A decade in review: building on the experiences of past
adolescent STI/HIV interventions to optimise future
J M Sales, R R Milhausen, R J DiClemente
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Sex Transm Infect 2006;82:431–436. doi: 10.1136/sti.2005.018002
The major purpose of this article is to systematically review
and synthesise empirical findings from selected adolescent
STI/HIV interventions conducted in the United States
between 1994 and 2004. Specifically, the most current
adolescent STI risk reduction interventions conducted in
diverse venues, such as in the community, schools, clinics,
and specialised adolescent centres (that is, detention
homes and drug programmes) were examined for reported
efficacy, and were assessed for programmatic and
methodological strengths and weaknesses. Next, a subset
of programmatic characteristics was identified that were
associated with the efficacy of STI risk reduction
programmes both within a particular venue, as well as
across all venues. Finally, we discuss the research and
practice implications of these findings for optimising future
evidence based STI risk reduction programmes for
adolescents in the United States.
health and wellbeing of adolescents in the
United States.1When compared to other age
groups, STIs disproportionately affect adoles-
cents with prevalence rates among some sub-
groups reaching epidemic proportions.2–4Not
only do STIs exact a significant toll on adoles-
cents in term of morbidity, they also significantly
impact society in terms of economic costs
Amplifying these concerns, however, is the
increasing health threat posed by HIV.6In an
era when an STI such as HIV can result in a fatal
illness, AIDS, we have begun measuring the
impact of sexual risk behaviours and their
adverse sequelae in terms of number of deaths
of adolescents and young adults from AIDS.
Given that STIs have significant adverse health
and social consequences for adolescents and
urgent public health priority.1 7 8
In response to the personal and public health
threat posed by STIs, over the past decade a
number of sexual risk reduction programmes for
adolescents in the United States have been
published. These programmes were designed to
modify STI/HIV associated sexual behaviours
All tables are available on
our website at http://
See end of article for
Jessica McDermott Sales,
PhD, Rollins School of
Public Health, Department
of Behavioral Sciences and
Health Education, Emory
University, 1520 Clifton
Road, NE, Rm 132,
Atlanta, GA 30322, USA;
Accepted for publication
31 January 2006
he risk of acquiring a sexually transmitted
infection (STI) has become one of the most
substantial and immediate threats to the
and psychosocial mediators (that is, attitudes,
perceived normative influences, social skills)
associated with STI/HIV acquisition, and have
been developed, implemented, and evaluated in
venues,11or other locations such as prisons,
detention centres, or inpatient substance abuse
Several recent reviews have been reported on
the effects of STI/HIV interventions for adoles-
cents.12–14While informative, these reviews were
limited by either being focused only on a
particular subset of interventions (that is, inter-
ventions for sexually experienced adolescents
only) or including only a small number of
published interventions because of restrictive
employed in the review (that is, the two reviews
included only 16 and 20 interventions, respec-
tively). Thus, there is considerable interest and
need for a qualitative review which critically
evaluates both the programmatic and methodo-
logical strengths and limitations of a larger, more
representative sample of the published, evidence
based STI prevention programmes for adoles-
cents across diverse venues.
The purpose of this paper is to systematically
review and synthesise, using a qualitative meth-
odology, the empirical findings from a larger,
more representative sample of adolescent STI/
HIV interventions conducted in the United States
in the past decade. Such a review and synthesis
offers an opportunity to examine the reported
efficacy of the most current STI risk reduction
interventions conducted in a variety of venues,
such as in the community, schools, clinics, and
specialised adolescent centres (that is, prisons,
detention centres, and drug treatment centres) in
an attempt to identify relevant strengths or
characteristics across programmes that success-
fully (that is, success is defined as a statistically
significant (p(0.05) reported change in beha-
viour that reduces risk of contracting an STI/
HIV) contribute to reducing sexual risk taking in
adolescents. Although programme effects are of
primary interest, it is difficult, if not impossible,
Abbreviations: ASSESS, awareness, skills, self efficacy/
self esteem, and social support; CYS, community youth
service; ENABL, education now and babies later; IMB,
information motivation behaviour; MAC, monogamy,
abstinence, condoms; PCE, peer counsellor/educator;
STD, sexually transmitted diseases; STI, sexually
transmitted infections; YAPP, youth AIDS prevention
to completely disentangle programme effects from the
methodology used to evaluate these programmes. Clearly,
weak research designs and other methodological limitations
can result in unreliable, imprecise, and invalid findings.
Therefore, we assessed the programmatic and methodological
characteristics of each reviewed STI risk reduction interven-
tion, identified a subset of programmatic characteristics that
were most probably associated with programmatic efficacy in
terms of modifying adolescents’ sexual risk behaviour within
a particular intervention venue, as well as across all venues
and, finally, examined the research and practice implications
of these findings for optimising future evidence based STI
risk reduction programmes for adolescents in the United
An electronic search of the professional literature was
performed using online computer databases. The following
databases were used: EBSCO Academic Search Premier; Alt
HealthWatch; Medline; ERIC; Health Business FullTEXT;
Health Source: Nursing/Academic Edition; Health Source:
Development Collection; Ovid; and Psychinfo. To aid retrieval
of relevant and sound studies, search filters were used for the
included databases. Keywords used in the Boolean search
included: ‘‘adolescent,’’ ‘‘intervention,’’ ‘‘STD,’’ ‘‘STI’’, STI/
HIV and ‘‘STD/HIV.’’ Additionally, other published reviews of
interventions for decreasing sexual risk taking among
adolescents were used to locate other appropriate studies.12–14
Articles were reviewed to determine if they fulfilled
additional criteria. Specifically, to be included in the review
the studies had to be: (1) school, community, or clinic based
interventions or interventions developed for special popula-
tions; (2) published in peer reviewed journals; and (3)
published between 1994 and 2004. Studies were excluded
from this analysis if: (1) people other than adolescents were
included in the intervention (for the purpose of this review,
‘‘adolescent’’ was defined as anyone age 11–22 years), and (2)
they did not incorporate behavioural or biomedical outcomes.
Studies conducted exclusively among university students were
excluded even if participants were late adolescents.
A priori criteria were established for assessing the rigour of
each study based on several sources. Firstly, criteria for
adapted from a previous review article reviewing sexual risk
reduction interventions for women.15We identified 13
evaluation criteria from this source: (1) clear description of
study site and sample; (2) specification of theoretical
framework; (3) description of programme implementation;
(4) description of intervention content and behaviour change
techniques sufficiently detailed to permit replication; (5)
description of content for control group treatment; (6)
specification of length of follow up; (7) use of blinding
procedures to prevent bias; (8) specification of retention rates
reported for each study condition; (9) adherence to intention
to treat principles in the data analysis; (10) assessment of
pretest equivalence on sociodemographic and behavioural
factors between study conditions; (11) clear description of
data analytic techniques; (12) specification of a measure of
variability for the designated effect size; and (13) sample size
justification. We considered these criteria essential to a well
designed, implemented and evaluated study.
SYNOPSIS OF EVALUATION
The literature search initially revealed a total of 910
articles that reported on data from a sexual risk reduction
intervention. Seven hundred and forty eight of the citations
were immediately eliminated because they did not meet the
inclusion criteria or because they were duplicate citations.
See table 1 for a summary of the search and elimination
This systematic review has identified 39 STI risk reduction
interventions for adolescents that were conducted in four
different settings (schools, clinics, community based, and
specialised locations for particular populations such as
juvenile detention facilities for incarcerated youth). Of the
39 interventions reviewed, 13 were conducted in schools,16–28
12 were conducted in clinics,29–40nine were developed for
special populations and implemented in specialised locations
(including jails, in patient treatment centres, etc),41–49and five
were community based.50–54One intervention was implemen-
ted in a clinic setting and a detention centre facility so it will
be discussed in both the clinic and special populations
sections.34To provide a thorough review of each of the
aforementioned studies, we provide information pertaining
to the intervention programme, research methodology, and
primary outcomes of each study in tables 2–9. A number of
key findings emerge from this review and synthesis. Firstly,
we present the findings within a particular intervention
venue (that is, all of the findings for school based
interventions are reviewed together, etc), followed by a
synthesis of common strengths and weakness across all
reviewed studies regardless of the intervention venue.
School based interventions (tables 2 and 6)
Three quarters of the school based interventions reported
some behaviour change as a result of participation in the
intervention. Reducing frequency of unprotected sexual
intercourse was the most frequent outcome.16 18 20 23–25 27
However, several studies did report a delay in initiation of
course.19 24 25One study found an increase in risk behaviour
post-intervention.22The sexuality focused, school based
interventions that were successful in reducing risk behaviour
appear to be theoretically based, implemented by trained
teachers or health educators, and include a variety of skills
and knowledge building didactic and interactive activities.
in frequencyof inter-
Clinic based interventions (tables 3 and 7)
One third of the clinic based interventions included in this
review reported no significant differences between the
intervention and control condition in terms of behavioural
outcomes.30 31 34 39Increases in condom use were the most
commonlycited changes.29 32 37 40
Interventions that did not reduce risk behaviours tended to
be single session,30 31 39or have no theoretical framework.30 39
Characteristics of successful programmes included a focus on
a single gender or ethnic group, HIV/STI education with skills
building activities (that is, condom application), condom
negotiation and sexual communication components, and
personalised risk assessments.
frequency.32 33 35 38 40
Special population interventions (tables 4 and 8)
The majority of interventions targeting special populations
reported some behavioural change as a result of the
intervention. Reducing the frequency of unprotected sexual
intercourse was the most common behavioural outcome
reported by six of the 10 studies. However, reducing the
number of sexual partners was reported in several stu-
dies,42 47 49as well as reducing the frequency of intercourse.49
Two studies observed no behavioural change,34 46, and one
identified behavioural change for both the intervention and
control group.48Although it is difficult to compare these
interventions, given the diversity of the samples, a common-
ality across successful interventions was a strong theoretical
432Sales, Milhausen, DiClemente
framework, implementation by trained research staff, and a
broad content area delivered using a variety of didactic and
interactive teaching methods.
Community based interventions (tables 5 and 9)
All of the community based interventions reported some
behavioural change as a result of participation in the
intervention. Reducing frequency of unprotected sexual
intercourse was the most frequent outcome reported,50 51 54
followed by reducing number of sexual partners52and sexual
activity.50 53The most successful community based interven-
tions were theoretically based, tailored to the target popula-
tion, implemented by trained facilitators, and the content
was diverse and delivered using a wide variety of methods.
STRENGTHS AND LIMITATIONS ACROSS
A number of key findings emerge across all reviewed
interventions, regardless of venue. Foremost, this review
suggests that interventions with more success decreasing
high risk sexual behaviour were those that specifically
tailored and delivered the intervention to a particular
subgroup of adolescents (for example, African American
females).32 36 40 50Various researchers have supported and
advocated for a tailored approach for STI/HIV risk reduction
interventions, arguing that these interventions ultimately
have the greatest likelihood of being successful.55 56
Secondly, the use of theory in intervention development
and implementation was associated with improved STI risk
behaviour outcomes. Social learning theory and social
cognitive theory were the frameworks most consistently used
in successful programmes.16 18 24 25 32 35 40 50 51
grammes incorporated modelling,
attempted to increase self efficacy with regard to safer sexual
behaviour. Also associated with positive change was the
ory.20 40 47 49
Finally, interventions that went beyond STI education to
include an emphasis on psychological correlates of risk were
effective at decreasing STI risk behaviour. For example,
interventions that included broader based content, such as
problem solving, capacity building, social skill building, and
enhanced gender and ethnic pride, had the greatest impact
on behaviour.16 18 20 32 35 40As Robin and colleagues note,
‘‘Interventions more generally targeted toward increasing
resiliency and competencies are emerging as promising
approaches to reducing sexual risk behavior’’ (p 18).14
What remains unclear is the relation between intervention
duration and intervention efficacy. Some evidence suggests
interventions with few sessions (less time intensive) are as
effective at reducing risk as interventions with many sessions
(more time intensive).9Conversely, other reviews indicate
that duration may influence the effectiveness of pro-
grammes.14In our review, interventions with multiple
sessions were some of the most effective (for example,
Basen-Enquist et al,16Coyle et al,18] and Lonczak et al24) and
least effective (for example, Weeks et al27). The only clear
relation between duration and reduction of sexual risk
behaviour was observed among clinic based studies: time
intensive, multisession interventions were more effective
than brief interventions.32 35
Additionally, determining consistency of programmatic
effects across studies, even though most were randomised
controlled designs, has been difficult given the variability in
the reporting of programme results. For example, many
studies did not report their effect size, or failed to provide
sufficient statistical information to compute an effect size.
Such variability restricts assessing comparability of findings
between programmes. Moreover, lack of structured reporting
of STI interventions reduces the level of certainty with which
these interventions could be replicated.
Although we could not directly compare effect sizes
between interventions across venues for a variety of reasons
(for example, lack of structured reporting across studies), the
evidence compiled in this review is encouraging as it suggests
that there are effective interventions in each of the venues
(that is, clinic, community, school, and specialised settings).
In addition, our review and synthesis of results from
adolescent STI/HIV interventions yields several observations
that can inform and optimise the development, implementa-
tion, and evaluation of future STI/HIV prevention interven-
tions for adolescents.
FUTURE DIRECTIONS OF STI/HIV PREVENTION
INTERVENTIONS FOR ADOLESCENTS
Just as important as understanding the successes of effective
interventions for adolescents, is the importance of identifying
and confronting existing challenges to designing, implement-
ing, and evaluating STI/HIV risk reduction interventions. By
doing so, we hope to bring into sharper focus those areas that
hold considerable promise for STI/HIV prevention for
adolescents and, as such, warrant rigorous exploration.
Thus, the following section highlights several areas where
potentially significant improvements can be made with
regard to future STI/HIV risk reduction interventions for
Tailoring interventions to the target population
One particularly important point emerging from this review,
regardless of venue, was that targeted interventions are
markedly more effective relative to general or broad based
interventions in terms of reducing STI associated behaviours.
Targeted interventions acknowledge that adolescents are a
heterogeneous mosaic of subgroups of different ethnicities/
cultures, behavioural risk characteristics, developmental levels,
sexual preferences, and gender differences. Because of the
interventions specifically for a restricted subgroup of adoles-
cents may produce optimal results in terms of reducing risk
associated behaviour. Thus, acknowledging that adolescents are
not a homogeneous group is a critical first step in providing an
impetus to design targeted and tailored interventions.
Target those behaviours that are most amenable to
Across venues, the risk behaviour most susceptible to change
was condom use during vaginal sex. A few programmes
showed promising effects in terms of increasing abstinence or
decreasing the number of sexual partners; however, these
findings were markedly less common. Future intervention
with adolescents, especially adolescents who are sexually
active, should target behaviours, like condom use, that have
been empirically demonstrated across a variety of adolescent
subgroups and venues to be most amenable to change.
Incorporating a focused approach targeting only specific
areas of behavioural change, which are both reasonable and
feasible for adolescents to accomplish, could result in a
prevention strategy that amplifies STI programme efficacy,
and lays the foundation for more sustainable programme
effects over time.
Expand the scope of STI/HIV intervention programmes
beyond the individual
For a variety of reasons, many of the studies reviewed
focused primarily on the adolescent, whereas contemporary
thinking in public health practice has shifted focus from the
adolescent alone to the adolescent embedded in a complex
ecology of peers, relational, familial, and cultural factors that
constantly shape their STI associated risk and protective
A decade of adolescent STI/HIV interventions433
behaviours.57–59It is possible that the next generation of STI
risk reduction interventions will be developed using a multi-
tier intervention framework. Specifically, such an interven-
tion would focus on integrating individual based preventive
counselling delivered, most likely, by a clinician, paediatri-
cian, or school counsellor, who then ‘‘refers’’ the adolescent
to community based prevention services. Such community
based prevention services would be designed to extend,
reinforce, and amplify the preventive message initially
delivered to the adolescent using group formatted or social
network intervention strategies that create an atmosphere
conducive to and supportive of adolescents’ adoption and
maintenance of STI preventive practices.
Enlist the family as a behavioural change agent
Given the central role the family has in many developmental
processes, including adolescents’ family as a behavioural
change agent could be particularly beneficial. Involving
parents may be an especially important strategy to help
delay adolescents’ sexual debut, reduce frequency of inter-
course, limit number of sexual partners, or support health
promoting behaviours, such as protected sex. These goals
may be achieved by fostering improved communication
between parents and adolescents and intensified parental
Incorporate long term maintenance strategies into
In general, this review found attenuation of intervention
effects over the course of time. Specifically, programme
effects were observed to decay (short term effects are
significant, but longer term effects were no longer signifi-
cant). Unfortunately, for behaviour change to be meaningful,
it must be durable. Given the scope and complexity of
influences that can affect adolescents’ sexual behaviour, it is
unclear whether short term STI/HIV preventive changes,
observed as a result of participating in a risk reduction
programme, can be sustained over protracted periods of time.
Thus, it is necessary to develop and incorporate innovative
prevention maintenance strategies to sustain, and if possible,
amplify STI programme efficacy.
Incorporate biological outcomes as a measure of
Historically, interventions have relied almost exclusively on
adolescents’ self reported behaviour change to assess
programme efficacy. Typically, and as was the case for almost
all of the interventions reviewed, adolescents’ reported their
frequency of condom use or number of different sexual
reported data have been criticised as subject to potential
reporting biases, inaccurate recall, and social desirability
bias.62 63Recently, the use of newly developed DNA assays
(polymerase chain reaction) to detect prevalent STIs has been
advocated as a complementary measure for evaluating
programme efficacy. Thus, future STI intervention studies,
when applicable and feasible, should consider the utility of
including biological markers as an objective and quantifiable
outcome measure of programme efficacy.
Structured reporting of STI/HIV interventions
A limiting factor previously identified earlier in this review
was the lack of structured reporting of STI/HIV interventions.
Variability in the reporting of STI/HIV intervention trials
severely limits comparability between trials. Moreover, the
lack of structured reporting reduces the level of certainty with
which such interventions could be carefully assessed,
weighed against other interventions, and as important,
reliably replicated. With the development and evaluation of
increasing numbers of STI/HIV interventions for adolescents,
structured reporting guidelines would provide a framework
that may enhance interpretation of research findings by
researchers, practitioners, and policy analysts.
Measure cost effectiveness in STI/HIV interventions
In our current fiscal environment, it becomes imperative that
we not only evaluate programme efficacy in terms of impact
(for example, changes in behaviour, attitudes, norms,
knowledge) and outcomes (for example, changes in morbid-
ity) but also with regard to cost effectiveness. Although this is
pertinent information for prevention scientists, the reporting
of such information is limited for adolescent STI/HIV
interventions. Such information is vitally important to
programme planners, policy makers, and other people
involved in the design and implementation of STI/HIV
prevention programmes that are responsible for the judicious
allocation of limited financial resources so as to maximise the
number of adverse outcomes (for example, STI or HIV
infection) averted through participation or exposure to an
intervention programme .
Translate and disseminate effective STI/HIV
As the findings from this review suggest, it is unlikely that
any single STI/HIV intervention would be appropriate and
equally effective for all adolescents given the heterogeneous
nature of this population. However, encouragingly, this
review has identified several effective STI/HIV prevention
programmes for a variety of adolescents, delivered across
multiple venues. The next challenge concerns moving beyond
the intervention study and taking the necessary steps
towards translating those interventions that have demon-
strated programmatic efficacy in a particular venue, and with
a particular group, into sustainable programmes that can be
widely disseminated among similar venues and populations.
N Although many STI/HIV interventions for adolescents
have been conducted in the past decade within the
United States, the most current reviews on the effects of
such STI/HIV interventions for adolescents only include
a subset of the published adolescent STI/HIV interven-
tions. Thus, this review critically evaluates a larger,
more representative sample of the published adoles-
cent STI/HIV interventions conducted in the United
States between 1994 and 2004
N Despite the fact that we could not statistically compare
effect size between interventions conducted in various
venues for a variety of reasons (for example, lack of
structured reporting across studies), the evidence
compiled in this review is especially encouraging as it
suggests that there are effective interventions (that is,
significantly reduce sexual risk taking behaviour such
as unprotected intercourse) in each of the venues
included (that is, clinic, community, school, and
N From the 39 interventions reviewed, we have identified
several features associated with effective interventions
conducted within specific venues, as well as common
characteristics of effective interventions across venues
N Our review highlights several areas were potentially
significant improvements can be made with regard to
future STI/HIV risk reduction interventions with ado-
434 Sales, Milhausen, DiClemente
Ultimately, preventing STI/HIV infections in adolescents not
only depends on the development and evaluation of
innovative behaviour change approaches, but also on how
effectively these interventions can be translated and inte-
grated into self sustaining components of clinic practice,
school curricula, or community programmes, particularly in
those areas and among those adolescent populations most
adversely impacted by the STIs and HIV epidemic.64
Although promising STI/HIV risk reduction programmes have
been developed and evaluated across a variety of venues,
including schools, community centres, clinics, and specialised
locations such as detention facilities, future programmes
delivered in all of these venues could be improved,65and
many of the existing programmes reviewed could be
However, optimising STI/HIV prevention efforts in the future
will require prioritising the development and evaluation of
innovative, theory based, empirically derived, and rigorously
designed research specially tailored to the ethnic/cultural,
gender, and sociodemographic characteristics of the target
population. Thus, although the ideal of a single STI/HIV
prevention strategy designed for all adolescents is appealing,
based on the findings of this review, it is unrealistic, both in
terms of feasibility and efficacy given the multicultural,
gendered, and sociodemographically diverse adolescent sub-
groups in the United States.
JMcDS was the primary author of the manuscript, and assisted in the
conceptual design of the review and resulting manuscript, as well as
searched for, identified, and reviewed the interventions meeting our
search criteria; RRM searched for, identified, and reviewed the
interventions meeting our search criteria, assisted with portions of
the writing pertaining to search and evaluation methods, as well as
reviewed and provided critical feedback of drafts of the manuscript;
RJDiC assisted with the conceptual design of the review and resulting
manuscript and reviewed and provided critical feedback of drafts of
J M Sales, R R Milhausen, R J DiClemente, Rollins School of Public
Health, Emory University, Atlanta, GA, USA
J M Sales, R R Milhausen, R J DiClemente, Center for AIDS Research,
Emory University, Atlanta, GA, USA
R J DiClemente, School of Medicine, Department of Pediatrics, Division
of Infectious Diseases, Epidemiology, and Immunology, Emory
University, Atlanta, GA, USA
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Call for papers: Themed issue on Practical issues in HIV care
Rob Miller, Annemiek de Ruiter
In October 2007 STI will produce a special edition of the journal addressing practical
issues in the management of people with HIV. We invite articles on research that are relevant
to a wide range of clinicians who see people with HIV as part of their work in sexual health,
genitourinary medicine or primary care. We also welcome reviews that provide an overview
of key issues for practice and articles addressing special considerations for specific groups of
patients, the challenges of providing care in different settings, interesting case reports and
broader issues of preventing onward transmission and providing long-term care.
Rob Miller and Annemiek de Ruiter will act as Editors of this themed issue, working with a
team of expert reviewers.
Authors wishing to write original or review articles for this edition should submit their
manuscripts electronically via Bench.Press at www.stijournal.com. Please select ‘‘HIV
special’’ as the article type when submitting your manuscript. All manuscripts will be peer
reviewed. The following article types will be considered: original research articles (up to 2500
words, maximum 30 references and 3–4 tables or figures), short reports (up to 750 words, up
to 10 references and one figure or table), review article (up to 3000 words and 60
Deadline from the receipt of manuscripts is 31 March 2007. Articles received after this date
will not be considered.
436 Sales, Milhausen, DiClemente