Effects of a brief video intervention on treatment initiation and adherence among patients attending human immunodeficiency virus treatment clinics

Background

Persons with human immunodeficiency virus (HIV) who get and keep a suppressed viral load are unlikely to transmit HIV. Simple, practical interventions to help achieve HIV viral suppression that are easy and inexpensive to administer in clinical settings are needed. We evaluated whether a brief video containing HIV-related health messages targeted to all patients in the waiting room improved treatment initiation, medication adherence, and retention in care.

Methods and findings

In a quasi-experimental trial all patients (N = 2,023) attending two HIV clinics from June 2016 to March 2017 were exposed to a theory-based, 29-minute video depicting persons overcoming barriers to starting treatment, taking medication as prescribed, and keeping medical appointments. New prescriptions at index visit, HIV viral load test results, and dates of return visits were collected through review of medical records for all patients during the 10 months that the video was shown. Those data were compared with the same variables collected for all patients (N = 1,979) visiting the clinics during the prior 10 months (August 2015 to May 2016). Among patients exposed to the video, there was an overall 10.4 percentage point increase in patients prescribed treatment (60.3% to 70.7%, p< 0.01). Additionally, there was an overall 6.0 percentage point improvement in viral suppression (56.7% to 62.7%, p< 0.01), however mixed results between sites was observed. There was not a significant change in rates of return visits (77.5% to 78.8%). A study limitation is that, due to the lack of randomization, the findings may be subject to bias and secular trends.

Conclusions

Showing a brief treatment-focused video in HIV clinic waiting rooms can be effective at improving treatment initiation and may help patients achieve viral suppression. This feasible, low resource-reliant video intervention may be appropriate for adoption by other clinics treating persons with HIV.

Trial registration

http://www.ClinicalTrials.gov (NCT03508310).

Substance use and STI acquisition: Secondary analysis from the AWARE study

OBJECTIVES

Sexually transmitted infections (STIs) are significant public health and financial burdens in the United States. This manuscript examines the relationship between substance use and prevalent and incident STIs in HIV-negative adult patients at STI clinics.

METHODS

A secondary analysis of Project AWARE was performed based on 5012 patients from 9 STI clinics. STIs were assessed by laboratory assay and substance use by self-report. Patterns of substance use were assessed using latent class analysis. The relationship of latent class to STI rates was investigated using Poisson regression by population groups at high risk for STIs defined by participant's and partner's gender.

RESULTS

Drug use patterns differed by risk group and substance use was related to STI rates with the relationships varying by risk behavior group. Substance use treatment participation was associated with increased STI rates.

CONCLUSIONS

Substance use focused interventions may be useful in STI clinics to reduce morbidity associated with substance use. Conversely, gender-specific sexual health interventions may be useful in substance use treatment.

Urine Tests for Gonorrhea and Chlamydia: Great Technology but Will the Community Accept It?

Semi-structured interviews were conducted with 311 respondents in seven inner-city communities within the United States in an effort to examine factors that promote regular urine-based screening for chlamydia and gonorrhea. Results suggested that the majority of respondents were in favor of the use of urine-based testing for the detection of sexually transmitted infections (STIs), indicating that regular urine testing is important for diagnosis, early detection, prevention, and treatment of STIs. The most common concerns reported were stigma associated with STIs, the time required for testing, the possibility of receiving inaccurate laboratory results, and the higher cost of urine testing. The ease and accuracy of urine testing in addition to its high acceptance suggest that screening programs for STIs using urine-based testing could be implemented and used quite effectively to control the transmission of STIs.

Examining the Efficacy of HIV Risk-Reduction Counseling on the Sexual Risk Behaviors of a National Sample of Drug Abuse Treatment Clients: Analysis of Subgroups

HIV counseling with testing has been part of HIV prevention in the U.S. since the 1980s. Despite the long-standing history of HIV testing with prevention counseling, the CDC released HIV testing recommendations for health care settings contesting benefits of prevention counseling with testing in reducing sexual risk behaviors among HIV-negatives in 2006. Efficacy of brief HIV risk-reduction counseling (RRC) in decreasing sexual risk among subgroups of substance use treatment clients was examined using multi-site RCT data. Interaction tests between RRC and subgroups were performed; multivariable regression evaluated the relationship between RRC (with rapid testing) and sex risk. Subgroups were defined by demographics, risk type and level, attitudes/perceptions, and behavioral history. There was an effect (p < .0028) of counseling on number of sex partners among some subgroups. Certain subgroups may benefit from HIV RRC; this should be examined in studies with larger sample sizes, designed to assess the specific subgroup(s).

Assessing Patient Exposure to a Video-Based Intervention in STD Clinic Waiting Rooms: Findings From the Safe in the City Trial

Safe in the City, a video intervention for clinic waiting rooms, was previously shown to reduce sexually transmitted disease (STD) incidence. However, little is known about patients' recall of exposure to the intervention. Using data from a nested study of patients attending clinics during the trial, we assessed whether participants recalled Safe in the City, and, if so, how the intervention affected subsequent attitudes and behaviors. Analyses were restricted to responses to a 3-month follow-up questionnaire among participants who were exposed to the video (n = 708). Impact was measured as participants' reports of the video's effect on behaviors and attitudes. Associations were evaluated using multivariable logistic regression. Of participants who were exposed, 685 (97%) recalled viewing the video, and 68% recalled all three vignettes. After watching the video, participants felt more positive about condoms (69%) and comfortable acquiring condoms (56%), were reminded of important information about STDs and condoms (90%), and tried to apply what they learned to their lives (59%). Compared with those who recalled viewing one or two vignettes, participants who recalled viewing all three vignettes reported more positive attitudes toward condoms and peer/provider communication. These findings demonstrate that a low-resource video intervention for waiting rooms can provide sufficient exposure to positively influence STD-related attitudes/behaviors.

Sexual abstinence and other behaviours immediately following a new STI diagnosis among STI clinic patients: Findings from the Safe in the City trial

BACKGROUND

Few studies have assessed patients' sexual behaviours during the period immediately following a new diagnosis of a curable sexually transmitted infection (STI).

METHODS

Data were analysed from a behavioural study nested within the Safe in the City trial, which evaluated a video-based STI/HIV prevention intervention in three urban STI clinics. We studied 450 patients who reported having received a new STI diagnosis, or STI treatment, 3 months earlier. Participants reported on whether they seriously considered, attempted and succeeded in adopting seven sex-related behaviours in the interval following the diagnostic visit. We used multivariable logistic regression to identify, among men, correlates of two behaviours related to immediately reducing reinfection risk and preventing further STI transmission: sexual abstinence until participants were adequately treated and abstinence until their partners were tested for STIs.

RESULTS

Most participants reported successfully abstaining from sex until they were adequately treated for their baseline infection (89%-90%) and from sex with potentially exposed partners until their partners were tested for HIV and other STIs (66%-70%). Among men who intended to be abstinent until they were adequately treated, those who did not discuss the risks with a partner who was possibly exposed were more likely not to be abstinent (OR, 3.7; 95% CI 1.5 to 9.0) than those who had this discussion. Similarly, among men who intended to abstain from sex with any potentially exposed partner until the partner was tested for HIV and other STIs, those who reported not discussing the risks of infecting each other with HIV/STIs were more likely to be sexually active during this period (OR, 3.5; 95% CI 1.6 to 8.1) than were those who reported this communication.

CONCLUSIONS

Improved partner communication could facilitate an important role in the adoption of protective behaviours in the interval immediately after receiving a new STI diagnosis.

TRIAL REGISTRATION NUMBER

NCT00137670.

From Their Voices: Barriers to HIV Testing among Black Men Who Have Sex with Men Remain

Background: HIV testing continues to be a major priority for addressing the epidemic among young Black men who have sex with men (BMSM). Methods: This study explored barriers to HIV testing uptake, and recommendations for motivating HIV testing uptake among Black men who have sex with men (BMSM) aged 18 to 30. BMSM (N = 36) were recruited through flyers and social media for six focus groups. Results: From the perspectives and experiences of young BMSM, participants recommended that information be included in HIV testing messages that would help young BMSM do self HIV-risk appraisals. Particularly, participants recommended that more knowledge about Pre-Exposure Prophylaxis (PrEP) and the role of PrEP in safer-sex practices be provided. This information is important to help those untested, or who infrequently test, better understand their risk and need for testing. Likewise, participants recommended that more information about a person being undetectable and the risk of condomless sex with an HIV negative sex partner; this information will be helpful for both the HIV negative and HIV positive sex partner for making safer sex decisions. Participants also recommended that interventions should focus on more than drug use as risk; the risk posed by the use of alcohol before and during sex deserves attention among young BMSM. Conclusions: These findings may inform new HIV testing interventions being tailored for young BMSM. The interventions should also consider revisiting street-based peer-outreach approaches for those young BMSM with limited access to social media campaigns due to limited access or infrequent use of social media.

Consistency of Condom Use During Receptive Anal Intercourse Among Women and Men Who Have Sex With Men: Findings From the Safe in the City Behavioral Study

BACKGROUND

Unprotected receptive anal intercourse poses HIV risk for men who have sex with men (MSM) and heterosexual women. Little is known about differences in consistent condom use during anal intercourse among these populations.

METHODS

Data were analyzed from a nested study conducted from 2004 to 2005 within a behavioral intervention trial of approximately 40,000 urban US sexually transmitted disease clinic patients. Analyses were restricted to women and MSM who reported receptive anal intercourse with at least 1 partner in the prior 3 months at baseline, or 3-month follow-up surveys. Condom use was categorized as consistent (100% of receptive acts) or inconsistent/nonuse (0-99% of receptive acts). Multivariable regression with general estimating equations was used to identify factors associated with consistent condom use within each population.

RESULTS

Approximately 31% of women and 70% of MSM reported receptive anal intercourse at least once in the past 3 months. Men who have sex with men were significantly more likely to report consistent condom use compared with women. For women, intention to use condoms, partner support for condom use, the belief they could stop having sex when condoms were unavailable, and believing their partner had not given them a sexually transmitted infection (STI) were associated with using condoms consistently. For MSM, intention to use condoms, condom use self-efficacy, perceived partner support for condom use, having a nonmain partner, believing their partner had not given them an STI, and fewer sex acts were associated with consistent condom use.

CONCLUSIONS

Findings confirm the importance of considering anal intercourse when assessing STI/HIV risk in MSM and heterosexual women.

Relationship between social cognitive theory constructs and self-reported condom use: assessment of behaviour in a subgroup of the Safe in the City trial

OBJECTIVES

Previous studies have found social cognitive theory (SCT)-framed interventions are successful for improving condom use and reducing sexually transmitted infections (STIs). We conducted a secondary analysis of behavioural data from the Safe in the City intervention trial (2003-2005) to investigate the influence of SCT constructs on study participants' self-reported use of condoms at last intercourse.

METHODS

The main trial was conducted from 2003 to 2005 at three public US STI clinics. Patients (n=38,635) were either shown a 'safer sex' video in the waiting room, or received the standard waiting room experience, based on their visit date. A nested behavioural assessment was administered to a subsample of study participants following their index clinic visit and again at 3 months follow-up. We used multivariable modified Poisson regression models to examine the relationships among SCT constructs (sexual self-efficacy, self-control self-efficacy, self-efficacy with most recent partner, hedonistic outcome expectancies and partner expected outcomes) and self-reported condom use at last sex act at the 3-month follow-up study visit.

RESULTS

Of 1252 participants included in analysis, 39% reported using a condom at last sex act. Male gender, homosexual orientation and single status were significant correlates of condom use. Both unadjusted and adjusted models indicate that sexual self-efficacy (adjusted relative risk (RRa)=1.50, 95% CI 1.23 to 1.84), self-control self-efficacy (RRa=1.67, 95% CI 1.37 to 2.04), self-efficacy with most recent partner (RRa=2.56, 95% CI 2.01 to 3.27), more favourable hedonistic outcome expectancies (RRa=1.83, 95% CI 1.54 to 2.17) and more favourable partner expected outcomes (RRa=9.74, 95% CI 3.21 to 29.57) were significantly associated with condom use at last sex act.

CONCLUSIONS

Social cognitive skills, such as self-efficacy and partner expected outcomes, are an important aspect of condom use behaviour.

TRIAL REGISTRATION NUMBER

clinicaltrials.gov (NCT00137370).

Effect of risk-reduction counseling with rapid HIV testing on risk of acquiring sexually transmitted infections: the AWARE randomized clinical trial

IMPORTANCE

To increase human immunodeficiency virus (HIV) testing rates, many institutions and jurisdictions have revised policies to make the testing process rapid, simple, and routine. A major issue for testing scale-up efforts is the effectiveness of HIV risk-reduction counseling, which has historically been an integral part of the HIV testing process.

OBJECTIVE

To assess the effect of brief patient-centered risk-reduction counseling at the time of a rapid HIV test on the subsequent acquisition of sexually transmitted infections (STIs).

DESIGN, SETTING, AND PARTICIPANTS

From April to December 2010, Project AWARE randomized 5012 patients from 9 sexually transmitted disease (STD) clinics in the United States to receive either brief patient-centered HIV risk-reduction counseling with a rapid HIV test or the rapid HIV test with information only. Participants were assessed for multiple STIs at both baseline and 6-month follow-up.

INTERVENTIONS

Participants randomized to counseling received individual patient-centered risk-reduction counseling based on an evidence-based model. The core elements included a focus on the patient's specific HIV/STI risk behavior and negotiation of realistic and achievable risk-reduction steps. All participants received a rapid HIV test.

MAIN OUTCOMES AND MEASURES

The prespecified outcome was a composite end point of cumulative incidence of any of the measured STIs over 6 months. All participants were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum (syphilis), herpes simplex virus 2, and HIV. Women were also tested for Trichomonas vaginalis.

RESULTS

There was no significant difference in 6-month composite STI incidence by study group (adjusted risk ratio, 1.12; 95% CI, 0.94-1.33). There were 250 of 2039 incident cases (12.3%) in the counseling group and 226 of 2032 (11.1%) in the information-only group.

CONCLUSION AND RELEVANCE

Risk-reduction counseling in conjunction with a rapid HIV test did not significantly affect STI acquisition among STD clinic patients, suggesting no added benefit from brief patient-centered risk-reduction counseling.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01154296.

Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana

BACKGROUND

Preexposure prophylaxis with antiretroviral agents has been shown to reduce the transmission of human immunodeficiency virus (HIV) among men who have sex with men; however, the efficacy among heterosexuals is uncertain.

METHODS

We randomly assigned HIV-seronegative men and women to receive either tenofovir disoproxil fumarate and emtricitabine (TDF-FTC) or matching placebo once daily. Monthly study visits were scheduled, and participants received a comprehensive package of prevention services, including HIV testing, counseling on adherence to medication, management of sexually transmitted infections, monitoring for adverse events, and individualized counseling on risk reduction; bone mineral density testing was performed semiannually in a subgroup of participants.

RESULTS

A total of 1219 men and women underwent randomization (45.7% women) and were followed for 1563 person-years (median, 1.1 years; maximum, 3.7 years). Because of low retention and logistic limitations, we concluded the study early and followed enrolled participants through an orderly study closure rather than expanding enrollment. The TDF-FTC group had higher rates of nausea (18.5% vs. 7.1%, P<0.001), vomiting (11.3% vs. 7.1%, P=0.008), and dizziness (15.1% vs. 11.0%, P=0.03) than the placebo group, but the rates of serious adverse events were similar (P=0.90). Participants who received TDF-FTC, as compared with those who received placebo, had a significant decline in bone mineral density. K65R, M184V, and A62V resistance mutations developed in 1 participant in the TDF-FTC group who had had an unrecognized acute HIV infection at enrollment. In a modified intention-to-treat analysis that included the 33 participants who became infected during the study (9 in the TDF-FTC group and 24 in the placebo group; 1.2 and 3.1 infections per 100 person-years, respectively), the efficacy of TDF-FTC was 62.2% (95% confidence interval, 21.5 to 83.4; P=0.03).

CONCLUSIONS

Daily TDF-FTC prophylaxis prevented HIV infection in sexually active heterosexual adults. The long-term safety of daily TDF-FTC prophylaxis, including the effect on bone mineral density, remains unknown. (Funded by the Centers for Disease Control and Prevention and the National Institutes of Health; TDF2 ClinicalTrials.gov number, NCT00448669.).

The Relationship between Sexual Minority Verbal Harassment And Utilization of Health Services: Results from Countywide Risk Assessment Survey (CRAS) 2004

We examined the prevalence of and associations between sexual orientation-based verbal harassment and reported utilization of health services across levels of sexual orientation in a diverse sample of adult recipients of Los Angeles County-funded HIV-related health and social services. Thirty-two percent reported they had experienced verbal harassment, the majority (80.3%) of whom identified as lesbian, gay, orbisexual. Those who reported being verbally harassed received significantly more services overall than those who were not verbally harassed, and service utilization varied by sexual orientation. These findings inform future efforts to identify and assess social discrimination in health and social service settings.

Safe in the city: effective prevention interventions for human immunodeficiency virus and sexually transmitted infections

BACKGROUND

The public health literature documents the efficacy-effectiveness gap between research and practice resulting from the research priority of demonstrating efficacy at the expense of testing for effectiveness.

PURPOSE

The Safe in the City video-based HIV/sexually transmitted infection (STI) prevention intervention designed for sexually transmitted disease (STD) clinic waiting rooms is presented as a case study to demonstrate the application of a new framework to bridge efficacy and effectiveness. The goal of the study is to determine the extent to which clinics are implementing the intervention.

METHODS

As part of the case study, data were collected from a convenience sample of 81 publicly funded STD clinics during program implementation to determine whether clinics were showing the video. A baseline telephone survey was administered to clinic directors from November to December 2008, and a follow-up was conducted from March to May 2009. Data analysis was completed in 2009.

RESULTS

At baseline, 41% of STD clinics were showing Safe in the City, which increased to 58% at follow-up. None reported previous implementation of behavioral interventions delivered in waiting rooms. Almost one fourth of clinics adapted the intervention by showing the video on laptop computers in examination rooms or in other venues with different audiences.

CONCLUSIONS

The Safe in the City intervention was implemented by the majority of STD clinics and adapted for implementation. The framework for HIV/STI prevention intervention illustrates how measures of effectiveness were increased in the development, evaluation, dissemination, implementation and sustainability phases of research and program.

Condom use problems during anal sex among men who have sex with men (MSM): findings from the Safe in the City study

Our research aims were to: (1) assess the prevalence of two condom use problems: breakage or slippage and partial use (delayed application or early removal) among men who have sex with men (MSM) seeking services in urban US STD clinics; and (2) examine the association between these condom use problems and participant, partner and partnership characteristics. Analysis was restricted to HIV-negative MSM who reported having anal sex at least once in the preceding 3 months and who completed both the baseline and 3 month follow-up assessments. Two models were fitted using the generalized estimating equations (GEE) approach. A total of 263 MSM (median age=32 years) reported 990 partnerships. Partnerships with no condom use 422 (42.6%) were excluded. Thus, 207 MSM and 568 partnerships were included. Among condom users, 100% use was reported within 454 partnerships (79.9%) and <100% within 114 (20.1%), and 21(3.7%) reported both condom use problems, 25 (4.4%) reported only breakage, 67 (11.8%) reported only partial use, and 455 (80.1%) reported no errors. The breakage or slippage and partial use rates per condom used were 3.4% and 11.2%, respectively. A significantly higher rate of breakage or slippage occurred among non-main partnerships. Characteristics associated with increased odds for condom breakage or slippage were: lower education level (OR=2.78; CI: 1.1-7.5), non-main partner status (OR=4.1; CI: 1.5-11.7), and drunk or high during sex (OR=2.0; CI: 1.1-3.8), and for partial use: lower education level (OR=2.6; CI: 1.0-6.6), perceived partner sexually transmitted infections (STI) risk (OR=2.4; CI: 1.3-4.2), and inconsistent condom use (OR=3.7; CI: 2.0-6.6). A high percentage of MSM partnerships reported no condom use and among condom users, a sizable proportion did not use them consistently or correctly. MSM may benefit from interventions designed to increase proficiency for condom use with a particular focus on the behaviors of inconsistent and partial condom use.

Does health care setting matter in reports of discrimination?

We investigated the associations between the health care setting types that California adults report as their regular source of care, socioeconomic status, and perceived racial/ethnic medical care-related discrimination. Data were analyzed from the 2005 California Health Interview Survey (n = 36,694). Adults who identified clinics/health centers/hospital clinics or "other settings" as their usual source of health care had increased odds for perceived racial/ethnic discrimination compared with those who utilized private and health maintenance organizations doctors' offices, although this was true only for middle, but not lower or higher, socio-economic respondents. We suggest several explanations for these findings and improvements for assessing health care-based racial discrimination.

Effect of a brief video intervention on incident infection among patients attending sexually transmitted disease clinics

BACKGROUND

Sexually transmitted disease (STD) prevention remains a public health priority. Simple, practical interventions to reduce STD incidence that can be easily and inexpensively administered in high-volume clinical settings are needed. We evaluated whether a brief video, which contained STD prevention messages targeted to all patients in the waiting room, reduced acquisition of new infections after that clinic visit.

METHODS AND FINDINGS

In a controlled trial among patients attending three publicly funded STD clinics (one in each of three US cities) from December 2003 to August 2005, all patients (n = 38,635) were systematically assigned to either a theory-based 23-min video depicting couples overcoming barriers to safer sexual behaviors, or the standard waiting room environment. Condition assignment alternated every 4 wk and was determined by which condition (intervention or control) was in place in the clinic waiting room during the patient's first visit within the study period. An intent-to-treat analysis was used to compare STD incidence between intervention and control patients. The primary endpoint was time to diagnosis of incident laboratory-confirmed infections (gonorrhea, chlamydia, trichomoniasis, syphilis, and HIV), as identified through review of medical records and county STD surveillance registries. During 14.8 mo (average) of follow-up, 2,042 patients (5.3%) were diagnosed with incident STD (4.9%, intervention condition; 5.7%, control condition). In survival analysis, patients assigned to the intervention condition had significantly fewer STDs compared with the control condition (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.84 to 0.99).

CONCLUSIONS

Showing a brief video in STD clinic waiting rooms reduced new infections nearly 10% overall in three clinics. This simple, low-intensity intervention may be appropriate for adoption by clinics that serve similar patient populations.

TRIAL REGISTRATION

http://www.ClinicalTrials.gov (#NCT00137670).

Changes in sexual behavior and STD prevalence among heterosexual STD clinic attendees: 1993-1995 versus 1999-2000

OBJECTIVE

To examine trends in sex behaviors and STD prevalence over time among heterosexual STD clinic populations from 3 urban STD clinics in the United States.

STUDY DESIGN

Cross-sectional analysis comparing baseline data on risk (self-reported) and STDs (laboratory defined) from 2 randomized controlled trials evaluating counseling efficacy conducted about 5 years apart, Project RESPECT (1993-1995) and RESPECT-2 (1999-2000).

RESULTS

The participants from RESPECT (n = 2457) and RESPECT-2 (n = 3080) were demographically similar. However, the proportion of participants reporting any unprotected anal sex was much higher in RESPECT-2 (women: 7% vs. 18%; men: 7% vs. 17%). Also, substantially more participants reported a new sex partner in RESPECT-2 (women: 43% vs. 61%; men: 54% vs. 72%). In addition, more women reported 2 or more partners (37% vs. 48%) and a partner with another concurrent sex partner (19% vs. 32%). Slightly more women and men in RESPECT-2 reported 2 protective behaviors, having an HIV test and any condom use; however, consistent condom use did not differ. Conversely, the proportion of participants with bacterial STDs (chlamydia, gonorrhea, or syphilis) was much lower in RESPECT-2 (women: 24% vs. 18%; men: 38% vs. 24%).

CONCLUSIONS

Despite substantial promotion of safer sex behaviors over the past decade, many risk behaviors were stable over time, and some behaviors, such as unprotected anal sex, appeared substantially higher. Even in the absence of widespread behavior change, the prevalence of common bacterial STDs appeared to have decreased appreciably.

Patient and staff perspectives on the use of a computer counseling tool for HIV and sexually transmitted infection risk reduction

PURPOSE

To explore use of an interactive health communication tool--"Computer Assessment and Risk Reduction Education (CARE) for STIs/HIV."

METHODS

This was a mixed method study utilizing participant observation and in-depth interviews with patients (n = 43), and focus groups with staff (5 focus groups, n = 41) from 5 clinics in 3 states (1 Planned Parenthood, 1 Teen, 2 STD, and 1 mobile van clinic). Data were managed using Atlas.ti. Inter-rater reliability of qualitative coding was .90.

RESULTS

Users were 58% nonwhite with mean age 24.7 years (74% < 25). Patients could use CARE with minimal to no assistance. Time for session completion averaged 29.6 minutes. CARE usefulness was rated an average of 8.2 on an ascending utility scale of 0 to 10. Patient themes raised as strengths were novelty, simplicity, confidentiality, personalization, and plan development, increased willingness to be honest, lack of judgment, and a unique opportunity for self-evaluation. Staff themes raised as strengths were enhanced data collection, handout customization, education standardization, behavioral priming, and expansion of services. Patient limitation themes included limited responses and lack of personal touch. Staff limitation themes were selecting users, cost, patient-provider role, privacy, and time for use.

CONCLUSIONS

CARE was well-received and easily usable by most (especially 18-25-year-olds). Patient and staff perceptions support the use of CARE as an adjunct to usual practice and as a method to expand services. Honesty, reduced time constraints, and lack of judgment associated with CARE appeared to enhance self-evaluation, which may prove an important component in moving patients forward in the behavior change process.

Costs and cost-effectiveness of adolescent compliance with treatment for latent tuberculosis infection: results from a randomized trial

PURPOSE

Assess the costs and cost-effectiveness of an incentive-based tuberculosis (TB) program designed to promote adolescents' compliance with treatment for latent TB infection (LTBI).

METHODS

Randomized controlled trial. Adolescents between the ages of 11 and 19 years who were referred to one of two participating clinics after being screened for TB and receiving a positive diagnosis indicating LTBI (n = 794) were assigned to one of four groups: usual care, peer counseling, contingency contracting, and combined peer counseling/contingency contracting. Primary outcome variables were completion of isoniazid preventive therapy (IPT), total treatment costs, and lifetime TB-related costs per quality-adjusted life year (QALY) in each of the four study groups (three treatment, one control). Cost effectiveness was evaluated using a five-stage Markov model and a Monte Carlo simulation with 10,000 trials.

RESULTS

Average costs were 199 dollars for usual care (UC), 277 dollars for peer counseling (PC), 326 dollars for contingency contracting (CC), and 341 dollars for PC + CC combined. The differences among these groups were all significant at the p = .001 level. Only the PC + CC group improved the rate of IPT completion (83.8%) relative to usual care (75.9%) (p = .051), with an overall incremental CE ratio of 209 dollars per QALY relative to usual care.

CONCLUSION

Incentives combined with peer counseling are a cost-effective strategy for helping adolescents to complete care when combined with peer counseling.

High incidence of new sexually transmitted infections in the year following a sexually transmitted infection: a case for rescreening

BACKGROUND

Studies show 11% to 15% of women treated for Chlamydia trachomatis are reinfected 3 to 4 months after treatment, suggesting the need for rescreening. There is little information on infections among men, infections with Neisseria gonorrhoeae or Trichomonas vaginalis, or long-term follow-up.

OBJECTIVE

To determine the incidence of new sexually transmitted infections during the year after a visit to a sexually transmitted disease (STD) clinic and associated risk factors.

DESIGN

Secondary analysis of data from a randomized, controlled trial (RESPECT-2).

SETTING

3 urban STD clinics.

PATIENTS

Sexually active patients enrolled in an HIV prevention counseling trial.

MEASUREMENTS

Patient characteristics at the initial visit; behaviors during follow-up; and new infections with C. trachomatis, N. gonorrhoeae, or T. vaginalis (women only) detected during 4 scheduled return visits and any other interim visits.

RESULTS

2419 persons had 8129 three-month follow-up intervals. Among 1236 women, 25.8% had 1 or more new infections (11.9% acquired C. trachomatis, 6.3% acquired N. gonorrhoeae, and 12.8% acquired T. vaginalis); among 1183 men, 14.7% had 1 or more new infections (9.4% acquired C. trachomatis, and 7.1% acquired N. gonorrhoeae). Black persons and those with sexually transmitted infections at baseline were at highest risk for recurrent infection (adjusted odds ratio, 2.5 and 2.4, respectively). For persons infected at baseline, the risk for infection was high at 3 and 6 months (16.3 per 100 three-month intervals) and remained high at 9 and 12 months (12.0 per 100 three-month intervals). Most (67.2%) infections were diagnosed during study-related visits, and 66.2% of these patients reported no symptoms.

LIMITATIONS

Because patients were recruited from STD clinics, results may not be generalizable.

CONCLUSIONS

Men and women who receive diagnoses of C. trachomatis, N. gonorrhoeae, or T. vaginalis infections should return in 3 months for rescreening because they are at high risk for new asymptomatic sexually transmitted infections. Although single-dose therapy may adequately treat the infection, it often does not adequately treat the patient.

A Cost-Effectiveness Analysis of Interventions to Increase Repeat Testing in Patients Treated for Gonorrhea or Chlamydia at Public Sexually Transmitted Disease Clinics

BACKGROUND

Persons who have been infected with chlamydia or gonorrhea (CT/GC) are at elevated risk for reinfection. The cost-effectiveness of interventions designed to encourage public sexually transmitted disease (STD) clinic patients to return for rescreening has not been well-evaluated.

GOAL

The goal of this study was to conduct a program- and societal-perspective cost-effectiveness analysis of five interventions designed to encourage public STD clinic patients infected with CT/GC to return for rescreening 3 months after initial treatment.

STUDY

Researchers at two STD clinics collected cost data for the five interventions. These were combined with study data on return rates and CT/GC positivity rates among returning patients to compare the cost-effectiveness of the interventions.

RESULTS

The cost per patient counseled with a brief recommendation to return, followed by a telephone reminder after 3 months, was higher than two interventions: a brief recommendation to return with no reminder and a $20 incentive, received on return. However, the brief recommendation with a telephone reminder yielded the highest return rate (33%) and was the least costly in terms of cost per infection treated ($622 program, $813 societal). In-depth motivational counseling that helped clients identify risk factors and provided reasons for returning was more costly than a phone reminder alone and was not more effective.

CONCLUSIONS

Phone reminders are more cost-effective than motivational counseling and improve return rates over a brief recommendation given at the time of initial treatment.

A community-based intervention designed to increase preventive health care seeking among adolescents: the Gonorrhea Community Action Project

OBJECTIVES

We evaluated the effectiveness of an intervention designed to increase preventive health care seeking among adolescents.

METHODS

Adolescents and young adults aged 12 to 21 years, recruited from community-based organizations in 2 different communities, were randomized into either a 3-session intervention or a control condition. We estimated outcomes from 3-month follow-up data using logistic and ordinary least squares regression.

RESULTS

Female intervention participants were significantly more likely than female control participants to have scheduled a health care appointment (odds ratio [OR]=3.04), undergone a checkup (OR=2.87), and discussed with friends or family members the importance of undergoing a checkup (OR=4.5). There were no differences between male intervention and male control participants in terms of outcomes.

CONCLUSIONS

This theory-driven, community-based group intervention significantly increased preventive health care seeking among female adolescents. Further research is needed, however, to identify interventions that will produce successful outcomes among male adolescents.

Efficacy of a booster counseling session 6 months after HIV testing and counseling: a randomized, controlled trial (RESPECT-2)

BACKGROUND

HIV counseling prevents sexually transmitted diseases (STDs), with most of the benefit accumulating in the first 6 months.

STUDY

The authors conducted a multicenter, randomized, controlled trial of a 20-minute additional (booster) counseling session 6 months after HIV counseling compared with no additional counseling for prevention of STDs (gonorrhea, chlamydia, trichomoniasis). Participants were 15- to 39-year-old STD clinic patients in Denver, Long Beach, and Newark.

RESULTS

Booster counseling was completed by 1120 (67.8%) of 1653 assigned to receive it. An incident STD during the 6 to 12 months after initial counseling (and within the 6 months after scheduled booster counseling) was detected in 141 of 1653 (8.5%) participants in the booster counseling group and 144 of 1644 (8.8%) in the no-booster group (relative risk, 0.97; 95% confidence interval, 0.78-1.22). Three months after booster counseling, sexual risk behaviors were reported less frequently by the booster group than the no-booster group.

CONCLUSIONS

Booster counseling 6 months after HIV testing and counseling reduced reported sexual risk behavior but did not prevent STDs.

Relative Efficacy of Prevention Counseling With Rapid and Standard HIV Testing: A Randomized, Controlled Trial (RESPECT-2)

BACKGROUND

Two risk-reduction counseling sessions can prevent sexually transmitted diseases (STDs); however, return rates for test results are low.

STUDY

A randomized, controlled trial compared rapid HIV testing and counseling in 1 visit with standard HIV testing and counseling in 2 visits. Main outcomes were STDs (gonorrhea, chlamydia, trichomoniasis, syphilis, HIV) within 12 months. Participants were 15- to 39-year-old STD clinic patients in Denver, Long Beach, and Newark. STD screening and questionnaires were administered every 3 months.

RESULTS

Counseling was completed by 1632 of 1648 (99.0%) of the rapid-test group and 1144 of 1649 (69.4%) of the standard-test group. By 12 months, STD was acquired by 19.1% of the rapid group and 17.1% of the standard group (relative risk [RR], 1.11; confidence interval [CI], 0.96-1.29). STD incidence was higher in the rapid-test group than in the standard-test group among men (RR, 1.34; CI, 1.06-1.70), men who had sex with men (RR, 1.86; 95% CI, 0.92-3.76), and persons with no STDs at enrollment (RR, 1.21; 95% CI, 0.99-1.48). Behavior was similar in both groups.

CONCLUSIONS

Counseling with either test had similar effects on STD incidence. For some persons, counseling with standard testing may be more effective than counseling with rapid testing.

Factors associated with sexually transmitted disease clinic attendance

Most people in the United States who are infected with sexually transmitted diseases (STDs) do not attend STD clinics for treatment in spite of the low-cost efficacious treatment. We asked a clinic and a community sample about perceived benefits and problems of attending an STD clinic. Analyses yielded two treatment-oriented and two socially oriented, factors, which were also expressed in qualitative interviews. Further analyses suggested that treatment-oriented factors were more strongly associated with clinic attendance than were social factors, although respondents were more positive about expected quality of treatment than they were about retaining confidentiality. We suggest that implications of the results favor integrating STD care with other health care.

Comparison of Methods to Increase Repeat Testing in Persons Treated for Gonorrhea and/or Chlamydia at Public Sexually Transmitted Disease Clinics

BACKGROUND

Retesting 3 to 4 months after treatment for those infected with chlamydia and/or gonorrhea has been recommended.

GOAL

We compared various methods of encouraging return for retesting 3 months after treatment for chlamydia or gonorrhea.

STUDY

In study 1, participants were randomly assigned to: 1) brief recommendation to return, 2) intervention 1 plus $20 incentive paid at return visit, or 3) intervention 1 plus motivational counseling at the first visit and a phone reminder at 3 months. In study 2, participants at 1 clinic were randomly assigned to 4) intervention 1, 5) intervention 1 plus phone reminder, or 6) intervention 1 plus motivational counseling but no telephone reminder.

RESULTS

Using multiple logistic regression, the odds ratios for interventions 2 and 3, respectively, compared with intervention 1 were 1.2 (95% confidence interval [CI], 0.6-2.5) and 2.6 (95% CI, 1.3-5.0). The odds ratios for interventions 5 and 6 compared with intervention 4 were 18.1 (95% CI, 1.7-193.5) and 4.6 (95% CI, 0.4-58.0).

CONCLUSIONS

A monetary incentive did not increase return rates compared with a brief recommendation. A reminder phone call seemed to be the most effective method to increase return.

Seroepidemiology of infection with human papillomavirus 16, in men and women attending sexually transmitted disease clinics in the United States

BACKGROUND

The study sought to characterize the seroprevalence, seropersistence, and seroincidence of human papillomavirus (HPV)-16 antibody, as well as the behavioral risk factors for HPV-16 seropositivity.

METHODS

Serologic data at baseline and at 6- and 12-month follow-up visits were used to examine the seroprevalence, seropersistence, and seroincidence of HPV-16 antibody in 1595 patients attending United States clinics treating sexually transmitted disease. Testing for antibody to HPV-16 was performed by capture enzyme-linked immunosorbent assay (ELISA) using viruslike particles.

RESULTS

The seroprevalence of HPV-16 antibody was 24.5% overall and was higher in women than in men (30.2% vs. 18.7%, respectively). In those who were HPV-16 seropositive at baseline, antibody response persisted to 12 months in 72.5% of women and in 45.6% of men. The seroincidence of HPV-16 antibody was 20.2/100 person-years (py) overall, 25.4/100 py in women, and 15.7/100 py in men. In multivariate analysis, the seroprevalence of HPV-16 antibody was significantly associated with female sex, age >20 years, and the number of episodes of sex with occasional partners during the preceding 3 months, whereas the seroincidence of HPV-16 antibody was significantly associated with female sex, age >20 years, baseline negative ELISA result greater than the median value, and the number of episodes of unprotected sex with occasional partners during the preceding 3 months.

CONCLUSION

Sex- and age-related differences in both the seropositivity and seroincidence of HPV-16 antibody persisted after adjustment for behavioral and sociodemographic risk factors, and behavioral risk factors during the preceding 3 months were stronger predictors of the seroprevalence and seroincidence of HPV-16 antibody than was lifetime sexual behavior.

Is HIV/sexually transmitted disease prevention counseling effective among vulnerable populations?: a subset analysis of data collected for a randomized, controlled trial evaluating counseling efficacy (Project RESPECT)

OBJECTIVE

The objective of this study was to evaluate counseling efficacy among high-risk groups.

STUDY

We conducted a subset analysis of data collected from July 1993 through September 1996 during a randomized, controlled trial (Project RESPECT). Participants (n = 4328) from 5 public U.S. sexually transmitted disease (STD) clinics were assigned to enhanced counseling, brief counseling, or educational messages. For 9 subgroups (sex, age, city, education, prior HIV test, STD at enrollment, race/ethnicity, injection drug use, exchanging sex for money/drugs), we compared STD outcomes for those assigned either type of counseling with STD outcomes for those assigned educational messages.

RESULTS

After 12 months, all subgroups assigned counseling (brief or enhanced) had fewer STDs than those assigned educational messages. STD incidence was similar for most subgroups assigned enhanced or brief counseling. All subgroups had an appreciable number of STDs prevented per 100 persons counseled, especially adolescents (9.4 per 100) and persons with STD at enrollment (8.4 per 100).

CONCLUSIONS

HIV/STD prevention counseling (brief or enhanced counseling) resulted in fewer STDs than educational messages for all subgroups of STD clinic clients, including high-risk groups such as adolescents and persons with STDs at enrollment.

Incidence of herpes simplex virus type 2 infection in 5 sexually transmitted disease (STD) clinics and the effect of HIV/STD risk-reduction counseling

The seroincidence of herpes simplex virus type 2 (HSV-2) infection was determined among 1766 patients attending sexually transmitted disease (STD) clinics and enrolled in a randomized, controlled trial of human immunodeficiency virus (HIV)/STD risk-reduction counseling (RRC). Arm 1 received enhanced RRC (4 sessions); arm 2, brief RRC (2 sessions); and arm 3, the control arm, brief informational messages. The overall incidence rate was 11.7 cases/100 person-years (py). Independent predictors of incidence of HSV-2 infection included female sex; black race; residence in Newark, New Jersey; <50% condom use with an occasional partner; and, in females, incident trichomoniasis and bacterial vaginosis. Only 10.8% of new HSV-2 infections were diagnosed clinically. Incidence rates were 12.9 cases/100 py in the control arm, 11.8 cases/100 py in arm 2, and 10.3 cases/100 py in arm 1 (hazard ratio, 0.8 [95% confidence interval, 0.6-1.1], vs. controls). The possible benefit of RRC in preventing acquisition of HSV-2 infection offers encouragement that interventions more specifically tailored to genital herpes may be useful and should be an important focus of future studies.

Are counselor demographics associated with successful human immunodeficiency virus/sexually transmitted disease prevention counseling?

BACKGROUND AND OBJECTIVE

HIV prevention counseling has changed behavior and reduced incident sexually transmitted diseases (STDs) in research participants.

GOAL

This article assesses whether counselor demographics or counselor-client dyad characteristics influenced prevention counseling in Project RESPECT as measured by intervention completion and incident STD after counseling.

STUDY DESIGN

We analyzed data from Project RESPECT, a randomized, controlled trial of HIV counseling interventions in STD clinics.

RESULTS

There was no significant association between client failure to complete the intervention and demographic characteristics of the 32 counselors or dyad characteristics. Clients who did not complete the intervention were significantly more likely to acquire a new STD infection by the 12-month visit than those who completed the intervention (adjusted odds ratio, 1.7; confidence interval, 1.2-2.4). There was no significant association between new STDs and counselor characteristics or dyad characteristics.

CONCLUSIONS

Counselor or counselor-client dyad characteristics evaluated in this study were not associated with intervention completion or the prevention of new STDs.

Condom effectiveness for reducing transmission of gonorrhea and chlamydia: the importance of assessing partner infection status

This analysis examined the importance of differential exposure to infected partners in epidemiologic studies of latex condom effectiveness for prevention of sexually transmitted infections. Cross-sectional, enrollment visit data were analyzed from Project RESPECT, a trial of counseling interventions conducted at five publicly funded US sexually transmitted disease clinics between 1993 and 1997. The association between consistent condom use in the previous 3 months and prevalent gonorrhea and chlamydia (Gc/Ct) was compared between participants known to have infected partners and participants whose partner infection status was unknown. Among 429 participants with known Gc/Ct exposure, consistent condom use was associated with a significant reduction in prevalent gonorrhea and chlamydia (30% vs. 43%; adjusted prevalence odds ratio = 0.42, 95% confidence interval: 0.18, 0.99). Among 4,314 participants with unknown Gc/Ct exposure, consistent condom use was associated with a lower reduction in prevalent gonorrhea and chlamydia (24% vs. 25%; adjusted prevalence odds ratio = 0.82, 95% confidence interval: 0.66, 1.01). The number of unprotected sex acts was significantly associated with infection when exposure was known (p for trend < 0.01) but not when exposure was unknown (p for trend = 0.73). Restricting analyses to participants with known exposure to infected partners provides a feasible and efficient mechanism for reducing confounding from differential exposure to infected partners in condom effectiveness studies.

Chlamydia trachomatis among patients infected with and treated for Neisseria gonorrhoeae in sexually transmitted disease clinics in the United States

BACKGROUND

For two decades, treatment guidelines for sexually transmitted diseases (STDs) have recommended empirical co-treatment for chlamydia when patients are treated for gonorrhea. Because the epidemiology of and diagnostic testing for STDs have changed over time, co-treatment may no longer be needed as a clinical or public health strategy.

OBJECTIVE

To assess the prevalence of chlamydia among patients at STD clinics who are infected with and treated for Neisseria gonorrhoeae and to determine whether co-treatment recommendations are still justified.

DESIGN

Cross-sectional analysis of data from a multisite study.

SETTING

Five public STD clinics (Baltimore, Maryland; Denver, Colorado; Long Beach, California; Newark, New Jersey; and San Francisco, California), July 1993 through October 1995.

PATIENTS

3885 heterosexual patients (2184 men and 1701 women) who agreed to participate in a trial of counseling interventions and had conclusive results from diagnostic tests for gonorrhea and chlamydia performed routinely as part of the trial.

MEASUREMENTS

Infection with Chlamydia trachomatis as determined by polymerase chain reaction.

RESULTS

Chlamydia trachomatis was detected in 20% (95% CI, 16% to 24%) of 411 men and 42% (CI, 35% to 50%) of 151 women with laboratory-confirmed N. gonorrhoeae. Chlamydia trachomatis was detected in 19% (CI, 15% to 22%) of 410 men and 35% (CI, 28% to 43%) of 154 women with treatment indications for gonorrhea who would not otherwise have been treated for chlamydia: chlamydia prevalence among these patients was significantly higher than among patients without treatment indications for either gonorrhea or chlamydia: 7% in men and 9% in women (relative risk, 2.58 [CI, 1.92 to 3.47] and 4.12 [CI, 3.05 to 5.57], respectively).

CONCLUSION

The frequent presence of chlamydia among patients at STD clinics who received treatment for gonorrhea, including sex partners of gonorrhea-infected patients, supports continuing current recommendations for co-treatment.

Assessment of tuberculosis treatment completion in an ethnically diverse population using two data sources. Implications for treatment interventions

Many adolescents who are prescribed therapy for tuberculosis (TB) infection fail to complete it. This article presents the results of a demographic and epidemiological assessment of TB treatment completion in adolescent populations using (a) surveillance data from the Los Angeles Health County Department and (b) a prospective/retrospective medical chart review from targeted clinics. Patients who did not complete the 6-month recommended medical treatment for latent tuberculosis therapy (LTBI) averaged 13 weeks in care. Younger age (OR = 1.15; 95% CI 1.03-1.29), birth in the United States (OR = 1.92; 95% CI 1.14-3.22, compared to Mexico), and Asian ethnicity were associated with completion of care. In multiple logistic regression analysis, age (OR = .88; 95% CI .78-.98) and Latino ethnicity (OR = .53; 95% CI .29-.95) remained significant predictors of completion of treatment. These findings indicate the need for age-specific educational reinforcement and cultural differentials in completing care for LTBI.

Seroprevalence and correlates of herpes simplex virus type 2 infection in five sexually transmitted-disease clinics

The seroprevalence of herpes simplex virus type 2 (HSV-2) infection was studied among 4128 patients from sexually transmitted disease (STD) clinics who were enrolled in a randomized controlled trial of human immunodeficiency virus and STD counseling efficacy. HSV-2 seroprevalence was 40.8% and was higher in women than in men (52.0% vs. 32.4%; P<.0001) and higher in blacks than in nonblacks (48.1% vs. 29.6%; P<.0001). Among 14-19-year-old patients, 36.8% of black women and 25.8% of nonblack women were infected with HSV-2. Independent predictors of HSV-2 seropositivity included female sex, black race, older age, less education, more lifetime sex partners, prior diagnosis of syphilis or gonorrhea, and lack of HSV-1 antibody. The majority of HSV-2-seropositive persons (84.7%) had never received a diagnosis of genital herpes. HSV-2 infection is common in STD clinic attendees in the United States, even among young age groups, especially among women. Efforts to prevent genital herpes should begin at an early age. The high rate of undiagnosed HSV-2 infection likely contributes to ongoing transmission.

Behavioral interventions for the control of tuberculosis among adolescents

OBJECTIVES

Activation of latent tuberculosis infection into tuberculosis disease (TB), the primary killer among infectious diseases worldwide, can be prevented with six months of anti-TB medication. A large percentage of adolescents started on medication, however, fail to complete their treatment. The authors developed and tested the effects of innovative educational strategies on infected adolescents at two health centers serving ethnically diverse populations.

METHODS

The authors used a randomized experimental four-group design to assess the independent and combined effects of peer counseling and a participant-parent contingency contract intervention.

RESULTS

A total of 794 adolescents were recruited into the study, for a 79% participation rate. The overall rate of treatment completion was 79.8%. Self-efficacy for medication-taking behavior at post-test correlated strongly with completion of care (R = 0.367, p = 0.002). Participants randomized to the peer counseling groups demonstrated significantly greater improvements in self-efficacy and mastery than the usual care control group. Based on the study results, continuing education seminars and workshops were implemented for TB control staff at the two health clinics and for all TB Control Division staff at the Los Angeles County Health Department. Educational materials and a training manual for enhancing completion of treatment of latent TB infection through tailored educational approaches were developed and disseminated to the clinics.

CONCLUSIONS

Health education and incentives are helpful adjuncts to the completion of treatment for latent tuberculosis infection in adolescents.

Relationships of stigma and shame to gonorrhea and HIV screening

OBJECTIVES

The purpose of this study was to assess the relationships between stigma and shame associated with seeking treatment for sexually transmitted diseases (STDs) and undergoing testing for gonorrhea and HIV.

METHODS

Participants were 847 males and 1126 females (mean age: 24.9 years) in 7 cities. Two scales assessed STD-related stigma and STD-related shame.

RESULTS

Rates of stigma and shame were higher among participants without a gonorrhea test in the past year and among those without an HIV test. Sex, age, health service use, previous suspicion of gonorrhea, and low levels of stigma were independently associated with gonorrhea testing. Age, enrollment site, use of health services, gonorrhea testing, and low levels of stigma were independently associated with HIV testing.

CONCLUSIONS

Shame is part of the experience of seeking STD-related care, but stigma may be a more powerful barrier to obtaining such care.

Designing partner-notification programs to maximize client participation: a factorial survey approach

BACKGROUND

Factorial survey methods were used to elicit preferences for partner-notification contact, interviewing, and treatment procedures. Most of the experimental alternatives were not rated as highly as standard practice, although there were differences in ratings in accordance with respondents' roles as infected persons or sex partners of infected persons.

GOAL

To report on research that identifies the preferences of clients and potential clients for different features of partner-notification programs.

STUDY DESIGN

A factorial survey was used to investigate which aspects of current and potential partner-notification programs increase the likelihood of cooperation. Six dimensions defined the hypothetical programs: (1) the sex of the client, (2) the ethnicity of the person meeting with the client,(3) the location of the first meeting with the client, (4) the method of collecting data on sex partners, (5) the contact and referral methods for partners, and (6) how infected sex partners receive medical treatment. Respondents (n = 186) were recruited from a county-run STD clinic, a community clinic, and a community-based organization that primarily provided drug treatment. Each respondent evaluated five different vignettes from two different perspectives: (1) as an infected person and (2) as a sex partner of an infected person.

RESULTS

Regression analysis of the responses showed that most experimental approaches to partner notification were negatively evaluated in comparison with evaluations for the conventional program description. There were some differences between the two sets of results, depending on the role of the respondent, suggesting that as sex partners of infected persons, respondents are less concerned about confidentiality at the notification stage but more concerned about it at the treatment stage. Finally, there was no effect of the ethnic or sex match between the disease intervention specialist program staff and the client; this demonstrates that professionalism and training can overcome cultural or ethnic disparities between program staff and clients.

'Don't know' and 'didn't think of it': condom use at first intercourse by Latino adolescents

We examined the specific reasons Latino adolescents did or did not use condoms at first intercourse and their specific reasons for their perceived risk for contracting HIV. Latino adolescents (n = 618), ages 11-19, completed a face-to-face interview that included information on demographics (sex, age, family-status (lives with both natural parents versus other family structure) and country of birth) and sexual behaviour. The respondents cited 'don't know' (25.9%), 'not available' (25.9%) and 'didn't think of it' (23.5%) as the most frequent reasons for not using condoms at first intercourse. Anyone can get it (41.8%), unknown knowledge of partner's serostatus (24.7%) and unprotected sex (23.8%) were the top three reasons for perceiving oneself as being at risk for contracting HIV. Sexually active adolescents were more likely to perceive themselves at risk for contracting HIV than adolescents that had not had sex. Males were significantly more likely to report using condoms for protection at first intercourse than females. The remaining demographic factors were not significantly related to use of condoms at first intercourse nor to perceived risk for contracting HIV.

Patterns of adolescent alcohol, cigarette, and marijuana use over a 6-month period

In the current study, alcohol, cigarette, and marijuana use among adolescents (N= 794, 48.6% female) was assessed at two time points, and four patterns of use were identified: (1) abstainers: no lifetime use; (2) new users: no use at baseline but had used by the follow-up period; (3) experimenters: use prior to the baseline but no use in the period up to the follow-up; and (4) consistent users: self-report of use prior to the baseline and the follow-up. Mean levels of psychosocial variables (mastery, self-esteem, and parental social support) were compared across the four patterns of use for each substance. Only analyses including parental social support as the dependent variable were significant. Adolescents with higher levels of social support were more likely to be classified as abstainers or experimenters of alcohol than consistent users. More frequent users of cigarettes at baseline were likely to be classified as frequent users at the follow-up. The discussion focuses on the identification of the situational context of substance use for alcohol, cigarettes, and marijuana.

Incentives vs outreach workers for latent tuberculosis treatment in drug users

BACKGROUND

Drug users are at increased risk for latent tuberculosis infection (LTBI) and also at increased risk for noncompletion of medication regimens for treatment of LTBI or tuberculosis disease. Directly observed therapy (DOT) provided by outreach workers, the use of incentives, or both have been suggested as a means to increase adherence.

OBJECTIVE

To compare the independent and combined effects of monetary incentives and outreach worker provision of DOT for LTBI treatment in a sample of active drug users.

METHODS

The research design was a randomized controlled trial in a community outreach program setting. Participants consisted of a volunteer sample of 163 active injection drug and crack cocaine users placed on twice weekly DOT. Condition 1 of the interventions consisted of provision of DOT by an outreach worker at a location chosen by the participant (active outreach) and a $5 per visit incentive. Condition 2 was comprised of active outreach with no monetary incentive, and Condition 3, provision of DOT at the study community site and a $5 per visit incentive. The main outcome measures were percentage of medication taken as prescribed and completion of medication regimen.

RESULTS

The percentage of prescribed medication taken was higher for those who received incentives, either with (71%) or without (68%) active outreach, compared to those who received active outreach alone (13%). Only 4% of participants assigned to Condition 2 completed treatment, compared to 53% of Condition 1 participants, and 60% of Condition 3 participants.

CONCLUSIONS

Monetary incentives were clearly superior to active outreach. Active outreach in combination with monetary incentives did not increase adherence over incentives alone.

Structure of outcome beliefs in condom use. The Project RESPECT Study Group

To study the structure of beliefs about condom use outcomes, the authors derived and tested 4 psychosocial hypothetical models: (a) a 2-factor model of the personal and social outcomes of condom use; (b) a 2-factor model of the pros and cons of the behavior; (c) a 3-factor model (i.e., physical, self-evaluative, and social) of outcome expectancies; and (d) a thematic 4-factor model of the protection, self-concept, pleasure, and interaction implications of the behavior. All 4 models were studied with a confirmatory factor analysis approach in a multisite study of 4,638 participants, and the thematic solution was consistently the most plausible. Self-concept and pleasure were most strongly associated with attitudes toward using condoms, intentions to use condoms, and actual condom use, whereas protection and interaction generally had little influence.

Behavioral interventions for the control of tuberculosis among adolescents

OBJECTIVES

Activation of latent tuberculosis infection into tuberculosis disease (TB), the primary killer among infectious diseases worldwide, can be prevented with six months of anti-TB medication. A large percentage of adolescents started on medication, however, fail to complete their treatment. The authors developed and tested the effects of innovative educational strategies on infected adolescents at two health centers serving ethnically diverse populations.

METHODS

The authors used a randomized experimental four-group design to assess the independent and combined effects of peer counseling and a participant-parent contingency contract intervention.

RESULTS

A total of 794 adolescents were recruited into the study, for a 79% participation rate. The overall rate of treatment completion was 79.8%. Self-efficacy for medication-taking behavior at post-test correlated strongly with completion of care (R = 0.367, p = 0.002). Participants randomized to the peer counseling groups demonstrated significantly greater improvements in self-efficacy and mastery than the usual care control group. Based on the study results, continuing education seminars and workshops were implemented for TB control staff at the two health clinics and for all TB Control Division staff at the Los Angeles County Health Department. Educational materials and a training manual for enhancing completion of treatment of latent TB infection through tailored educational approaches were developed and disseminated to the clinics.

CONCLUSIONS

Health education and incentives are helpful adjuncts to the completion of treatment for latent tuberculosis infection in adolescents.

Acculturation and interrelationships between problem and health-promoting behaviors among Latino adolescents

PURPOSE

To examine: (a) the effects of acculturation on a healthy lifestyle including problem behaviors (substance use and sex acts) and health-promoting behaviors (e.g., seat belt use, vitamin intake, hours of sleep per night) and (b) the interrelationships among problem and health-promoting behaviors among Latino adolescents.

METHODS

Face-to-face interviews were conducted with Latino adolescents (n = 609) with questions covering the following areas: acculturation, sociodemographics, problem behaviors, and health-promoting behaviors. The participants ranged in age from 11 to 19 (mean = 15) years. Bivariate correlations and factor analyses were used to examine the relationship between problem and health-promoting behaviors. A combination of one-way analyses of variance (ANOVAs), Chi-square tests, and Student's t-tests were used to analyze the effects of acculturation on problem and health-promoting behaviors.

RESULTS

Higher levels of acculturation were associated with an increased likelihood of exhibiting problem behaviors and a decreased likelihood of exhibiting certain health-promoting behaviors. Foreign-born Latinos were significantly less likely to engage in problem behaviors. Problem behaviors were likely to co-occur; however, the co-occurrence of health-promoting behaviors was not evident. The results also revealed the co-occurrence of problem behaviors with selected health-promoting behaviors.

CONCLUSIONS

Among Latino adolescents, there seems to be evidence that problem behaviors and certain health-promoting behaviors do co-occur. To the extent that "healthy lifestyles" are conceptualized as the presence of health-promoting behaviors and the absence of problem behaviors, less acculturated Latino adolescents seem to fare better than those that are more acculturated. Interventions to promote "healthy lifestyles" among Latino adolescents should be tailored to take into consideration the effect of acculturation.

Structure of outcome beliefs in condom use. The Project RESPECT Study Group

To study the structure of beliefs about condom use outcomes, the authors derived and tested 4 psychosocial hypothetical models: (a) a 2-factor model of the personal and social outcomes of condom use; (b) a 2-factor model of the pros and cons of the behavior; (c) a 3-factor model (i.e., physical, self-evaluative, and social) of outcome expectancies; and (d) a thematic 4-factor model of the protection, self-concept, pleasure, and interaction implications of the behavior. All 4 models were studied with a confirmatory factor analysis approach in a multisite study of 4,638 participants, and the thematic solution was consistently the most plausible. Self-concept and pleasure were most strongly associated with attitudes toward using condoms, intentions to use condoms, and actual condom use, whereas protection and interaction generally had little influence.

Does measured behavior reflect STD risk? An analysis of data from a randomized controlled behavioral intervention study. Project RESPECT Study Group

BACKGROUND

Many studies measure sex behavior to determine the efficacy of sexually transmitted disease (STD)/HIV prevention interventions.

GOAL

To determine how well measured behavior reflects STD incidence.

STUDY DESIGN

Data from a trial (Project RESPECT) were analyzed to compare behavior and incidence of STD (gonorrhea, chlamydia, syphilis, HIV) during two 6-month intervals.

RESULTS

A total of 2879 persons had 5062 six-monthly STD exams and interviews; 8.9% had a new STD in 6 months. Incidence was associated with demographic factors but only slightly associated with number of partners and number of unprotected sex acts with occasional partners. Many behaviors had paradoxical associations with STD incidence. After combining behavior variables to compare persons with highest and lowest risk behaviors, the STD incidence ratio was only 1.7.

CONCLUSION

Behavioral interventions have prevented STD. We found people tend to have safe sex with risky partners and risky sex with safe partners. Therefore, it is difficult to extrapolate the disease prevention efficacy of an intervention from a measured effect on behavior alone.