Interventions to Increase Condom Use and Reduce STI
Interventions to Increase Condom Use and Reduce STI
Objective: In the absence of an effective HIV vaccine, safer sexual practices are necessary to avert new infections. Therefore, we examined the efficacy of behavioral interventions to increase condom use and reduce sexually transmitted infections (STIs), including HIV.
Design: Studies that examined a behavioral intervention focusing on reducing sexual risk, used a randomized controlled trial or a quasi-experimental design with a comparison condition, and provided needed information to calculate effect sizes for condom use and any type of STI, including HIV.
Methods: Studies were retrieved from electronic databases (eg, PubMed, PsycINFO) and reference sections of relevant papers. Forty-two studies with 67 separate interventions (N = 40,665; M age = 26 years; 68% women; 59% Black) were included. Independent raters coded participant characteristics, design and methodological features, and intervention content. Weighted mean effect sizes, using both fixed-effects and random-effects models, were calculated. Potential moderators of intervention efficacy were assessed.
Results: Compared with controls, intervention participants increased their condom use [d+ = 0.17, 95% confidence interval (CI) = 0.04, 0.29; k = 67], had fewer incident STIs (d+ = 0.16, 95% CI = 0.04, 0.29; k = 62), including HIV (d+ = 0.46, 95% CI = 0.13, 0.79; k = 13). Sample (eg, ethnicity) and intervention features (eg, skills training) moderated the efficacy of the intervention.
Conclusions: Behavioral interventions reduce sexual risk behavior and avert STIs and HIV. Translation and widespread dissemination of effective behavioral interventions are needed.
HIV remains a public health concern, with an estimated 2.6 million new infections occurring annually. Despite treatment advances, HIV presents significant health and social challenges. HIV is also costly, with medical care in the United States from the time of infection until the time of death estimated at $385,200. Global costs associated with antiretroviral therapy are estimated to be US $896 annually per person. In addition, new infections cost the US $29.7 billion annually in productivity losses. If incidence trends continue, the added annual cost of HIV care in the US will be between $128 and $237 billion dollars. To reduce the burden of HIV, prevention efforts need to be expanded. Identifying and evaluating successful behavioral interventions is critical to ensure that effective interventions are implemented with appropriate samples and in appropriate settings to achieve reductions in HIV transmission. To achieve this goal, meta-analytic techniques can help to quantitatively synthesize the behavioral intervention literature.
Meta-analyses of behavioral interventions have documented improvements in behavioral outcomes (eg, condom use) among a number of groups (eg, adolescents). Relatively fewer meta-analyses have examined biological outcomes, likely due to an insufficient number of studies measuring sexually transmitted infections (STIs) and/or HIV available to date. As a result, many of those meta-analyses have been underpowered. A recent meta-analysis found behavioral interventions improved both behavioral and biological outcomes among clients at STI clinics in the United States. Although there was sufficient power to test incident STIs (excluding HIV), this study was limited in that HIV incidence could be evaluated in only 5 of the 48 studies reviewed. Overall, it is unclear whether incident STIs, including HIV, are reduced after behavioral risk reduction interventions. Because condom use and incident STIs are independent outcomes, examining both behavioral and biological endpoints within a wider range of studies can increase our understanding of the efficacy of behavioral interventions.
The current study extends previous meta-analyses by focusing on the effects of behavioral interventions to improve both behavioral and biological outcomes. Specifically, meta-analytic techniques were used to evaluate the efficacy of behavioral interventions to reduce incident STIs, including HIV, and to promote condom use. We hypothesize that those participants receiving a behavioral intervention targeting HIV prevention would increase their condom use and would be less likely to acquire STIs, including HIV, relative to controls.
We also examine the extent to which the efficacy of behavioral interventions was a function of participant or intervention characteristics. Moderators included the following: (A) gender, age, race, and sexual orientation; (B) baseline STI or HIV; (C) intervention content (motivation and/or skills training, addressing sociocultural barriers, providing condoms, and tailored or targeted content); (D) matching facilitators to participants (on gender or race), and (E) intervention length. We hypothesize that interventions will be more efficacious when they (A) sampled greater proportions of those who are most affected by HIV (women, young adults, Blacks, Latinos, MSM, and heterosexuals); (B) sampled patients diagnosed with an STI or HIV at baseline, as infected participants may be more motivated to decrease their risk behavior; (C) targeted motivation and provided skills training, consistent with motivational and skill-based theories of HIV prevention; (D) tailored content to the individual, targeted content toward a specific group (eg, women), or matched facilitators to the gender or race of the participants, as tailoring and/or targeting the intervention content may enhance message relevancy; and (E) were longer, providing participants with additional opportunities to practice skills.
Abstract and Introduction
Abstract
Objective: In the absence of an effective HIV vaccine, safer sexual practices are necessary to avert new infections. Therefore, we examined the efficacy of behavioral interventions to increase condom use and reduce sexually transmitted infections (STIs), including HIV.
Design: Studies that examined a behavioral intervention focusing on reducing sexual risk, used a randomized controlled trial or a quasi-experimental design with a comparison condition, and provided needed information to calculate effect sizes for condom use and any type of STI, including HIV.
Methods: Studies were retrieved from electronic databases (eg, PubMed, PsycINFO) and reference sections of relevant papers. Forty-two studies with 67 separate interventions (N = 40,665; M age = 26 years; 68% women; 59% Black) were included. Independent raters coded participant characteristics, design and methodological features, and intervention content. Weighted mean effect sizes, using both fixed-effects and random-effects models, were calculated. Potential moderators of intervention efficacy were assessed.
Results: Compared with controls, intervention participants increased their condom use [d+ = 0.17, 95% confidence interval (CI) = 0.04, 0.29; k = 67], had fewer incident STIs (d+ = 0.16, 95% CI = 0.04, 0.29; k = 62), including HIV (d+ = 0.46, 95% CI = 0.13, 0.79; k = 13). Sample (eg, ethnicity) and intervention features (eg, skills training) moderated the efficacy of the intervention.
Conclusions: Behavioral interventions reduce sexual risk behavior and avert STIs and HIV. Translation and widespread dissemination of effective behavioral interventions are needed.
Introduction
HIV remains a public health concern, with an estimated 2.6 million new infections occurring annually. Despite treatment advances, HIV presents significant health and social challenges. HIV is also costly, with medical care in the United States from the time of infection until the time of death estimated at $385,200. Global costs associated with antiretroviral therapy are estimated to be US $896 annually per person. In addition, new infections cost the US $29.7 billion annually in productivity losses. If incidence trends continue, the added annual cost of HIV care in the US will be between $128 and $237 billion dollars. To reduce the burden of HIV, prevention efforts need to be expanded. Identifying and evaluating successful behavioral interventions is critical to ensure that effective interventions are implemented with appropriate samples and in appropriate settings to achieve reductions in HIV transmission. To achieve this goal, meta-analytic techniques can help to quantitatively synthesize the behavioral intervention literature.
Meta-analyses of behavioral interventions have documented improvements in behavioral outcomes (eg, condom use) among a number of groups (eg, adolescents). Relatively fewer meta-analyses have examined biological outcomes, likely due to an insufficient number of studies measuring sexually transmitted infections (STIs) and/or HIV available to date. As a result, many of those meta-analyses have been underpowered. A recent meta-analysis found behavioral interventions improved both behavioral and biological outcomes among clients at STI clinics in the United States. Although there was sufficient power to test incident STIs (excluding HIV), this study was limited in that HIV incidence could be evaluated in only 5 of the 48 studies reviewed. Overall, it is unclear whether incident STIs, including HIV, are reduced after behavioral risk reduction interventions. Because condom use and incident STIs are independent outcomes, examining both behavioral and biological endpoints within a wider range of studies can increase our understanding of the efficacy of behavioral interventions.
The current study extends previous meta-analyses by focusing on the effects of behavioral interventions to improve both behavioral and biological outcomes. Specifically, meta-analytic techniques were used to evaluate the efficacy of behavioral interventions to reduce incident STIs, including HIV, and to promote condom use. We hypothesize that those participants receiving a behavioral intervention targeting HIV prevention would increase their condom use and would be less likely to acquire STIs, including HIV, relative to controls.
We also examine the extent to which the efficacy of behavioral interventions was a function of participant or intervention characteristics. Moderators included the following: (A) gender, age, race, and sexual orientation; (B) baseline STI or HIV; (C) intervention content (motivation and/or skills training, addressing sociocultural barriers, providing condoms, and tailored or targeted content); (D) matching facilitators to participants (on gender or race), and (E) intervention length. We hypothesize that interventions will be more efficacious when they (A) sampled greater proportions of those who are most affected by HIV (women, young adults, Blacks, Latinos, MSM, and heterosexuals); (B) sampled patients diagnosed with an STI or HIV at baseline, as infected participants may be more motivated to decrease their risk behavior; (C) targeted motivation and provided skills training, consistent with motivational and skill-based theories of HIV prevention; (D) tailored content to the individual, targeted content toward a specific group (eg, women), or matched facilitators to the gender or race of the participants, as tailoring and/or targeting the intervention content may enhance message relevancy; and (E) were longer, providing participants with additional opportunities to practice skills.
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