrossref
72.
Bai  S, Zeledon  LR, D’Amico  EJ,  et al.  Reducing health risk behaviors and improving depression in adolescents.   J Pediatr Psychol. 2018;43(9):1004-1016. doi:10.1093/jpepsy/jsy048 PubMedGoogle ScholarCrossref
73.
O’Cleirigh  C, Safren  SA, Taylor  SW,  et al.  Cognitive Behavioral Therapy for Trauma and Self-Care (CBT-TSC) in men who have sex with men with a history of childhood sexual abuse: a randomized controlled trial.   AIDS Behav. 2019;23(9):2421-2431. doi:10.1007/s10461-019-02482-zPubMedGoogle ScholarCrossref
74.
Redding  CA, Prochaska  JO, Armstrong  K,  et al.  Randomized trial outcomes of a TTM-tailored condom use and smoking intervention in urban adolescent females.   Health Educ Res. 2015;30(1):162-178. doi:10.1093/her/cyu015 PubMedGoogle ScholarCrossref
75.
Shafii  T, Benson  SK, Morrison  DM, Hughes  JP, Golden  MR, Holmes  KK.  Results from e-KISS: electronic-KIOSK Intervention for Safer Sex: a pilot randomized controlled trial of an interactive computer-based intervention for sexual health in adolescents and young adults.   PLoS One. 2019;14(1):e0209064. doi:10.1371/journal.pone.0209064 PubMedGoogle Scholar
76.
Magill  M, Hallgren  KA.  Mechanisms of behavior change in motivational interviewing: do we understand how MI works?   Curr Opin Psychol. 2019;30:1-5. doi:10.1016/j.copsyc.2018.12.010 PubMedGoogle ScholarCrossref
77.
Magill  M, Apodaca  TR, Borsari  B,  et al.  A meta-analysis of motivational interviewing process: technical, relational, and conditional process models of change.   J Consult Clin Psychol. 2018;86(2):140-157. doi:10.1037/ccp0000250 PubMedGoogle ScholarCrossref
78.
Wenzel  A.  Basic strategies of cognitive behavioral therapy.   Psychiatr Clin North Am. 2017;40(4):597-609. doi:10.1016/j.psc.2017.07.001 PubMedGoogle ScholarCrossref
79.
Petrova  D, Garcia-Retamero  R.  Effective evidence-based programs for preventing sexually-transmitted infections: a meta-analysis.   Curr HIV Res. 2015;13(5):432-438. doi:10.2174/1570162X13666150511143943 PubMedGoogle ScholarCrossref
80.
Ruiz-Perez  I, Murphy  M, Pastor-Moreno  G, Rojas-García  A, Rodríguez-Barranco  M.  The effectiveness of HIV prevention interventions in socioeconomically disadvantaged ethnic minority women.   Am J Public Health. 2017;107(12):e13-e21. doi:10.2105/AJPH.2017.304067 PubMedGoogle ScholarCrossref
81.
Marcell  AV, Gibbs  S, Lehmann  HP.  Brief condom interventions targeting males in clinical settings: a meta-analysis.   Contraception. 2016;93(2):153-163. doi:10.1016/j.contraception.2015.09.009 PubMedGoogle ScholarCrossref
82.
O’Connor  E, Lin  JS, Burda  BU, Henderson  JT, Walsh  ES, Whitlock  EP.  Behavioral Sexual Risk Reduction Counseling in Primary Care to Prevent Sexually Transmitted Infections: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality; 2014.
83.
DiClemente  RJ, Wingood  GM, Rose  ES,  et al.  Efficacy of sexually transmitted disease/human immunodeficiency virus sexual risk-reduction intervention for African American adolescent females seeking sexual health services.   Arch Pediatr Adolesc Med. 2009;163(12):1112-1121. doi:10.1001/archpediatrics.2009.205 PubMedGoogle ScholarCrossref
84.
DiClemente  RJ, Wingood  GM, Sales  JM,  et al.  Efficacy of a telephone-delivered sexually transmitted infection/human immunodeficiency virus prevention maintenance intervention for adolescents.   JAMA Pediatr. 2014;168(10):938-946. doi:10.1001/jamapediatrics.2014.1436 PubMedGoogle ScholarCrossref
85.
Rhodes  SD, Alonzo  J, Mann  L,  et al.  Small-group randomized controlled trial to increase condom use and HIV testing among Hispanic/Latino gay, bisexual, and other men who have sex with men.   Am J Public Health. 2017;107(6):969-976. doi:10.2105/AJPH.2017.303814 PubMedGoogle ScholarCrossref
86.
Community Preventive Services Task Force. HIV, STIs and teen pregnancy. The Community Guide. Accessed January 9, 2020. https://www.thecommunityguide.org/topic/hiv-stis-and-teen-pregnancy
87.
Guilamo-Ramos  V, Benzekri  A, Thimm-Kaiser  M,  et al.  A triadic intervention for adolescent sexual health.   Pediatrics. 2020;145(5):e20192808. doi:10.1542/peds.2019-2808 PubMedGoogle Scholar
88.
Harvey  SM, Washburn  I, Oakley  L, Warren  J, Sanchez  D.  Competing priorities: partner-specific relationship characteristics and motives for condom use among at-risk young adults.   J Sex Res. 2017;54(4-5):665-676. doi:10.1080/00224499.2016.1182961 PubMedGoogle ScholarCrossref
89.
El-Bassel  N, Gilbert  L, Witte  S, Wu  E, Hunt  T, Remien  RH.  Couple-based HIV prevention in the United States.   J Acquir Immune Defic Syndr. 2010;55(suppl 2):S98-S101. doi:10.1097/QAI.0b013e3181fbf407 PubMedGoogle ScholarCrossref
90.
Crosby  RA, Charnigo  RJ, Salazar  LF,  et al.  Enhancing condom use among Black male youths: a randomized controlled trial.   Am J Public Health. 2014;104(11):2219-2225. doi:10.2105/AJPH.2014.302131 PubMedGoogle ScholarCrossref
91.
Kennedy  SB, Nolen  S, Pan  Z, Smith  B, Applewhite  J, Vanderhoff  KJ.  Effectiveness of a brief condom promotion program in reducing risky sexual behaviours among African American men.   J Eval Clin Pract. 2013;19(2):408-413. doi:10.1111/j.1365-2753.2012.01841.x PubMedGoogle ScholarCrossref
92.
Hidalgo  MA, Kuhns  LM, Hotton  AL, Johnson  AK, Mustanski  B, Garofalo  R.  The MyPEEPS randomized controlled trial: a pilot of preliminary efficacy, feasibility, and acceptability of a group-level, HIV risk reduction intervention for young men who have sex with men.   Arch Sex Behav. 2015;44(2):475-485. doi:10.1007/s10508-014-0347-6 PubMedGoogle ScholarCrossref
93.
Koblin  BA, Bonner  S, Powell  B,  et al.  A randomized trial of a behavioral intervention for black MSM: the DiSH study.   AIDS. 2012;26(4):483-488. doi:10.1097/QAD.0b013e32834f9833 PubMedGoogle ScholarCrossref
94.
Kurtz  SP, Stall  RD, Buttram  ME, Surratt  HL, Chen  M.  A randomized trial of a behavioral intervention for high risk substance-using MSM.   AIDS Behav. 2013;17(9):2914-2926. doi:10.1007/s10461-013-0531-z PubMedGoogle ScholarCrossref
95.
Parsons  JT, Lelutiu-Weinberger  C, Botsko  M, Golub  SA.  A randomized controlled trial utilizing motivational interviewing to reduce HIV risk and drug use in young gay and bisexual men.   J Consult Clin Psychol. 2014;82(1):9-18. doi:10.1037/a0035311 PubMedGoogle ScholarCrossref
96.
Mustanski  B, Garofalo  R, Monahan  C, Gratzer  B, Andrews  R.  Feasibility, acceptability, and preliminary efficacy of an online HIV prevention program for diverse young men who have sex with men: the Keep It Up! intervention.   AIDS Behav. 2013;17(9):2999-3012. doi:10.1007/s10461-013-0507-z PubMedGoogle ScholarCrossref
97.
Harawa  NT, Williams  JK, McCuller  WJ,  et al.  Efficacy of a culturally congruent HIV risk-reduction intervention for behaviorally bisexual black men: results of a randomized trial.   AIDS. 2013;27(12):1979-1988. doi:10.1097/QAD.0b013e3283617500 PubMedGoogle ScholarCrossref
98.
Lauby  J, Milnamow  M, Joseph  HA,  et al.  Evaluation of Project RISE, an HIV prevention intervention for black bisexual men using an ecosystems approach.   AIDS Behav. 2018;22(1):164-177. doi:10.1007/s10461-017-1892-5 PubMedGoogle ScholarCrossref
99.
Operario  D, Gamarel  KE, Iwamoto  M,  et al.  Couples-focused prevention program to reduce HIV risk among transgender women and their primary male partners.   AIDS Behav. 2017;21(8):2452-2463. doi:10.1007/s10461-016-1462-2 PubMedGoogle ScholarCrossref
100.
Thompson  RG  Jr, Elliott  JC, Hu  MC, Aivadyan  C, Aharonovich  E, Hasin  DS.  Short-term effects of a brief intervention to reduce alcohol use and sexual risk among homeless young adults.   Addict Res Theory. 2017;25(1):24-31. doi:10.1080/16066359.2016.1193165 PubMedGoogle ScholarCrossref
101.
Hunter  P, Dalby  J, Marks  J, Swain  GR, Schrager  S.  Screening and prevention of sexually transmitted infections.   Prim Care. 2014;41(2):215-237. doi:10.1016/j.pop.2014.02.003 PubMedGoogle ScholarCrossref
102.
Rao  A, Tobin  K, Davey-Rothwell  M, Latkin  CA.  Social desirability bias and prevalence of sexual HIV risk behaviors among people who use drugs in Baltimore, Maryland: implications for identifying individuals prone to underreporting sexual risk behaviors.   AIDS Behav. 2017;21(7):2207-2214. doi:10.1007/s10461-017-1792-8 PubMedGoogle ScholarCrossref
103.
Rose  E, Diclemente  RJ, Wingood  GM,  et al.  The validity of teens’ and young adults’ self-reported condom use.   Arch Pediatr Adolesc Med. 2009;163(1):61-64. doi:10.1001/archpediatrics.2008.509 PubMedGoogle ScholarCrossref
US Preventive Services Task Force
Evidence Report
August 18, 2020

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

Author Affiliations
  • 1Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
JAMA. 2020;324(7):682-699. doi:10.1001/jama.2020.10371
Abstract

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

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

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

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

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

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

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

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

Introduction

In 2008 the Centers for Disease Control and Prevention estimated that more than 20 million sexually transmitted infections (STIs) occur each year in the US.1 Surveillance data since then, and especially from 2014 to 2018, indicate substantial increases in the incidence of most STIs,2 including syphilis and gonorrhea, that were previously rare or declining.3 STI incidence is highest among adolescents and young adults.1 For example, 61% of the 1.1 million cases of chlamydia reported in 2018 in the US were among individuals aged 15 to 24 years.3 The high rates of STI in the US contribute to chronic disease, cancer, infertility, adverse birth outcomes, and mortality, posing a substantial burden to population health.3 Reported disparities in STI rates by region of the country, age, race, ethnicity, and sexual orientation are attributed to structural and social conditions, sexual behavior, and unequal access to health care, education, and public health programs.4,5

Primary care clinicians have an important role in primary and secondary prevention of STIs. In addition to providing recommended STI screening and treatments, primary care clinicians can identify patients at increased risk for STIs by obtaining comprehensive sexual histories.2,6 In 2014 the US Preventive Services Task Force (USPSTF) recommended intensive behavioral counseling for all sexually active adolescents and for adults at an increased risk for sexually transmitted infections (B recommendation).7,8 The current review of the evidence on behavioral counseling interventions for STI prevention was conducted to inform a USPSTF update to its current recommendation.

Methods
Scope of Review

An analytic framework was developed with 3 key questions (KQs) (Figure 1) that examined the effectiveness of behavioral counseling interventions in reducing STIs, related morbidity and mortality, or other health outcomes (KQ1); decreasing risky sexual behaviors or increasing protective behaviors (KQ2); and potential harms of behavioral counseling interventions (KQ3). Additional methodological details are publicly available in the full evidence report.10

Data Sources and Searches

To identify studies published since the previous review,8 literature searches were conducted from January 2013 through May 31, 2019, in MEDLINE, PubMed (for publisher-supplied records only), PsycINFO, and the Cochrane Central Register of Controlled Trials (eMethods in the Supplement). Additional studies were located by reviewing reference lists of other systematic reviews and through suggestions from experts. Ongoing surveillance was conducted after May 2019 through May 22, 2020, to identify newly published studies that might affect the findings of the review. This was accomplished through article alerts and targeted searches of journals with a high impact factor and journals relevant to the topic. The last surveillance on May 22, 2020, identified no new studies.

Study Selection

Two reviewers independently evaluated articles from the previous review in addition to citations and full-text articles from the literature searches against prespecified inclusion criteria (Figure 2 and eTable 1 in the Supplement). Given changes to the medical and social context of STI risk and prevention, studies from the previous review published more than 20 years ago (years 1999 or earlier) were not included. For all KQs, included studies were required to target sexual behavior change to prevent STIs. Studies among adults and adolescents, including those who were pregnant, were included. Studies that included people living with HIV were not excluded unless the study population and intervention was focused solely on HIV-positive populations. Studies that focused solely on behavior change to prevent unintended pregnancy or change behaviors such as drug and alcohol use associated with risky sexual behavior were not included. Additionally, studies limited to populations requiring complex, specialized interventions outside the scope of primary care to address their specific STI risk (eg, HIV-serodiscordant couples, commercial sex workers) were not included in the review. Randomized clinical trials (RCTs) and nonrandomized controlled intervention studies involving behavioral counseling to prevent or reduce STIs were included. Trials that assessed effectiveness of circumcision for HIV prevention, STI testing only, biomedical prevention interventions, or those conducted within closed or preexisting social networks were not included.

Studies were required to have outcomes assessed at 3 months’ postbaseline or longer and be conducted in or recruited from general primary care settings and other preventive care outpatient settings, including family planning clinics, STI clinics, school-based health clinics, and behavioral/mental health clinics. Studies were limited to those conducted in countries categorized as “very high” on the Human Development Index (2016) published by the United Nations Development Programme.11 Included studies were limited to those published in English and deemed good or fair quality based on USPSTF quality rating standards.9

Data Extraction and Quality Assessment

Two reviewers applied USPSTF design-specific criteria9 to assess the methodological quality of all eligible studies, and each study was assigned a quality rating of “good,” “fair,” or “poor” (eTable 2 in the Supplement). Discordant quality ratings were resolved by discussion or by a third reviewer and adjudicated as needed. Studies rated as poor quality were excluded from the review. Good-quality RCTs were those that met all or nearly all the prespecified quality criteria. Fair-quality studies did not meet all criteria but did not have serious threats to their internal validity related to design, execution, or reporting. Intervention studies rated as poor quality generally had several important limitations, including at least 1 of the following risks of bias: very high attrition (defined as >40%); differential attrition between intervention groups (defined as >20%); lack of baseline comparability between groups without adjustment; or problematic issues in trial conduct, analysis, or reporting of results. One reviewer extracted data from all included studies rated as fair- or good quality directly into evidence tables, and a second reviewer checked the data for accuracy.

Data Synthesis and Analysis

Data were synthesized separately for each KQ, and tables were created to describe study results for all included outcomes, with stratification by intervention and study population characteristics. Narrative summary and summary tables were used to describe important features of the included evidence, including study design and setting, interval validity, and important characteristics about patients and interventions. Based on a priori plans to evaluate differences in intervention effects by age, 2 sets of data tables were prepared—1 set for studies focused on adolescent and young adult populations and the second for those on adult populations. Age categories represented broad age spans of included populations. To examine age effects, within-study age-specific subgroup analyses were extracted when available, regardless of the subgroup comparison methods.

Meta-analyses of STI incidence, condom use, and unprotected intercourse were conducted. The DerSimonian and Laird model was used for pooling odd ratios (ORs) of STI incidence. Adjusted study-reported ORs were used if reported, and ORs were calculated based on the reported proportion of participants with an STI in each group if adjusted differences were not reported or results were presented in a format that could not be combined for meta-analysis of ORs (eg, hazard ratios). A funnel plot was created and an Egger test was conducted to explore small-study effects, which can be related to publication bias.12 Additionally, meta-regression and subgroup analyses were conducted to explore factors associated with effect size. Because fewer than 10 trials could be included in these analyses and statistical heterogeneity was fairly high (I2 = 50% and higher), restricted maximum likelihood models were run with the Knapp-Hartung correction for small samples, because the DerSimonian and Laird method tends to underestimate the width of the 95% CI when the number of studies is small or statistical heterogeneity is high.13 Several factors were examined as potential effect modifiers, including but not limited to recruitment setting (eg, STI clinic vs other settings), participant characteristics (eg, whether the study was limited to adolescents or young adults, whether the study was limited to male or female participants only), amount of intervention contact time (eg, length and number of sessions), modality (eg, in-person individual or group counseling), administrator (eg, licensed health professional), and study design features (eg, type of control). Analyses to assess the sensitivity of pooled effects to individual studies or types of studies—for example, those unique in terms of reported STI outcomes or study design—were conducted when potential outliers were identified.

For KQ1, STI outcomes based on laboratory-confirmed clinical tests, conducted as part of the study, recorded in the medical records of study participants, and/or found in public health surveillance registries were analyzed. A few studies reported incidence of a specific STI, while others considered intervention effects on the diagnosis of any STI. For meta-analysis, these outcomes were combined. The follow-up periods ranged from 6 to 24 months; when several time points were reported, those closest to 12 months were included in the meta-analysis. For KQ2, condom use outcomes were reported using a variety of measures. A pooled analysis of dichotomous condom use measures was conducted, with selection based on any of the following in order of preference: consistent condom use (variably defined), condom use at last intercourse, any condom use, and condom used at first intercourse with new partners. Female condom use was included for this outcome and was reported in 1 trial.14

Stata version 15.1 (StataCorp LP) was used for all analyses. All significance testing was 2-sided, and results were considered statistically significant at P < .05.

The strength of evidence was rated for each KQ based on consistency (similarity of effect direction and size), precision (degree of certainty around an estimate), reporting bias (potential for bias related to publication, selective outcome reporting, or selective analysis reporting), and study quality (ie, study limitations).

Results

Two reviewers evaluated 4649 citations and 273 full-text articles against inclusion criteria, and 39 studies (62 articles)14-75 met inclusion criteria for this systematic review (Figure 2). Twenty-two studies (20 RCTs14,17-20,23-25,28,30-32,36,38,45-47,49,50,53; 2 nonrandomized controlled intervention studies42,51) were carried forward from the previous USPSTF report, and 17 new RCTs15,16,55,58-61,66-75 were identified for inclusion (Table 1, Table 2, Table 3, Table 4). The newly available studies included 4 conducted among adolescents,58,67,72,74 5 conducted among a mix of adolescents and young adults,59,61,68,71,75 and 1 focused solely on young adults.55 The remaining 7 enrolled mostly adults and spanned a wider age range.15,16,60,66,69,70,73 Among the studies of adults and mixed-age populations, the mean age of participants was younger than 30 years in most studies, and none reported a mean age of 40 years or older. Thus, among studies that included adults, young adults (ie, aged 18-25 years) were most often recruited. Of the 39 included studies, 35 (90%) tested intervention effectiveness among individuals at an increased risk for an STI, including some participants with a recent STI diagnosis. Characteristics used to identify trial participants at increased risk for acquiring an STI included demographic characteristics associated with higher prevalence of STI in the US (eg, aged 15 to 24 years, African American race, Hispanic ethnicity), self-reported sexual and behavioral factors associated with STI risk (eg, men who have sex with men [MSM], multiple partners, unprotected intercourse), and personal health history (eg, recent STI or visit to STI clinic).

Most interventions were conducted in the following health care settings: general primary care, obstetrics and gynecology, STI clinics, women’s health clinics, adolescent medicine, and family planning clinics (eTables 3 and 4 in the Supplement). Nine studies20,31,47,49,51,55,60,71,75 included a low–contact time intervention group (<30 minutes), 1315-17,24,28,36,38,42,45,46,61,68,69 included a moderate–contact time intervention group (30-120 minutes), and more than half (21/39 [54%])14,17-20,23,25,30-32,50,53,58,59,66-68,70,72-74 tested a high–contact time intervention group (>2 hours) (eTable 5 in the Supplement). The most common therapeutic approach in the included interventions was motivational interviewing,76,77 which was used in 11 studies16,19,20,23,36,46,69,72,74,75; another 7 studies used cognitive behavioral therapy approaches.17,30,50,53,68,72,73,78 Group counseling was the most common intervention component and was used in 25 intervention groups. Group counseling was frequently paired with other treatment components, such as individual counseling, videos, video games, or telephone contact. In most studies of group counseling, participants were of the same gender. Fourteen of the intervention groups primarily involved mobile-phone text or computer interventions, and all but 2 of these involved low or moderate contact times ranging from 5 to 90 minutes.15,16,19,45,55,60,61,67,69,71,74,75

Benefits on Health Outcomes

Key Question 1. Do behavioral counseling interventions that aim to decrease risky sexual behaviors or increase protective behaviors, or both, reduce sexually transmitted infections (STIs) or related morbidity and mortality?

Key Question 1a. Does the effectiveness of behavioral counseling interventions differ for subpopulations (eg, defined by age, STI history, sexual orientation, gender, pregnancy status)?

Key Question 1b. Does the effectiveness of behavioral counseling interventions differ by intervention characteristics (eg, intensity or mode)?

No studies reported intervention effects on STI morbidity or mortality, but 21 included studies16,17,20,23-25,30-32,36,38,42,45,46,50,51,53,60,61,69,75 (n = 59 328) reported on the effectiveness of behavioral interventions for preventing STI, nearly all were conducted among populations at increased risk (20/21 [95%]), and 19 reported measures that could be combined for meta-analysis (eTables 6 and 7 in the Supplement). These interventions were significantly associated with a lower incidence of STI at follow-up, most often reported at 6 to 12 months, with an overall pooled OR of 0.66 (95% CI, 0.54-0.81; I2 = 74%; n = 52 072) (Figure 3). Only 4 studies16,36,38,69 reported higher absolute STI rates in the control condition, but the rates were not significantly different from rates in the intervention groups. STI incidence rates were highly variable across studies; control group rates ranged from 0% to 50%, while intervention group rates ranged from 0% to 37%. Statistical heterogeneity was substantial, and there was also considerable clinical heterogeneity, particularly in terms of populations and intervention characteristics. Planned subgroup comparisons were conducted to examine sources of heterogeneity (described below). A sensitivity analysis excluding a study of bacterial vaginosis prevention among lesbian and bisexual women did not change the overall result (pooled OR, 0.65 [95% CI, 0.52-0.80]; I2 = 75.3%; 18 studies).

Rigorous tests of intervention effectiveness for different subpopulations within trials were not reported. One trial51 reported several prespecified exploratory subgroup comparisons but did not test for interactions or account for multiple comparisons, while other trials presented post hoc exploratory subgroup comparisons67 or secondary analyses on a subset of trial participants.25 Instead, most of the included evidence focused exclusively on a specific subpopulation defined by sex, age, sexual history, pregnancy status, and racial/ethnic identity. Some subpopulations were not well-represented in the body of evidence; for example, only 2 included studies32,69 recruited participants for interventions occurring during pregnancy. Many of the interventions designed for specific subpopulations were found to be effective, such as those for African American and Latina adolescents, adult minority women, and mixed-gender populations making visits to STI clinics. Trials among men, adolescent boys, MSM, and average risk populations were not well-represented in the body of evidence. Based on meta-regression tests for subgroup effects for STI prevention, larger effect sizes were associated with studies conducted among adolescents (P = .002), high-contact interventions (more than 2 hours compared with 2 hours or less) (P = .02), or group counseling sessions (P = .02) (eTable 12 in the Supplement). Overall, subgroup comparisons tended to include few studies in at least 1 category, and confounding of study population and intervention characteristics limited conclusions about which specific factors were responsible for intervention effectiveness.

Benefits on Behavioral Outcomes

Key Question 2. Do behavioral counseling interventions decrease risky sexual behaviors or increase protective behaviors that can reduce the risk of STIs?

Key Question 2a.Does the effectiveness of behavioral counseling interventions differ for subpopulations (eg, defined by age, STI history, sexual orientation, gender, pregnancy status)?

Key Question 2b. Does the effectiveness of behavioral counseling interventions differ by intervention characteristics (eg, intensity or mode)?

In total, 34 studies (n = 21 471) contributed evidence on the effectiveness of behavioral counseling interventions in changing a variety of sexual risk and protective behaviors (eTables 8 and 9 in the Supplement). Like the studies reporting STI outcomes, most of included evidence (30/34 [88%]) was from studies of people at increased risk for STI. Follow-up time in the studies reporting behavioral outcomes ranged from 3 to 14 months (mode, 12 months), and for the few studies reporting extended follow-up beyond 1 year, effects tended to diminish. Statistical heterogeneity was modest, but clinical heterogeneity was high because of the diverse populations and intervention approaches. Behavioral outcomes were not consistently reported, and measures were variable.

Eighteen14,15,17,18,24,25,31,32,45-47,49,55,58,61,68,70,74 studies reported on the effectiveness of behavioral interventions for condom use. Of these, 13 studies14,17,24,25,31,45,47,49,55,58,61,70,74 (n = 5253) reported dichotomous condom-use outcomes with measures that were pooled for meta-analysis (Table 5; eTables 8 and 9 in the Supplement). The pooled result across these studies suggested that the intervention was associated with a higher odds of condom use (OR, 1.31 [95% CI, 1.10-1.56]; I2 = 40%) (Table 5).The percentage reporting condom use varied depending on the measure reported (eg, condom use at last sex, consistent condom use). Absolute differences between groups ranged from –7% to 27%. Eight17,24,25,31,32,45,46,61 of the studies reporting condom use outcomes also reported STI incidence, and the direction and statistical significance of effects were internally consistent; studies with higher levels of reported behavioral changes found greater reductions in STI diagnoses.

Twenty-one studies (n = 13 665) reported a measure of unprotected intercourse (eTables 8 and 9 in the Supplement). Of these, 14 studies (n = 9183)15,16,19,20,24,25,30-32,38,58,67,70,73 reported the number of times participants engaged in unprotected sexual intercourse or intercourse without a condom over various time frames, with different degrees of specificity regarding the type of partner or sexual intercourse act. When combined to estimate an overall association, there was a small but statistically significant difference between groups. Fewer unprotected intercourse occasions were reported among those assigned to the intervention conditions (pooled mean difference, –0.94 [95% CI, –1.40 to –0.48]; I2 = 16%) (Table 5).

Other behavioral outcomes, such as the number of sexual partners and sexual abstinence, were reported by fewer studies and tended to be consistent with effects seen for other reported outcomes (eTables 10 and 11 in the Supplement). Only 1 trial tested an intervention aimed at reducing future STI risk before the onset of sexual activity. The moderate–contact-time trial (Families Talking Together) enrolled male and female Hispanic or African American adolescents and their mothers at the time of a pediatric care visit and supported parental communication and education about sexual health.28 At 9 months of follow-up, a lower proportion of adolescents in the intervention group reported ever having had sexual intercourse compared with the control group (6.8% vs 22.2%, P < .05 as reported in primary study).

Evidence on potential subpopulation differences available from within-trial comparisons was limited for the same reasons described above for STI outcomes. Comparisons of effect differences at the study level were not conducted for self-reported behavioral outcomes due to inconsistency in the outcome measures and the relatively small numbers of studies available for subgroup meta-regression analysis.

Harms

Key Question 3. What potential harms are associated with behavioral counseling interventions to reduce STI infections?

Few studies reported potential adverse consequences related to the STI-prevention behavioral interventions that were evaluated, and no evidence of statistically significant intervention harms was identified. Seven trials (n = 3458) reported potentially adverse consequences that might theoretically arise from the behavioral interventions evaluated.17,25,32,45,61,66,75 A study conducted among adolescents and young adults that involved a text-messaging intervention reported 3 driver-caused road traffic crashes related to texting: 2 in the intervention group and 1 in the control group. The study was too small to permit estimation of the difference with any precision, and it was unclear whether the texting associated with the accidents was study related. No other studies relying on text-messaging interventions reported adverse events related to driving and texting.

Discussion

This evidence report reviewed studies on behavioral counseling interventions to prevent STIs; the evidence is summarized by KQ in Table 6. An individual’s risk of acquiring an STI is influenced by many factors, including their sexual practices; relationship dynamics (eg, power and communication); skills, ability, and willingness to engage in health protective behaviors; and the prevalence of untreated STI in their social networks and community. For those at increased risk, behavioral counseling interventions provided in or referred from primary care settings can be effective in changing sexual risk and protective behaviors, lowering the risk of STI diagnosis for up to 1 year.

The randomized trials included in this review recruited participants at increased risk based on their reported sexual risk behaviors, history of STIs, and sociodemographic risk factors, including age and race/ethnicity. Most trials were focused on the prevention of STIs from heterosexual intercourse, with a few exceptions.36,67,73 Increasing the use of male condoms during sex and reducing unprotected sexual intercourse was a primary aim of most interventions. Group and individual counseling provided by trained facilitators or health professionals were commonly included components of interventions, tending to involve more than 2 hours of contact time over the course of several weeks or months. Counseling interventions involving more than 2 hours of contact time may be associated with larger reductions in diagnosed STI at follow-up, although confounding of intervention and population characteristics limited conclusions that could be drawn about differences in effectiveness. Other reviews that have focused on different settings, study designs, and populations in evaluating STI behavioral counseling interventions have reported beneficial effects in a comparable range.79-81

Compared with the 2014 USPSTF review,8 this review included 17 new studies15,16,55,58-61,66-75 and broadly supports the previous conclusions.82 Of the 17 additional studies contributing evidence to this update, just 5 reported STI diagnosis outcomes.16,60,61,69,75 Three of these 5 studies were low– or moderate–contact time interventions using tailored computer-based75 or text messages61 delivered to male and female adolescent and young adult populations or, in the case of a small trial in Great Britain (Men’s Safer Sex), a 10-minute website visit intervention for adult men.60 The previous USPSTF review called for the development and testing of less time-intensive and media-based interventions that might be applicable to broader populations. It is encouraging that there were new studies evaluating low– and moderate–contact time interventions available for the current review. Effect sizes of the newly added low- and moderate-contact interventions were comparable in size to effects seen in high-contact trials and contributed to the overall estimate of the effectiveness of behavioral interventions for STI prevention. Overall, however, the evidence on STI prevention in this review was primarily from previously included trials,23-25,30,31,42,50,51,53 and most of these were high–contact time interventions focused on narrowly defined populations at increased risk for STIs.

Many studies reported outcomes at 12 or more months of follow-up, including several that reported statistically significant differences at 6 months that were no longer observed at 12 months. Thus, for studies reporting shorter follow-up times, it is possible that observed effects would have diminished with longer observation. The sustainability of the intervention effects observed in this review is unclear. Establishing new sexual habits and skills may have lasting effects or may require reinforcement to have continued health benefits. A comparative effectiveness study that was not included in this review, but that tested an adaptation of an included intervention,25 found that ongoing telephone reinforcement was effective for maintaining STI prevention benefits for African American adolescents receiving the HORIZONS intervention.83,84

The review was designed to identify evidence for interventions that can be feasibly implemented in or referred from US-based primary care health care settings. A broader body of evidence on STI prevention programs in the US and globally provides evidence on prevention strategies beyond this context. For example, evidence on interventions evaluated among people identified through social groups or institutions was not reviewed (eg, schools, churches, worksites), so an effective intervention with Latino MSM that recruited individuals from social settings such as bars or dance clubs and involving recruitment of friends was not included.85 Thus, the absence of studies for some important populations at increased risk for STI in this review does not necessarily mean there are no effective interventions available. Other resources, such as the Community Guide of the Community Preventive Services Task Force,86 provide reviews on effective community-based STI prevention programs.

Clinician risk assessments are necessary when ascertaining the eligibility of patients at increased risk of STIs for behavioral counseling interventions, yet few of the included studies incorporated risk assessment by primary care clinicians into the study design. Tests of interventions among populations of patients identified using defined STI risk assessment procedures could strengthen the applicability of evidence to primary care populations. Given that there may be considerable variation in sexual history–taking practices in primary care, the implementation of behavioral counseling interventions for populations at increased risk will likely require greater attention to this aspect of clinician training and health care delivery. There also remains a need for research on lower-intensity behavioral interventions that could be applied in primary care settings serving patients across a range of levels of STI risk. Pragmatic studies in health systems could provide important evidence on intervening in the context of routine primary care, especially when patients screen positive for an STI or report sexual risk behaviors such as multiple concurrent partners and unprotected intercourse.

One included trial was implemented in a pediatric health care setting and found to be effective for delaying self-reported initiation of sexual intercourse. The Families Talking Together intervention enrolled mother-child dyads and was designed for African American and Hispanic youth before they became sexually active.28 A trial replicating these results among a larger sample of Hispanic, African American, and mixed-race youth published in May 2020 was identified in ongoing surveillance of the literature and provides additional evidence that the intervention was effective for reducing self-reported behavioral risk factors for STI (ie, time to sexual debut, condom use).87 The included literature primarily evaluated intervention effectiveness within narrowly defined population groups (such as African American women or adolescent girls), and it is unknown whether the reported effect estimates would also be observed for the interventions if adapted to other populations. Most studies primarily included heterosexual participants at increased STI risk. Several groups that can experience increased risk for STIs were underrepresented in the evidence, however, including older adults, gay boys and men, and transgender populations. There also were only 2 studies in this review conducted among pregnant women, despite the clinical importance of preventing vertical transmission of STIs and complications that can be associated with STIs during delivery. Recent reports of a steep increase in mortality from congenital syphilis heighten the urgency of identifying pregnant individuals at increased risk and providing effective preventive interventions, as well as STI screening and treatment during pregnancy.3 Notably, none of the effectiveness trials eligible for this review enrolled sexual partner dyads despite the recognized role of interpersonal communication and relationship factors in STI risk.88,89

Limitations

This review has several limitations. First, studies that assessed the comparative effectiveness of different types of behavioral counseling interventions were not included because the topic scope was informed by the USPSTF Procedure Manual.9 Accordingly, the review was designed to support a recommendation based on intervention efficacy, and several studies were excluded because they did not include a usual-care or no-intervention control condition. Some excluded studies focused on high-risk populations not well-represented in the included body of evidence, such as African American boys and men,90,91 MSM,92-96 bisexual Black men,97,98 transgender women,99 and homeless young adults.100 In addition, relatively few of the included studies were replications or adaptations of effective interventions.42

Second, this review focused on interventions evaluated in the past 20 years, more than one-third of which were published prior to 2010. Changes in sexual risk behaviors and risks during this period may have implications for the applicability of the body of evidence. The development of effective treatments and a prophylactic agent for HIV infection may have shifted population risk perceptions. In addition, the emergence of social networking and dating app platforms has altered the landscape that defines sexual networks and sexual practices.101 Since adolescents and young adults have the highest rates of STI, research is needed to develop interventions addressing the current sexual, social, and interpersonal contexts that emerging adolescents and young adults will navigate.

Third, a variety of measures of condom use were reported across the trials, limiting estimation of pooled effects for behavioral outcomes. STI prevention generally requires consistent condom use, but many of the studies evaluated reported condom use only at last sex or whether condoms were ever used. Furthermore, behavioral outcomes were self-reported and subject to recall bias, Hawthorne effects, and social desirability bias.79,102,103 Nevertheless, in studies reporting the incidence of diagnosed STIs, results for behavioral measures were generally consistent in the degree and direction of effects.

Conclusions

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

Back to top
Article Information

Corresponding Author: Jillian T. Henderson, PhD, MPH, Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente Northwest 3800 N Interstate Ave, Portland, OR 97227 (Jillian.T.Henderson@kpchr.org).

Accepted for Publication: June 19, 2020.

Author Contributions: Dr Henderson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Henderson, Bean, O’Connor.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Henderson, Senger, Bean.

Critical revision of the manuscript for important intellectual content: Henderson, Henninger, Redmond, O’Connor.

Statistical analysis: Redmond, O’Connor.

Administrative, technical, or material support: Senger, Henninger, Bean, Redmond.

Supervision: Henderson.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research was funded under contract HHSA2902015000017I, Task Order No. 5, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services.

Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope, analytic framework, and key questions for this review. AHRQ had no role in study selection, quality assessment, or synthesis. AHRQ staff provided project oversight, reviewed the report to ensure that the analysis met methodological standards, and distributed the draft for peer review. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript findings.

Disclaimer: The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.

Additional Contributions: We gratefully acknowledge the following individuals for their contributions to this project: Kathleen Irwin, MD, MPH, and Tina Fan, MD, MPH (AHRQ); current and former members of the US Preventive Services Task Force who contributed to topic deliberations; Jennifer Lin, MD (Kaiser Permanente Center for Health Research), for mentoring and project oversight, and Smyth Lai, MLS, and Katherine Essick, BS (Kaiser Permanente Center for Health Research), for technical and editorial assistance. The USPSTF members, peer reviewers, and federal partner reviewers did not receive financial compensation for their contributions.

Additional Information: A draft version of this evidence report underwent external peer review from 4 content experts (Errol Lamont Fields, MD, PhD, Johns Hopkins University School of Medicine; Marie Harvey, DrPH, MPH, Oregon State University; Ralph DiClemente, PhD, New York University; Michelle Ybarra, PhD, MPH, Johns Hopkins University School of Medicine); and 3 federal partners: the Centers for Disease Control and Prevention, US Food and Drug Association, and National Institutes of Health. Comments were presented to the USPSTF during its deliberation of the evidence and were considered in preparing the final evidence review.

Editorial Disclaimer: This evidence report is presented as a document in support of the accompanying USPSTF Recommendation Statement. It did not undergo additional peer review after submission to JAMA.

References
1.
Satterwhite  CL, Torrone  E, Meites  E,  et al.  Sexually transmitted infections among US women and men.   Sex Transm Dis. 2013;40(3):187-193. doi:10.1097/OLQ.0b013e318286bb53 PubMedGoogle ScholarCrossref
2.
Centers for Disease Control and Prevention.  Sexually Transmitted Disease Surveillance 2017. US Department of Health and Human Services; 2018.
3.
Centers for Disease Control and Prevention.  Sexually Transmitted Disease Surveillance 2018. US Department of Health and Human Services; 2019.
4.
Ward  H.  Prevention strategies for sexually transmitted infections.   Sex Transm Infect. 2007;83(suppl 1):i43-i49. doi:10.1136/sti.2006.023598 PubMedGoogle ScholarCrossref
5.
Ford  JV, Ivankovich  MB, Douglas  JM  Jr,  et al.  The need to promote sexual health in America.   Sex Transm Dis. 2017;44(10):579-585. doi:10.1097/OLQ.0000000000000660 PubMedGoogle ScholarCrossref
6.
National Center for HIV/AIDS, Viral Hepatitis, and TB Prevention. A Guide to Taking a Sexual History. Centers for Disease Control and Prevention. Published 2011. Accessed April 24, 2019. https://www.cdc.gov/std/treatment/sexualhistory.pdf
7.
LeFevre  ML; US Preventive Services Task Force.  Behavioral counseling interventions to prevent sexually transmitted infections: U.S. Preventive Services Task Force recommendation statement.   Ann Intern Med. 2014;161(12):894-901. doi:10.7326/M14-1965 PubMedGoogle ScholarCrossref
8.
O’Connor  EA, Lin  JS, Burda  BU, Henderson  JT, Walsh  ES, Whitlock  EP.  Behavioral sexual risk-reduction counseling in primary care to prevent sexually transmitted infections: a systematic review for the U.S. Preventive Services Task Force.   Ann Intern Med. 2014;161(12):874-883. doi:10.7326/M14-0475 PubMedGoogle ScholarCrossref
9.
 U.S. Preventive Services Task Force Procedure Manual. U.S. Preventive Services Task Force; 2015.
10.
Henderson  JT, Henninger  M, Bean  SI, Senger  CA, Redmond  N, O’Connor  EA.  Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections: Updated Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 192. Agency for Healthcare Research and Quality; 2020. AHRQ publication 19-05260-EF-1.
11.
Human Development Report 2016: Human Development for Everyone. United Nations Development Programme. Published 2016. Accessed July 9, 2020. http://hdr.undp.org/sites/default/files/2016_human_development_report.pdf
12.
Egger  M, Davey Smith  G, Schneider  M, Minder  C.  Bias in meta-analysis detected by a simple, graphical test.   BMJ. 1997;315(7109):629-634. doi:10.1136/bmj.315.7109.629 PubMedGoogle ScholarCrossref
13.
Brockwell  SE, Gordon  IR.  A comparison of statistical methods for meta-analysis.   Stat Med. 2001;20(6):825-840. doi:10.1002/sim.650 PubMedGoogle ScholarCrossref
14.
Ehrhardt  AA, Exner  TM, Hoffman  S,  et al.  A gender-specific HIV/STD risk reduction intervention for women in a health care setting.   AIDS Care. 2002;14(2):147-161. doi:10.1080/09540120220104677 PubMedGoogle ScholarCrossref
15.
Billings  DW, Leaf  SL, Spencer  J, Crenshaw  T, Brockington  S, Dalal  RS.  A randomized trial to evaluate the efficacy of a web-based HIV behavioral intervention for high-risk African American women.   AIDS Behav. 2015;19(7):1263-1274. doi:10.1007/s10461-015-0999-9 PubMedGoogle ScholarCrossref
16.
Carey  MP, Senn  TE, Walsh  JL,  et al.  Evaluating a brief, video-based sexual risk reduction intervention and assessment reactivity with STI clinic patients.   AIDS Behav. 2015;19(7):1228-1246. doi:10.1007/s10461-014-0960-3 PubMedGoogle ScholarCrossref
17.
Berenson  AB, Rahman  M.  A randomized controlled study of two educational interventions on adherence with oral contraceptives and condoms.   Contraception. 2012;86(6):716-724. doi:10.1016/j.contraception.2012.06.007 PubMedGoogle ScholarCrossref
18.
Berkman  A, Pilowsky  DJ, Zybert  PA,  et al.  HIV prevention with severely mentally ill men: a randomised controlled trial.   AIDS Care. 2007;19(5):579-588. doi:10.1080/09540120701213989 PubMedGoogle ScholarCrossref
19.
Carey  MP, Carey  KB, Maisto  SA, Gordon  CM, Schroder  KE, Vanable  PA.  Reducing HIV-risk behavior among adults receiving outpatient psychiatric treatment.   J Consult Clin Psychol. 2004;72(2):252-268. doi:10.1037/0022-006X.72.2.252 PubMedGoogle ScholarCrossref
20.
Carey  MP, Senn  TE, Vanable  PA, Coury-Doniger  P, Urban  MA.  Brief and intensive behavioral interventions to promote sexual risk reduction among STD clinic patients.   AIDS Behav. 2010;14(3):504-517. doi:10.1007/s10461-009-9587-1 PubMedGoogle ScholarCrossref
21.
Carey  MP, Vanable  PA, Senn  TE, Coury-Doniger  P, Urban  MA.  Evaluating a two-step approach to sexual risk reduction in a publicly-funded STI clinic: rationale, design, and baseline data from the Health Improvement Project-Rochester (HIP-R).   Contemp Clin Trials. 2008;29(4):569-586. doi:10.1016/j.cct.2008.02.001 PubMedGoogle ScholarCrossref
22.
Champion  JD.  Behavioural interventions and abuse: secondary analysis of reinfection in minority women.   Int J STD AIDS. 2007;18(11):748-753. doi:10.1258/095646207782212180 PubMedGoogle ScholarCrossref
23.
Champion  JD, Collins  JL.  Comparison of a theory-based (AIDS Risk Reduction Model) cognitive behavioral intervention versus enhanced counseling for abused ethnic minority adolescent women on infection with sexually transmitted infection.   Int J Nurs Stud. 2012;49(2):138-150. doi:10.1016/j.ijnurstu.2011.08.010 PubMedGoogle ScholarCrossref
24.
Crosby  R, DiClemente  RJ, Charnigo  R, Snow  G, Troutman  A.  A brief, clinic-based, safer sex intervention for heterosexual African American men newly diagnosed with an STD.   Am J Public Health. 2009;99(suppl 1):S96-S103. doi:10.2105/AJPH.2007.123893 PubMedGoogle ScholarCrossref
25.
DiClemente  RJ, Wingood  GM, Harrington  KF,  et al.  Efficacy of an HIV prevention intervention for African American adolescent girls.   JAMA. 2004;292(2):171-179. doi:10.1001/jama.292.2.171 PubMedGoogle ScholarCrossref
26.
Dworkin  SL, Beckford  ST, Ehrhardt  AA.  Sexual scripts of women: a longitudinal analysis of participants in a gender-specific HIV/STD prevention intervention.   Arch Sex Behav. 2007;36(2):269-279. doi:10.1007/s10508-006-9092-9 PubMedGoogle ScholarCrossref
27.
Enrhardt  AA, Exner  TM, Hoffman  S,  et al.  HIV/STD risk and sexual strategies among women family planning clients in New York: Project FIO.   AIDS Behav. 2002;6(1):1-13. doi:10.1023/A:1014534110868 Google ScholarCrossref
28.
Guilamo-Ramos  V, Bouris  A, Jaccard  J, Gonzalez  B, McCoy  W, Aranda  D.  A parent-based intervention to reduce sexual risk behavior in early adolescence.   J Adolesc Health. 2011;48(2):159-163. doi:10.1016/j.jadohealth.2010.06.007 PubMedGoogle ScholarCrossref
29.
Hoffman  S, Exner  TM, Leu  CS, Ehrhardt  AA, Stein  Z.  Female-condom use in a gender-specific family planning clinic trial.   Am J Public Health. 2003;93(11):1897-1903. doi:10.2105/AJPH.93.11.1897 PubMedGoogle ScholarCrossref
30.
Jemmott  JB  III, Jemmott  LS, Braverman  PK, Fong  GT.  HIV/STD risk reduction interventions for African American and Latino adolescent girls at an adolescent medicine clinic.   Arch Pediatr Adolesc Med. 2005;159(5):440-449. doi:10.1001/archpedi.159.5.440 PubMedGoogle ScholarCrossref
31.
Jemmott  LS, Jemmott  JB  III, O’Leary  A.  Effects on sexual risk behavior and STD rate of brief HIV/STD prevention interventions for African American women in primary care settings.   Am J Public Health. 2007;97(6):1034-1040. doi:10.2105/AJPH.2003.020271 PubMedGoogle ScholarCrossref
32.
Kershaw  TS, Magriples  U, Westdahl  C, Rising  SS, Ickovics  J.  Pregnancy as a window of opportunity for HIV prevention: effects of an HIV intervention delivered within prenatal care.   Am J Public Health. 2009;99(11):2079-2086. doi:10.2105/AJPH.2008.154476 PubMedGoogle ScholarCrossref
33.
Lang  DL, DiClemente  RJ, Hardin  JW,  et al.  Threats of cross-contamination on effects of a sexual risk reduction intervention: fact or fiction.   Prev Sci. 2009;10(3):270-275. doi:10.1007/s11121-009-0127-z PubMedGoogle ScholarCrossref
34.
Marrazzo  JM, Thomas  KK, Agnew  K, Ringwood  K.  Prevalence and risks for bacterial vaginosis in women who have sex with women.   Sex Transm Dis. 2010;37(5):335-339. doi:10.1097/OLQ.0b013e3181ca3cac PubMedGoogle Scholar
35.
Marrazzo  JM, Thomas  KK, Fiedler  TL, Ringwood  K, Fredricks  DN.  Relationship of specific vaginal bacteria and bacterial vaginosis treatment failure in women who have sex with women.   Ann Intern Med. 2008;149(1):20-28. doi:10.7326/0003-4819-149-1-200807010-00006 PubMedGoogle ScholarCrossref
36.
Marrazzo  JM, Thomas  KK, Ringwood  K.  A behavioural intervention to reduce persistence of bacterial vaginosis among women who report sex with women.   Sex Transm Infect. 2011;87(5):399-405. doi:10.1136/sti.2011.049213 PubMedGoogle ScholarCrossref
37.
Melendez  RM, Hoffman  S, Exner  T, Leu  CS, Ehrhardt  AA.  Intimate partner violence and safer sex negotiation: effects of a gender-specific intervention.   Arch Sex Behav. 2003;32(6):499-511. doi:10.1023/A:1026081309709 PubMedGoogle ScholarCrossref
38.
Metsch  LR, Feaster  DJ, Gooden  L,  et al.  Effect of risk-reduction counseling with rapid HIV testing on risk of acquiring sexually transmitted infections: the AWARE randomized clinical trial.   JAMA. 2013;310(16):1701-1710. doi:10.1001/jama.2013.280034 PubMedGoogle ScholarCrossref
39.
Milhausen  RR, DiClemente  RJ, Lang  DL, Spitalnick  JS, Sales  JM, Hardin  JW.  Frequency of sex after an intervention to decrease sexual risk-taking among African-American adolescent girls.   Sex Educ. 2008;8:47-57. doi:10.1080/14681810701811803 Google ScholarCrossref
40.
Miller  S, Exner  TM, Williams  SP, Ehrhardt  AA.  A gender-specific intervention for at-risk women in the USA.   AIDS Care. 2000;12(5):603-612. doi:10.1080/095401200750003789 PubMedGoogle ScholarCrossref
41.
Mittal  M, Senn  TE, Carey  MP.  Mediators of the relation between partner violence and sexual risk behavior among women attending a sexually transmitted disease clinic.   Sex Transm Dis. 2011;38(6):510-515. doi:10.1097/OLQ.0b013e318207f59b PubMedGoogle Scholar
42.
Neumann  MS, O’Donnell  L, Doval  AS,  et al.  Effectiveness of the VOICES/VOCES sexually transmitted disease/human immunodeficiency virus prevention intervention when administered by health department staff: does it work in the “real world”?   Sex Transm Dis. 2011;38(2):133-139. doi:10.1097/OLQ.0b013e3181f0c051 PubMedGoogle ScholarCrossref
43.
O’Leary  A, Jemmott  LS, Jemmott  JB.  Mediation analysis of an effective sexual risk-reduction intervention for women: the importance of self-efficacy.   Health Psychol. 2008;27(2S)(suppl):S180-S184. doi:10.1037/0278-6133.27.2(Suppl.).S180 PubMedGoogle ScholarCrossref
44.
Peipert  J, Redding  CA, Blume  J,  et al.  Design of a stage-matched intervention trial to increase dual method contraceptive use (Project PROTECT).   Contemp Clin Trials. 2007;28(5):626-637. doi:10.1016/j.cct.2007.01.012 PubMedGoogle ScholarCrossref
45.
Peipert  JF, Redding  CA, Blume  JD,  et al.  Tailored intervention to increase dual-contraceptive method use: a randomized trial to reduce unintended pregnancies and sexually transmitted infections.   Am J Obstet Gynecol. 2008;198(6):630.e1-630.e8. doi:10.1016/j.ajog.2008.01.038 PubMedGoogle ScholarCrossref
46.
Petersen  R, Albright  J, Garrett  JM, Curtis  KM.  Pregnancy and STD prevention counseling using an adaptation of motivational interviewing: a randomized controlled trial.   Perspect Sex Reprod Health. 2007;39(1):21-28. doi:10.1363/3902107 PubMedGoogle ScholarCrossref
47.
Proude  EM, D’Este  C, Ward  JE.  Randomized trial in family practice of a brief intervention to reduce STI risk in young adults.   Fam Pract. 2004;21(5):537-544. doi:10.1093/fampra/cmh510 PubMedGoogle ScholarCrossref
48.
Sales  JM, Lang  DL, Hardin  JW, Diclemente  RJ, Wingood  GM.  Efficacy of an HIV prevention program among African American female adolescents reporting high depressive symptomatology.   J Womens Health (Larchmt). 2010;19(2):219-227. doi:10.1089/jwh.2008.1326 PubMedGoogle ScholarCrossref
49.
Scholes  D, McBride  CM, Grothaus  L,  et al.  A tailored minimal self-help intervention to promote condom use in young women.   AIDS. 2003;17(10):1547-1556. doi:10.1097/00002030-200307040-00016 PubMedGoogle ScholarCrossref
50.
Shain  RN, Piper  JM, Holden  AE,  et al.  Prevention of gonorrhea and chlamydia through behavioral intervention.   Sex Transm Dis. 2004;31(7):401-408. doi:10.1097/01.olq.0000135301.97350.84 PubMedGoogle ScholarCrossref
51.
Warner  L, Klausner  JD, Rietmeijer  CA,  et al; Safe in the City Study Group.  Effect of a brief video intervention on incident infection among patients attending sexually transmitted disease clinics.   PLoS Med. 2008;5(6):e135. doi:10.1371/journal.pmed.0050135 PubMedGoogle Scholar
52.
Wingood  GM, DiClemente  RJ, Harrington  KF,  et al.  Efficacy of an HIV prevention program among female adolescents experiencing gender-based violence.   Am J Public Health. 2006;96(6):1085-1090. doi:10.2105/AJPH.2004.053595 PubMedGoogle ScholarCrossref
53.
Wingood  GM, Diclemente  RJ, Robinson-Simpson  L, Lang  DL, Caliendo  A, Hardin  JW.  Efficacy of an HIV intervention in reducing high-risk human papillomavirus, nonviral sexually transmitted infections, and concurrency among African American women: a randomized-controlled trial.   J Acquir Immune Defic Syndr. 2013;63(suppl 1):S36-S43. doi:10.1097/QAI.0b013e3182920031 PubMedGoogle ScholarCrossref
54.
Card  JJ, Benner  TA, eds.  Model Programs for Adolescent Sexual Health: Evidence-based HIV, STI and Pregnancy Prevention Interventions. Springer; 2008:253-260.
55.
Lewis  MA, Rhew  IC, Fairlie  AM, Swanson  A, Anderson  J, Kaysen  D.  Evaluating personalized feedback intervention framing with a randomized controlled trial to reduce young adult alcohol-related sexual risk taking.   Prev Sci. 2019;20(3):310-320. doi:10.1007/s11121-018-0879-4PubMedGoogle ScholarCrossref
56.
Morrison-Beedy  D, Crean  HF, Passmore  D, Carey  MP.  Risk reduction strategies used by urban adolescent girls in an HIV prevention trial.   Curr HIV Res. 2013;11(7):559-569. doi:10.2174/1570162X12666140129110129 PubMedGoogle ScholarCrossref
57.
Mittal  M, Senn  TE, Carey  MP.  Fear of violent consequences and condom use among women attending an STD clinic.   Women Health. 2013;53(8):795-807. doi:10.1080/03630242.2013.847890 PubMedGoogle ScholarCrossref
58.
Morrison-Beedy  D, Jones  SH, Xia  Y, Tu  X, Crean  HF, Carey  MP.  Reducing sexual risk behavior in adolescent girls.   J Adolesc Health. 2013;52(3):314-321. doi:10.1016/j.jadohealth.2012.07.005 PubMedGoogle ScholarCrossref
59.
Sanci  L, Chondros  P, Sawyer  S,  et al.  Responding to young people’s health risks in primary care: a cluster randomised trial of training clinicians in screening and motivational interviewing.   PLoS One. 2015;10(9):e0137581. doi:10.1371/journal.pone.0137581 PubMedGoogle Scholar
60.
Bailey  JV, Webster  R, Hunter  R,  et al.  The Men’s Safer Sex project: intervention development and feasibility randomised controlled trial of an interactive digital intervention to increase condom use in men.   Health Technol Assess. 2016;20(91):1-124. doi:10.3310/hta20910 PubMedGoogle ScholarCrossref
61.
Free  C, McCarthy  O, French  RS,  et al.  Can text messages increase safer sex behaviours in young people? intervention development and pilot randomised controlled trial.   Health Technol Assess. 2016;20(57):1-82. doi:10.3310/hta20570 PubMedGoogle ScholarCrossref
62.
Besera  GT, Cox  S, Malotte  CK,  et al.  Assessing patient exposure to a video-based intervention in STD clinic waiting rooms: findings from the Safe in the City trial.   Health Promot Pract. 2016;17(5):731-738. doi:10.1177/1524839916631537 PubMedGoogle ScholarCrossref
63.
Recto  P, Champion  JD.  Psychological distress and associated factors among Mexican American adolescent females.   Hisp Health Care Int. 2016;14(4):170-176. doi:10.1177/1540415316676224 PubMedGoogle ScholarCrossref
64.
Gallo  MF, Margolis  AD, Malotte  CK,  et al; Safe in the City Study Group.  Sexual abstinence and other behaviours immediately following a new STI diagnosis among STI clinic patients: findings from the Safe in the City trial.   Sex Transm Infect. 2016;92(3):206-210. doi:10.1136/sextrans-2014-051982 PubMedGoogle ScholarCrossref
65.
Gift  TL, OʼDonnell  LN, Rietmeijer  CA,  et al; Safe in the City Study Group.  The program cost of a brief video intervention shown in sexually transmitted disease clinic waiting rooms.   Sex Transm Dis. 2016;43(1):61-64. doi:10.1097/OLQ.0000000000000388 PubMedGoogle ScholarCrossref
66.
Mittal  M, Thevenet-Morrison  K, Landau  J,  et al.  An integrated HIV risk reduction intervention for women with a history of intimate partner violence: pilot test results.   AIDS Behav. 2017;21(8):2219-2232. doi:10.1007/s10461-016-1427-5 PubMedGoogle ScholarCrossref
67.
Ybarra  ML, Prescott  TL, Phillips  GL  II, Bull  SS, Parsons  JT, Mustanski  B.  Pilot RCT results of an mHealth HIV prevention program for sexual minority male adolescents.   Pediatrics. 2017;140(1):e20162999. doi:10.1542/peds.2016-2999 PubMedGoogle Scholar
68.
Costa  EC, McIntyre  T, Trovisqueira  A, Hobfoll  SE.  Comparison of two psycho-educational interventions aimed at preventing HIV and promoting sexual health among Portuguese women.   Int J Sex Health. 2017;29(3):258-272. doi:10.1080/19317611.2017.1307300 Google ScholarCrossref
69.
Tzilos Wernette  G, Plegue  M, Kahler  CW, Sen  A, Zlotnick  C.  A pilot randomized controlled trial of a computer-delivered brief intervention for substance use and risky sex during pregnancy.   J Womens Health (Larchmt). 2018;27(1):83-92. doi:10.1089/jwh.2017.6408 PubMedGoogle ScholarCrossref
70.
Peragallo Montano  N, Cianelli  R, Villegas  N, Gonzalez-Guarda  R, Williams  WO, de Tantillo  L.  Evaluating a culturally tailored HIV risk reduction intervention among Hispanic women delivered in a real-world setting by community agency personnel.   Am J Health Promot. 2019;33(4):566-575. doi:10.1177/0890117118807716 PubMedGoogle ScholarCrossref
71.
Whiteley  LB, Brown  LK, Curtis  V, Ryoo  HJ, Beausoleil  N.  Publicly available internet content as a HIV/STI prevention intervention for urban youth.   J Prim Prev. 2018;39(4):361-370. doi:10.1007/s10935-018-0514-y PubMedGoogle ScholarCrossref
72.
Bai  S, Zeledon  LR, D’Amico  EJ,  et al.  Reducing health risk behaviors and improving depression in adolescents.   J Pediatr Psychol. 2018;43(9):1004-1016. doi:10.1093/jpepsy/jsy048 PubMedGoogle ScholarCrossref
73.
O’Cleirigh  C, Safren  SA, Taylor  SW,  et al.  Cognitive Behavioral Therapy for Trauma and Self-Care (CBT-TSC) in men who have sex with men with a history of childhood sexual abuse: a randomized controlled trial.   AIDS Behav. 2019;23(9):2421-2431. doi:10.1007/s10461-019-02482-zPubMedGoogle ScholarCrossref
74.
Redding  CA, Prochaska  JO, Armstrong  K,  et al.  Randomized trial outcomes of a TTM-tailored condom use and smoking intervention in urban adolescent females.   Health Educ Res. 2015;30(1):162-178. doi:10.1093/her/cyu015 PubMedGoogle ScholarCrossref
75.
Shafii  T, Benson  SK, Morrison  DM, Hughes  JP, Golden  MR, Holmes  KK.  Results from e-KISS: electronic-KIOSK Intervention for Safer Sex: a pilot randomized controlled trial of an interactive computer-based intervention for sexual health in adolescents and young adults.   PLoS One. 2019;14(1):e0209064. doi:10.1371/journal.pone.0209064 PubMedGoogle Scholar
76.
Magill  M, Hallgren  KA.  Mechanisms of behavior change in motivational interviewing: do we understand how MI works?   Curr Opin Psychol. 2019;30:1-5. doi:10.1016/j.copsyc.2018.12.010 PubMedGoogle ScholarCrossref
77.
Magill  M, Apodaca  TR, Borsari  B,  et al.  A meta-analysis of motivational interviewing process: technical, relational, and conditional process models of change.   J Consult Clin Psychol. 2018;86(2):140-157. doi:10.1037/ccp0000250 PubMedGoogle ScholarCrossref
78.
Wenzel  A.  Basic strategies of cognitive behavioral therapy.   Psychiatr Clin North Am. 2017;40(4):597-609. doi:10.1016/j.psc.2017.07.001 PubMedGoogle ScholarCrossref
79.
Petrova  D, Garcia-Retamero  R.  Effective evidence-based programs for preventing sexually-transmitted infections: a meta-analysis.   Curr HIV Res. 2015;13(5):432-438. doi:10.2174/1570162X13666150511143943 PubMedGoogle ScholarCrossref
80.
Ruiz-Perez  I, Murphy  M, Pastor-Moreno  G, Rojas-García  A, Rodríguez-Barranco  M.  The effectiveness of HIV prevention interventions in socioeconomically disadvantaged ethnic minority women.   Am J Public Health. 2017;107(12):e13-e21. doi:10.2105/AJPH.2017.304067 PubMedGoogle ScholarCrossref
81.
Marcell  AV, Gibbs  S, Lehmann  HP.  Brief condom interventions targeting males in clinical settings: a meta-analysis.   Contraception. 2016;93(2):153-163. doi:10.1016/j.contraception.2015.09.009 PubMedGoogle ScholarCrossref
82.
O’Connor  E, Lin  JS, Burda  BU, Henderson  JT, Walsh  ES, Whitlock  EP.  Behavioral Sexual Risk Reduction Counseling in Primary Care to Prevent Sexually Transmitted Infections: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality; 2014.
83.
DiClemente  RJ, Wingood  GM, Rose  ES,  et al.  Efficacy of sexually transmitted disease/human immunodeficiency virus sexual risk-reduction intervention for African American adolescent females seeking sexual health services.   Arch Pediatr Adolesc Med. 2009;163(12):1112-1121. doi:10.1001/archpediatrics.2009.205 PubMedGoogle ScholarCrossref
84.
DiClemente  RJ, Wingood  GM, Sales  JM,  et al.  Efficacy of a telephone-delivered sexually transmitted infection/human immunodeficiency virus prevention maintenance intervention for adolescents.   JAMA Pediatr. 2014;168(10):938-946. doi:10.1001/jamapediatrics.2014.1436 PubMedGoogle ScholarCrossref
85.
Rhodes  SD, Alonzo  J, Mann  L,  et al.  Small-group randomized controlled trial to increase condom use and HIV testing among Hispanic/Latino gay, bisexual, and other men who have sex with men.   Am J Public Health. 2017;107(6):969-976. doi:10.2105/AJPH.2017.303814 PubMedGoogle ScholarCrossref
86.
Community Preventive Services Task Force. HIV, STIs and teen pregnancy. The Community Guide. Accessed January 9, 2020. https://www.thecommunityguide.org/topic/hiv-stis-and-teen-pregnancy
87.
Guilamo-Ramos  V, Benzekri  A, Thimm-Kaiser  M,  et al.  A triadic intervention for adolescent sexual health.   Pediatrics. 2020;145(5):e20192808. doi:10.1542/peds.2019-2808 PubMedGoogle Scholar
88.
Harvey  SM, Washburn  I, Oakley  L, Warren  J, Sanchez  D.  Competing priorities: partner-specific relationship characteristics and motives for condom use among at-risk young adults.   J Sex Res. 2017;54(4-5):665-676. doi:10.1080/00224499.2016.1182961 PubMedGoogle ScholarCrossref
89.
El-Bassel  N, Gilbert  L, Witte  S, Wu  E, Hunt  T, Remien  RH.  Couple-based HIV prevention in the United States.   J Acquir Immune Defic Syndr. 2010;55(suppl 2):S98-S101. doi:10.1097/QAI.0b013e3181fbf407 PubMedGoogle ScholarCrossref
90.
Crosby  RA, Charnigo  RJ, Salazar  LF,  et al.  Enhancing condom use among Black male youths: a randomized controlled trial.   Am J Public Health. 2014;104(11):2219-2225. doi:10.2105/AJPH.2014.302131 PubMedGoogle ScholarCrossref
91.
Kennedy  SB, Nolen  S, Pan  Z, Smith  B, Applewhite  J, Vanderhoff  KJ.  Effectiveness of a brief condom promotion program in reducing risky sexual behaviours among African American men.   J Eval Clin Pract. 2013;19(2):408-413. doi:10.1111/j.1365-2753.2012.01841.x PubMedGoogle ScholarCrossref
92.
Hidalgo  MA, Kuhns  LM, Hotton  AL, Johnson  AK, Mustanski  B, Garofalo  R.  The MyPEEPS randomized controlled trial: a pilot of preliminary efficacy, feasibility, and acceptability of a group-level, HIV risk reduction intervention for young men who have sex with men.   Arch Sex Behav. 2015;44(2):475-485. doi:10.1007/s10508-014-0347-6 PubMedGoogle ScholarCrossref
93.
Koblin  BA, Bonner  S, Powell  B,  et al.  A randomized trial of a behavioral intervention for black MSM: the DiSH study.   AIDS. 2012;26(4):483-488. doi:10.1097/QAD.0b013e32834f9833 PubMedGoogle ScholarCrossref
94.
Kurtz  SP, Stall  RD, Buttram  ME, Surratt  HL, Chen  M.  A randomized trial of a behavioral intervention for high risk substance-using MSM.   AIDS Behav. 2013;17(9):2914-2926. doi:10.1007/s10461-013-0531-z PubMedGoogle ScholarCrossref
95.
Parsons  JT, Lelutiu-Weinberger  C, Botsko  M, Golub  SA.  A randomized controlled trial utilizing motivational interviewing to reduce HIV risk and drug use in young gay and bisexual men.   J Consult Clin Psychol. 2014;82(1):9-18. doi:10.1037/a0035311 PubMedGoogle ScholarCrossref
96.
Mustanski  B, Garofalo  R, Monahan  C, Gratzer  B, Andrews  R.  Feasibility, acceptability, and preliminary efficacy of an online HIV prevention program for diverse young men who have sex with men: the Keep It Up! intervention.   AIDS Behav. 2013;17(9):2999-3012. doi:10.1007/s10461-013-0507-z PubMedGoogle ScholarCrossref
97.
Harawa  NT, Williams  JK, McCuller  WJ,  et al.  Efficacy of a culturally congruent HIV risk-reduction intervention for behaviorally bisexual black men: results of a randomized trial.   AIDS. 2013;27(12):1979-1988. doi:10.1097/QAD.0b013e3283617500 PubMedGoogle ScholarCrossref
98.
Lauby  J, Milnamow  M, Joseph  HA,  et al.  Evaluation of Project RISE, an HIV prevention intervention for black bisexual men using an ecosystems approach.   AIDS Behav. 2018;22(1):164-177. doi:10.1007/s10461-017-1892-5 PubMedGoogle ScholarCrossref
99.
Operario  D, Gamarel  KE, Iwamoto  M,  et al.  Couples-focused prevention program to reduce HIV risk among transgender women and their primary male partners.   AIDS Behav. 2017;21(8):2452-2463. doi:10.1007/s10461-016-1462-2 PubMedGoogle ScholarCrossref
100.
Thompson  RG  Jr, Elliott  JC, Hu  MC, Aivadyan  C, Aharonovich  E, Hasin  DS.  Short-term effects of a brief intervention to reduce alcohol use and sexual risk among homeless young adults.   Addict Res Theory. 2017;25(1):24-31. doi:10.1080/16066359.2016.1193165 PubMedGoogle ScholarCrossref
101.
Hunter  P, Dalby  J, Marks  J, Swain  GR, Schrager  S.  Screening and prevention of sexually transmitted infections.   Prim Care. 2014;41(2):215-237. doi:10.1016/j.pop.2014.02.003 PubMedGoogle ScholarCrossref
102.
Rao  A, Tobin  K, Davey-Rothwell  M, Latkin  CA.  Social desirability bias and prevalence of sexual HIV risk behaviors among people who use drugs in Baltimore, Maryland: implications for identifying individuals prone to underreporting sexual risk behaviors.   AIDS Behav. 2017;21(7):2207-2214. doi:10.1007/s10461-017-1792-8 PubMedGoogle ScholarCrossref
103.
Rose  E, Diclemente  RJ, Wingood  GM,  et al.  The validity of teens’ and young adults’ self-reported condom use.   Arch Pediatr Adolesc Med. 2009;163(1):61-64. doi:10.1001/archpediatrics.2008.509 PubMedGoogle ScholarCrossref
×