HIV Prevention Interventions for Adolescents: A Review

Introduction and Background

Teenage sex has been viewed as a social problem for some time, but the spread of HIV/AIDS in society has increased fears about what can happen when young people have unprotected sex. The prevalence of HIV among young people has been increasing, with some populations seen as more vulnerable than others, such as homeless youth and Black and Hispanic youth. Programs have been developed to educate these young people, and studies examining how effective such programs can be have been undertaken to determine whether they work and to improve them where they do not.

Many researchers focus on family influences on adolescent sexual behavior, and communication between parents and their children about sexual issues has been one important research area. Some studies show that parental discussions on sexual matters either delay the first sexual experience or encourage contraceptive use among adolescents, but others show no effect. In fact, some studies suggest that communication with parents may encourage sexual behavior. Studies show that these relationships depend on factors such as who reports the communication, whether the parents hold traditional or liberal attitudes, the sex of the adolescent, which parent conducts the discussion, and whether the outcome is sexual debut or contraceptive use. The researchers concluded:

"We hypothesize that students who report having had discussions about HIV with their parents or other adults in their family will be less likely than those who had not to engage in HIV-related risk behaviors; those who discussed HIV with their peers will be more likely to report HIV-related risk behavior. We also expect that school-based instruction will increase communication with both parents and peers" (Rubinson, 1995, p. 235).

Studies also show that many young people do not have such discussions and do not change their behaviors, and more concerted efforts have been developed to educate these young people and to change their behavior before they become infected.

Objectives and Methods

Objectives

The following review of literature suggests some of the approaches being taken today and how effective they have been found to be. The survey is also intended to show some of the ways in which the efficacy of these programs has been tested, and to suggest where more study is needed to improve these programs and make them as effective as possible — with the ultimate goal of changing risky behavior and thereby reducing the incidence of HIV infection.

Selection Criteria

The studies examined include two types. One type offers surveys of a variety of studies to ascertain what sort of work is being done, what has been decided about the effectiveness of such programs, and so on. The other and more prevalent type consists of randomized controlled trials to test the effectiveness of specific programs and to demonstrate whether or not behavior is changed by exposure to these programs.

Participants considered in all cases are young people, most of high school age, examining both their sexual behavior and their exposure to some type of program intervention designed to change their behavior. The types of intervention examined consisted of different forms of educational modules in different settings. Such programs were usually informative about HIV and its method of transmission and offered recommendations for how to reduce the likelihood of infection. Outcomes were measured in terms of changes in behavior on the basis of such actions as increased use of condoms, reduced number of partners, lower drug use, and similar actions.

Search Strategy

Studies were found by making a systematic search of various electronic databases followed by a hand-search of journals to identify evaluations of behavioral interventions to reduce sexual risk behaviors among adolescents. Abstracts were read to determine the most relevant studies in each search.

Methods of the Review

Studies were selected if they illuminated some aspect of the issue and if they made a judgment about how effective either a given program or such programs in general were found to be. The sample, methodology, and results were extracted and used for purposes of comparison and explanation.

School-Based and Community Program Studies

Numerous studies were found, with many appearing in the 1990s as the scope of the AIDS problem became evident and fears about the behavior of young people increased. Studies into the current century have continued to address the increasing incidence of infection among certain populations, including young people, with more and more emphasis placed on the need for education to reduce the rate. The question of how effective a given program might be has also received growing attention.

Robin et al. (2004) offer a review of adolescent sexual risk-reduction programs that were evaluated using quasi-experimental or experimental methods and published in the 1990s. The authors describe evaluated programs and identify program and evaluation issues for health educators and researchers. They found the studies by making a systematic search of seven electronic databases and also hand-searched journals to identify evaluations of behavioral interventions to reduce sexual risk behaviors among adolescents. They included only articles that were published in the 1990s, that provided a theoretical basis for the program, offered information about the interventions, had clear aims, and used quasi-experimental or experimental evaluation methods — ultimately identifying 101 articles and finding 24 that met the criteria for inclusion. The researchers then reviewed these evaluations to assess their research and program characteristics, and found that the majority of studies included randomized controlled designs and employed delayed follow-up measures. They found that the most commonly measured outcomes were delay of initiation of sexual intercourse, condom use, contraceptive use, and frequency of sexual intercourse. The programs used ranged from 1 to 80 sessions, most with adult facilitators, and most commonly included skills-building activities about sexual communication, decision-making, and problem solving. The authors find that these programs suggest four overall factors that may impact program effectiveness: the extent to which programs focus on specific skills for reducing sexual risk behaviors; program duration and intensity; what constitutes the content of a total evaluated program, including researchers' assumptions about participants' exposure to prior and concurrent programs; and what kind of training is available for facilitators.

Emans et al. (1991) consider some of the newest medical advances in research on adolescent sexuality, such as contraceptive compliance, promotion of behavior change, relationships between ethnicity and pregnancy, and male reproductive health. Based on their analysis, the researchers find that the key issues for the 1990s would be the morbidity and mortality associated with sexually transmitted diseases. They further identify topics such as sexual activity and adolescent pregnancy, care of the pregnant teen, sexually transmitted diseases, HIV infection, the male adolescent, sexual abuse in adolescents, gay and lesbian youth, interventions, reproductive health care of adolescents with disabilities and chronic illnesses, and training of primary care physicians. More attention has been directed at the reproductive behavior of males because of HIV/AIDS. Research shows that sexual activity varies by racial and ethnic group, suggesting that interventions to delay sexual initiation may need to differ for different groups. The researchers note that such issues need to be examined even though condom use had increased among 17- to 19-year-olds from 21% to 58% in metropolitan areas. At the same time, evidence shows that condom use is lowest among the group of men at highest risk of STDs — that is, those who had ever used drugs, those who had ever had sex with a prostitute, and those with five or more partners per year. A survey of literature shows that male beliefs about contraception have been infrequently examined and that misconceptions about heterosexual transmission of HIV remain. The authors call for better screening for STD detection. They also find that fathers are more involved in prenatal care and postnatal intervention programs, and that 7% of children reported nonvoluntary sexual intercourse between the ages of 18 and 21, in the proportions of 12.7% of white women, 9% of black women, 1.9% of white males, and 6.1% of black males. Risk factors cited for white women include living apart from parents at age 16, poverty, physical and emotional limitations, and parental alcohol, smoking, and drug use. Sexual assault is a problem associated with hitchhiking and alcohol and drug use. The authors state that physicians need to be sensitive to this issue and seek needed information from their patients. Among 12th graders, 1% of males and 1% of females saw themselves as mostly or completely homosexual or lesbian, and another 10% were unsure. Among the interventions the authors say are needed are reproductive and STD information, multiple approaches in a variety of settings, adolescent clinics, and outreach.

Crosby et al. (2003) note the value of condom promotion strategies for adolescents and find that such strategies typically include provision of STD/HIV-associated knowledge, fostering favorable attitudes toward condom use, promoting positive peer norms regarding condom use, improving condom-related communication skills and self-efficacy, and overcoming barriers to condom use. The authors conduct a study to identify which of these constructs were prospectively associated with condom use among a high-risk sample of African-American adolescent females reporting sexual activity with a steady male partner. The subjects were adolescents aged 14 to 18 years, recruited from schools and health clinics. The subjects completed an in-depth survey and interview at baseline and again six months later. Subsequent analyses were limited to adolescents with steady partners who reported sexual activity between the baseline and six-month follow-up assessment periods (N = 179). At baseline, five-scale measures and a single-item measure were used to assess predictive constructs, and at follow-up, subjects were asked about their frequency of condom use over various recall periods. The researchers created multivariate models to control for the confounding influence of pregnancy status. They found that the findings were remarkably distinct, with evidence strongly supporting the predictive role of perceived barriers toward condom use and peer norms. Based on the measure of sexual communication, the researchers found significance for two of the six assessed outcomes. Measures of attitudes toward condom use, condom negotiation self-efficacy, and knowledge about STD/HIV prevention were found to be consistently nonsignificant. The researchers conclude that to improve the effectiveness of individual-level STD/HIV prevention programs designed for this population, any program must place an emphasis on reducing barriers to condom use, teaching partner communication skills, and fostering positive peer norms relevant to condom use.

One examination of a community-based program is offered by Harvey, Stuart, and Swan (2000), considering a community intervention trial undertaken in KwaZulu-Natal, South Africa to evaluate the effectiveness of a high school drama-in-education program. In this study, seven pairs of secondary schools were randomized to receive either written information about HIV/AIDS or the drama program. Questionnaire surveys of knowledge, attitude, and behavior were compared before and six months after the interventions. The sample consisted of 1,080 students in the first survey and 699 in the second. Improvements in knowledge (P = 0.0002) and attitudes (P < 0.00001) about HIV/AIDS were demonstrated in students at schools receiving the drama program when compared to pupils receiving written information alone, and these changes were found to be independent of age, gender, school, or previous sexual experience. In schools receiving the drama program, sexually active students increased their condom use (P < 0.01). The authors state that it is important to provide resources to sustain such programs as well as to gather stronger evidence of the effect on behavior by measuring changes in HIV incidence. The authors also note that adolescents' risk of becoming infected with HIV in South Africa is increased by a lifestyle involving exploration, experimentation, and rebellion. The high prevalence of sexually transmitted diseases and the high rate of adolescent pregnancy reflect a pattern of early onset of sexual intercourse, multiple partners, and low condom use. Prevention programs such as the Drama Approach to AIDS (DramAide) were initiated in Africa to reduce HIV transmission, and the randomized community intervention trial produced the results noted above.

Another African study is reported by Munodawafa, Marty, and Gwede (1995), analyzing the use of health instruction by student nurses in rural secondary schools in Zimbabwe and determining how effective such instruction may be. The project used twelve nurses on community deployment to provide health instruction among rural school-age populations. The program was analyzed using a quasi-experimental (pre- and post-test), non-equivalent control group design consisting of 141 school pupils in the intervention group and 144 pupils in the comparison group (N = 285). The curriculum focused on prevention of STDs, HIV/AIDS, and drug use (alcohol, tobacco, and marijuana), and a gain in health knowledge scores among the intervention group was reported at post-test. More than 70% of the pupils who received health instruction from student nurses gave a high approval rating of the nurses' performance, and student nurses, teachers, and tutors all supported school health instruction by student nurses, although tutors and teachers did differ on the question of teaching about condoms. The 12 student nurses were sent by nursing schools to five rural secondary schools in Masvingo Province to provide health education over a seven-week period to 141 students (9.33 hours per student). Curriculum topics included AIDS, other sexually transmitted diseases, and drugs. The AIDS/STD educational materials concentrated on modes of transmission, prevention methods, control of transmission, psychosocial issues, responsible sexual behavior, and problem-solving and decision-making strategies. This study primarily addresses how the student nurses and their instruction were received, and did not demonstrate the effectiveness of that instruction in changing behavior — the analysis that is most critically needed.

Morrison-Beedy, Nelson, and Volpe (2006) undertake a study to examine the rates of HIV-related risk behaviors and HIV testing rates between Black and White adolescent girls consenting to participate in an HIV prevention intervention. The sample consisted of 116 unmarried, sexually active girls aged 15 to 19, enrolled in a pilot randomized controlled trial of a gender-specific HIV prevention intervention, who classified themselves as Black (N = 43) or White (N = 73). These girls were unmarried and sexually active with a male partner in the past three months. The mean age for the Black girls was 16.7 years (SD = 1.4) and for the White girls was 17.5 years (SD = 1.3). The average level of education completed was 10th grade for Black participants and 11th grade for White participants. Sixty percent of the Black girls were classified as economically disadvantaged, versus 15% of the White participants. The girls were recruited by trained research assistants from an urban health clinic in central New York State that provides gynecologic and reproductive health services to teenagers.

Participants were asked to report on their sexual and substance use history and were then assessed on the basis of criteria established beforehand. Count data were used to report the following behaviors: (a) total number of sex partners in the past year; (b) number of men had sex with over the past three months; (c) number of partners who used intravenous drugs over the past three months; (d) number of times had sex for money or drugs over the past three months; (e) number of times had vaginal sex with and without a condom over the past three months; (f) number of times had anal sex with and without a condom over the past three months; (g) number of episodes of giving and receiving oral sex over the past three months; and (h) number of times used alcohol or drugs before sex over the past three months.

The Statistical Package for the Social Sciences (SPSS) was used to conduct chi-squared analysis, and independent t-tests were also used to compare mean variable scores between Black and White adolescent girls on HIV risk-related and health promotion behavior items. It was found that Black and White adolescent girls differed on frequency and incidence of several HIV-related risk behaviors (p < .05). White adolescent girls had a greater number of total sex partners in the last year and a greater number of partners who injected drugs than Black girls. White adolescent girls also reported more vaginal sex with a latex condom, more vaginal sex without a latex condom, and more episodes of oral sex (giving and receiving). No racial differences were found in the self-report of unprotected anal sex. White girls reported more alcohol use before sex than Black adolescent girls, while there was no difference in the self-report of drug use before sex or in engaging in sex for money or drugs. No statistical differences were noted in HIV-related risk behaviors based on the variables of socioeconomic status and education level, though some behaviors did differ by age, such that younger and older adolescent girls differed on frequency and incidence of some HIV risk-related behaviors. White adolescent girls were significantly less likely to get tested for HIV than Black girls, despite engaging in more risky behavior.

One situation that appears to lead to greater awareness and more behavior change is noted by Staub et al. (2007): case-finding for HIV, especially among high-risk youth. The researchers conduct a study showing that there is a significant increase in participation in voluntary HIV counseling and testing services immediately after implementation of a brief STI/HIV educational program in alternative education and juvenile detention facilities. The effectiveness of such programs, however, may be short-lived — an issue that needs to be given more attention.

References

Crosby, R. A., DiClemente, R. J., Wingood, G. M., Salazar, L. F., Harrington, K., Davies, S. L., & Oh, M. K. (2003). Identification of strategies for promoting condom use: A prospective analysis of high-risk African-American female teens. Prevention Science: The Official Journal of the Society for Prevention Research, 4(4), 263–270.

Emans, S. J., Brown, R. T., Davis, A., Felice, M., & Hein, K. (1991). Society for Adolescent Medicine position paper on reproductive health care for adolescents. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 12(8), 649–661.

Harvey, B., Stuart, J., & Swan, T. (2000). Evaluation of a drama-in-education programme to increase AIDS awareness in South African high schools: A randomized community intervention trial. International Journal of STD & AIDS, 11(2), 105–111.

Morrison-Beedy, D., Nelson, L. E., & Volpe, E. (2006, February 24). HIV risk behaviors and testing in adolescent girls: Evidence to guide clinical practice. Pediatric Nursing.

Munodawafa, D., Marty, P. J., & Gwede, C. (1995). Effectiveness of health instruction provided by student nurses in rural secondary schools of Zimbabwe: A feasibility study. International Journal of Nursing Studies, 32(1), 27–38.

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