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Three Part Question

In [adults sexually exposed to HIV] could any [behavioural interventions] be used to [reduce future risk-taking sexual behaviour]?

Clinical Scenario

It is 7am on a Saturday morning and you are seeing a 19 year-old female university student who is dishevelled and still wearing the clothes she wore to a club the night before. She smells faintly of alcohol. She tells you she had unprotected sex while drunk, and requests the morning-after pill and postexposure prophylaxis for HIV. When you question her as to her need for PEP, she tells you that her partner of the night before was a student from South Africa, and she was aware of the high prevalence of HIV infection there. While giving you her medical history, she tells you that she has had the morning-after pill four times in the past eight months, all purchased over-the-counter in the large city-centre pharmacy, to avoid, she says, 'sanctimonious proselytising' from her GP. As you give her her prescription, you wonder if there are any behavioural interventions that might help reduce her risk-taking behaviour.

Search Strategy

Medline 1966 - 06/2006, Embase 1980 - 06/2006 and Cinahl 1982 - 06/2006 using the OVID interface.
[HIV infections/pc OR Sexually Transmitted Diseases/pc] AND [exp Sex Education OR exp Health Education OR Health Behaviour] limit to (humans and english language and "adolescent" "all adult (19 plus years)")

Search Outcome

3 relevant papers were identified.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
The National Institute of Mental Health (NIMH) Multisite HIV USA	Men and women attending STD clinics and women attending health service organisations (HSOs) (mostly primary care clinics). The trial was implemented in 37 inner-city community-based clinics in five metropolitan areas. 38893 individuals were screened, and 3706 were enrolled. Eligibility criteria were: 20 years or older for STD clinic attenders, 18 years or older for HSO attenders; engaging in unprotected vaginal or anal sex in the 90 days prior to attendance and at least one of: having sex with a new partner, an STD, a partner they knew had other partners, sex with an injection drug user or with a person infected with HIV within the prior 90 days.	Randomised controlled trial. Participants were randomised to either receive the control (a 1-hour AIDS education session that included a videotape and a question-and answer period) or the intervention (when they were asked to attend seven 90- to 120-min HIV risk reduction sessions, conducted twice weekly in groups of 5 to 15 persons).	(i) self-reported number of unprotected vaginal and anal intercourse acts during the 90 days before each interview (ii) self-reported consistent condom use during the 90 days before each interview (iii) rate of incidence of STDs.	Very similar patterns of change were found across the three study populations.	Measurement of outcomes were largely based upon the participant self-reporting. Intake criteria was strict.
Boyer CB Barrett DC Peterman TA Bolan G 1997 USA	Non-follow up patients of an STD clinic were recruited if they were between the ages of 18 and 35 years, heterosexual, and residing in San Francisco at the time of recruitment. Patients were included if they were at high risk of acquiring another STD, i.e. had been diagnosed with an STD in the past, had current symptoms of an STD, or were a sexual contact to a person diagnosed with an STD. Non-English speaking were excluded. 399 participants.	Randomised controlled trial.	Laboratory diagnosis of STDs. Secondary outcome was number of risky sexual activities.	There were no differences between the intervention and control groups in their acquisition of STDs. In males, condom use increased more in the intervention group than the control group. The mean number of sexual partners without condom use was lower in the intervention group than in the control group.	A sample of STD-clinic attenders were initially approached. Those who agreed to participate were then randomised. Participants were exclusively heterosexual in a city with an extensive gay community.
Evans AE Edmundson-Drane, EW Harris KK 2000 USA	162 volunteer students enrolled on a Human Sexuality class of 178. 80.1% were between the ages of 19 and 23. Median age was 21. 113 had previous HIV education. The majority were comfortable with the use of computers.	Participants were randomly assigned to one of three groups: computer-assisted instruction (CAI), lecture, or no intervention group. Participants in the CAI group received a 1-hour long CAI session, participants in the lecture group received an hour-long lecture of content similar to the CAI program, and participants in the no intervention group received no intervention. After completing the interventions, all participants completed the HIV questionnaire which measured constructs associated with HIV-preventive behaviours.	Knowledge of HIV/AIDS and intention to practice HIV preventative behaviours.	Compared to participants in the lecture group, participants in the CAI group scored higher on the scales measuring knowledge of AIDS and intention to practice HIV-preventive behaviours.	Participants were of various demographic groups, and while the authors assure the reader that comparative analyses were done to ensure they made no difference, there is no mention of what these comparative analyses were. The authors do not explain why they used the questionnaires that they did.

Comment(s)

All of the papers cited support the hypothesis that behavioural interventions can reduce the incidence of risk-taking sexual behaviour. All the interventions they used were based upon increasing the knowledge base of HIV/AIDS/STDs in the participants, increasing knowledge of what risks the participants were putting themselves at, and giving the participants the means to help protect themselves. The interventions, however, were largely time- (and money) intensive, with the exception of the CAI intervention of Evans, Edmundson-Drane and Harris, which was an hour long and required technical support only. Behavioural interventions could be made available to those (high-risk especially) individuals presenting to the GUM clinic, general practice, even the emergency department, and those interventions would considerably reduce the risky behaviour of those individuals, if they were motivated enough to attend the sessions. If a 'quick-and-dirty' intervention was called for (e.g. when the individual at risk is not motivated to attend time-intensive sessions) a CAI session may reduce their risk. CAI is also relatively cheap in comparison, and could be much more widely available.

Clinical Bottom Line

Behavioural interventions reduce the incidence of risk-taking behaviour, but are expensive. CAI is relatively cheap and may be easier to make available, and may also help to reduce risk-taking behaviour.

References

1. The National Institute of Mental Health (NIMH) Multisite HIV The NIMH Multisite HIV Prevention Trial: Reducing HIV Sexual Risk Behaviour Science 1998; 1889-1894
2. Boyer CB Barrett DC Peterman TA Bolan G Sexually transmitted disease (STD) and HIV risk in heterosexual adults attending a public STD clinic: evaluation of a randomized controlled behavioural risk-reduction intervention trial AIDS 1997; 359-367
3. Evans AE Edmundson-Drane, EW Harris KK Computer-Assisted Instruction: An Effective Instructional Method for HIV Prevention Education? Journal of Adolescent Health 2000; 244-251