U.S. Preventive Services Task Force (USPSTF)
Discussion
On the basis of primary care–relevant trial data, good evidence suggests the effectiveness of moderate- to high-intensity behavioral counseling in reducing the incidence of overall STIs (excluding herpes simplex virus) in high-risk adult and sexually active adolescent populations, with more robust evidence for common bacterial STIs (such as gonorrhea and chlamydia) (Table 3). In general, the body of evidence from trials using self-reported behavior outcomes supports the interpretation of the evidence using biological outcomes. We found no trials evaluating the effectiveness of behavioral counseling interventions to prevent STIs in truly low-risk populations, because even trials conducted in primary care settings included only persons at higher risk (for example, sexually active adolescents, young adults age < 25 years) (Figure 3).
On the basis of 11 trials, no substantial harm is evident in counseling interventions for adults or adolescents (Table 3). In young adolescents, low-intensity risk reduction behavioral counseling transiently increased self-reported vaginal sexual intercourse in young adolescents. The importance of this transient finding is unclear, however, given that no change in overall sexual activity or vaginal sexual activity was apparent by the end of the trial at 9 months.21 Only 1 study reported on sexual debut, and it found that risk reduction counseling did not increase sexual activity in participants who were previously not sexually active.28 We found no trials for risk avoidance or abstinence-only counseling that met our inclusion criteria. Therefore, we could not assess potential harms or benefits associated with these types of counseling interventions. Our findings are consistent with a recent meta-analysis that included all studies examining a deliberate HIV risk reduction counseling intervention in a nonperinatal context, which found no inadvertent increase in the number of sexual occasions or sexual partners.29
Given the clinical heterogeneity among these trials, we could not draw definitive conclusions about the differential effect of interventions on specific populations or the differential effect of specific intervention elements (for example, theory, content, format, and intensity). On the basis of this body of evidence, however, population risk and intervention intensity seem to be the biggest predictors of a
counseling intervention's effect on STI incidence and self-reported behavior change. In general, there is more trial evidence in female than in male adults and adolescents. In adults, evidence for specific high-risk populations is strong: black and Hispanic populations, low-income urban populations, populations with a high baseline prevalence of STIs or history of STIs (20% to 100%), and persons with major psychiatric disease and comorbid recent history of substance abuse. Evidence for sexually active adolescents is also strong, specifically for ethnically diverse and low-income, urban, adolescent populations.
Intervention intensity, more than format or a particular behavioral model, may also be an important factor in the effectiveness of counseling interventions. However, no low-intensity or single-visit counseling interventions were used in the highest-risk populations (that is, trials conducted in STI clinics). The range of intensity for effective interventions was 40 minutes delivered in 2 sessions with
HIV testing17 to 18 hours over 9 sessions.25 One trial showed a potential benefit for a low-intensity (20-minute, one-to-one counseling) intervention to decrease laboratory-tested STIs at 12 months, but it did not include separate analysis of the low-intensity intervention group, probably because of statistical power limitations.13 Two trials in high-risk populations conducted in primary care (n = 1429) did not show a reduction in the incidence of self-reported STIs using low-intensity interventions.13,20-21 All effective interventions were based on individual risk-based counseling and included tailored risk reduction plans. Most of these interventions were developed with some amount of formative research within the targeted population. For adolescents, 2 of the effective interventions also included instruction on condom skills. In 1 of Jemmott and colleagues' studies, only the condom skills intervention group showed an effect on STI reduction.22 All effective interventions were based on common behavioral models, including the AIDS risk reduction model, cognitive behavioral theories, harm reduction, stages of change theory and motivational techniques, theory of reasoned action, and social cognitive theory. These behavioral models and social theories, however, were also the basis for interventions that did not show a risk reduction in STIs or behavioral change in high-risk populations seen in primary care.20-21,28
This body of evidence has several limitations. First, trials reporting STI incidence with non–statistically significant intervention effects do not imply that the interventions are ineffective.14,18,20-21, The overall incidence of even common bacterial STIs is relatively low. These studies, therefore, are subject to type II measurement error (such as inadequate power). Second, trials for key question 2 using self-reported behavioral outcomes should be interpreted with caution, especially if there is no consistency in direction or magnitude of effect among different behavioral outcomes. Self-reported STI incidence and self-reported behavioral outcomes are particularly subject to both assessment and reporting bias30, although methodological improvements in measurement can reduce these biases. Third, as a result of our stringency around internal validity and scope of interventions, our findings have limitations in generalizability. Many high-risk populations are not addressed. For some of these populations, sexual risk reduction is addressed elsewhere. In men who have sex with men and intravenous drug users, for example, good evidence indicates that community-based and community-level interventions can reduce risky behaviors.31-34 We found limited rigorous trial evidence for many high-risk groups. In addition, some types of counseling interventions (for example, HIV counseling and testing, risk avoidance counseling) are not adequately represented in our review, although they were recently reviewed elsewhere.34-35
Even more important than the limitations of applicability to different populations or interventions types, however, are the translational issues of delivering behavioral counseling interventions in practice. These issues are particularly pertinent for this body of evidence, because all identified effective counseling interventions were moderate to high intensity and, at minimum, involved multiple sessions and trained counselors. All trials had dedicated research staff for the recruitment (screening), intervention,
and assessments.
Evidence is lacking for the effectiveness of low-intensity behavioral counseling interventions, especially in lower-risk populations. The few trials that evaluated low-intensity interventions had study design factors that may have contributed to their non–statistically significant intervention effect findings.13,20-21,26 Thus, we need trials that evaluate low-intensity counseling interventions, which may be applicable to primary care. Appendix Table 2 (available at www.annals.org) lists trials that are currently in progress. From rigorous trials evaluating behavioral counseling interventions, we conclude that population risk and intervention intensity seem to be the strongest predictors of intervention effect. Good evidence suggests that moderate- to high-intensity behavioral counseling is effective in reducing STI incidence in high-risk populations in both STI clinics and primary care settings. Rigorous trials that replicate the effectiveness of proven counseling interventions in other populations are needed to demonstrate the feasibility and generalizability of primary care behavioral counseling interventions to prevent STIs. In addition, methodologically rigorous trial evidence on the effectiveness of primary care behavioral counseling to prevent STIs is lacking—particularly for men and male adolescents, pregnant women, and certain high-risk populations.
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Acknowledgment: The authors thank Taryn Cardenas, BS, and Kevin Lutz, MFA, for their invaluable help in preparing this manuscript; Daphne Plaut, MLS, for conducting the literature searches; and Tracy Beil, MS, for help in conducting the evidence review. They also thank David Meyers, MD, and the staff at AHRQ, the USPSTF, and the expert reviewers for their contribution to this evidence review.
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AHRQ Publication No. 08-05123-EF-4
Current as of October 2008
Internet Citation:
Lin JS, Whitlock E, O'Connor E, Bauer V. Behavioral Counseling to Prevent Sexually Transmitted Infections: A Systematic Review for the U.S. Preventive Service Task Force. AHRQ Publication 08-05123-EF-4, October 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf08/sti/stiart.htm
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