Article

Preventing Recurrent Sexually Transmitted Diseases in Minority Adolescents

Department of Obstetrics and Gynecology, University of Texas Health Sciences Center San Antonio, San Antonio, Texas 78229-3900, USA.
Obstetrics and Gynecology (Impact Factor: 5.18). 06/2008; 111(6):1417-25. DOI: 10.1097/AOG.0b013e318177143a
Source: PubMed
ABSTRACT
To compare the efficacy of a randomized controlled trial of the Sexual Awareness For Everyone (SAFE) behavioral intervention on teenagers (aged 14 to 18 years) compared with adult rates of reinfection with Neiserria gonorrhea or Chlamydia trachomatis cervicitis, and to identify behaviors associated with recurrent infection.
Mexican-American and African-American females with a nonviral sexually transmitted disease (STD) were enrolled in SAFE or assigned to the control group. All participants were interviewed and examined at baseline, 6, and 12 months. The primary outcome variable was reinfection with N. gonorrhea or C. trachomatis. Secondary outcomes were changes in risky sexual behavior.
Teens randomized to participation in SAFE had a statistically lower incidence of recurrent N. gonorrhea and C. trachomatis at 0 to 6 months (52%, P=.04) and cumulatively (39%, P=.04) compared with teens in the control group. Cumulatively, teens as a group had higher rates of reinfection (33.1%) than adults (14.4%) (P<.001). Adolescent reinfection was explained by unprotected sex with untreated partners (adjusted odds ratio [OR] 5.58), nonmonogamy (adjusted OR 5.14), and rapid partner turnover (adjusted OR 2.02). In adults, reinfection was predicted by unprotected sex with untreated partners (adjusted OR 4.90), unsafe sex (adjusted OR 2.18), rapid partner turnover (adjusted OR 3.13), and douching after sex (adjusted OR 2.14).
Sexual Awareness for Everyone significantly reduced recurrent STDs in teenagers. Adults and teens randomized to the SAFE intervention had significant decreases in high-risk sexual behaviors as compared with those in the control group. Although not specifically designed for teens, the SAFE intervention worked very well in this high-risk population.
www.clinicaltrials.gov, ClinicalTrials.gov, HSC2004415H.
I.

Full-text

Available from: Alan Holden
Preventing Recurrent Sexually Transmitted
Diseases in Minority Adolescents
A Randomized Controlled Trial
Andrea Ries Thurman,
MD
, Alan E. C. Holden,
PhD
, Rochelle N. Shain,
PhD
, Sondra Perdue,
DrPh
,
and Jeanna M. Piper,
MD
OBJECTIVE: To compare the efficacy of a randomized
controlled trial of the Sexual Awareness For Everyone
(SAFE) behavioral intervention on teenagers (aged 14 to
18 years) compared with adult rates of reinfection with
Neiserria gonorrhea or Chlamydia trachomatis cervicitis,
and to identify behaviors associated with recurrent infec-
tion.
METHODS: Mexican-American and African-American
females with a nonviral sexually transmitted disease
(STD) were enrolled in SAFE or assigned to the control
group. All participants were interviewed and examined
at baseline, 6, and 12 months. The primary outcome
variable was reinfection with N. gonorrhea or C. tra-
chomatis. Secondary outcomes were changes in risky
sexual behavior.
RESULTS: Teens randomized to participation in SAFE had
a statistically lower incidence of recurrent N. gonorrhea
and C. trachomatis at 0 to 6 months (52%, P.04) and
cumulatively (39%, P.04) compared with teens in the
control group. Cumulatively, teens as a group had higher
rates of reinfection (33.1%) than adults (14.4%) (P<.001).
Adolescent reinfection was explained by unprotected sex
with untreated partners (adjusted odds ratio [OR] 5.58),
nonmonogamy (adjusted OR 5.14), and rapid partner
turnover (adjusted OR 2.02). In adults, reinfection was
predicted by unprotected sex with untreated partners
(adjusted OR 4.90), unsafe sex (adjusted OR 2.18), rapid
partner turnover (adjusted OR 3.13), and douching after
sex (adjusted OR 2.14).
CONCLUSION: Sexual Awareness for Everyone signifi-
cantly reduced recurrent STDs in teenagers. Adults and
teens randomized to the SAFE intervention had signifi-
cant decreases in high-risk sexual behaviors as compared
with those in the control group. Although not specifically
designed for teens, the SAFE intervention worked very
well in this high-risk population.
CLINICAL TRIAL REGISTRATION: www.clinicaltrials.gov,
ClinicalTrials.gov, HSC2004415H
(Obstet Gynecol 2008;111:1417–25)
LEVEL OF EVIDENCE: I
I
n a previous randomized controlled trial (RCT), we
found that the Sexual Awareness For Everyone
(SAFE) behavioral intervention significantly reduced
the rate of recurrent Neiserria gonorrhea and Chlamydia
trachomatis infections among reproductive-age Mexi-
can-American and African-American women.
1
Subse-
quently, we found that risk reduction was largely
explained by five modifiable behaviors: unprotected
sex with untreated partners, lack of mutual monog-
amy, unsafe sex (defined as never using condoms with
one or more casual sexual partners or more than five
unprotected sex acts in the past 3 months and incor-
rect or problematic condom use), rapid (less than 3
months) partner turnover, and douching after
intercourse.
2
Our cohort included minority females at high risk
for recurrent sexually transmitted diseases (STDs). All
had a current STD, and 70% were under 24 years old.
3
Mexican-American and African-American women
are disproportionately affected by STDs.
3
In the
United States in 2005, the incidence of C. trachomatis
per 100,000 population was 1,729 in African-Ameri-
From the Department of Obstetrics and Gynecology, University of Texas Health
Sciences Center San Antonio, San Antonio, Texas; and the National Institutes
of Health, National Institute of Allergy and Infectious Diseases, Bethesda,
Maryland.
Supported by a grant (U01 AI40029) from the National Institute of Allergy and
Infectious Diseases.
Corresponding author: Andrea Ries Thurman, MD, Assistant Professor, Obstet-
rics and Gynecology, University of Texas Health Sciences Center San Antonio,
7703 Floyd Curl Drive, Mail Code 7836, San Antonio, TX 78229-3900;
email: thurmana@uthscsa.edu.
Financial Disclosure
The authors have no potential conflicts of interest to disclose.
© 2008 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/08
VOL. 111, NO. 6, JUNE 2008 OBSTETRICS & GYNECOLOGY 1417
Page 1
can females, 733 in Mexican-American females, and
237 in Caucasian females.
3
Adolescents are at the
highest risk for STDs, with one in four sexually active
teens acquiring an STD each year.
4,5
There is much debate on how to alter high-risk
sexual behavior in adolescents.
6–14
It is assumed that
teens and adults have different cognitive processes,
life stressors, motivations, and life conditions that may
influence behavior change. In this secondary analysis,
our goal was to answer two questions: 1) was the
SAFE intervention equally effective in preventing
recurrent STDs in adolescents and adults, and 2) what
modifiable behaviors accounted for differences in
reinfection among the two cohorts?
METHODS
This study was approved by the Institutional Review
Boards at the University of Texas Health Science
Center at San Antonio and the San Antonio Metro-
politan Health District. The methods of this RCT
have been published previously.
1
Briefly, Mexican-
American and African-American females, aged 14 to
45 years, diagnosed with a nonviral STD including
Neiserria gonorrhea, Chlamydia trachomatis, syphilis, and
Trichomonas vaginalis, were contacted by our research
clinic. Participants were randomized to the SAFE
intervention or the control group. The randomization
scheme is presented in detail in the original publica-
tion and was stratified by ethnicity.
1
Figure 1 details
the enrollment of the original SAFE cohort and the
present subset analysis.
In the control group, individual STD risk reduc-
tion counseling, lasting approximately 15 minutes,
was provided by nurse clinicians according to guide-
lines issued by the Centers for Disease Control and
Prevention.
15
Those in the study group received the
SAFE intervention, which entailed three, weekly,
3-hour, small group, multicomponent behavioral cog-
nitive interventions.
1
The sessions consisted of an
average of five or six (range 3–12) participants and a
female facilitator, all of the same ethnicity. We
adapted the acquired immunodeficiency syndrome
(AIDS) Risk Reduction Model to guide intervention
development, supplemented with extensive ethno-
graphic data to ensure suitability to our popula-
tion.
16,17
At intervention sessions, we used role-play-
ing, interactive video, handouts, and group discussion
to emphasize the preventive strategies of abstinence,
periodic abstinence, mutual monogamy, correct and
consistent use of condoms, full compliance with treat-
ment protocols, reduction in the number of partners,
avoidance of sexual intercourse until the participant
Fig. 1. Flow of participants through study.
Thurman. Recurrent Sexually Transmitted
Diseases. Obstet Gynecol 2008.
1418 Thurman et al Recurrent Sexually Transmitted Diseases OBSTETRICS & GYNECOLOGY
Page 2
and her partner(s) completed treatment, taking time
between partners to be selective, avoidance of douch-
ing, and seeking medical care whenever a participant
suspected infection.
1
Overall goals were to have par-
ticipants recognize their risk for contracting STDs,
including human immunodeficiency virus (HIV),
commit to behavior change, and acquire the neces-
sary skills to effect change.
All participants were interviewed, examined,
screened, and treated for STDs at baseline and at 6
and 12 months of follow-up. Subjects were encour-
aged to return to our clinic as needed for any symp-
toms of or concern for reinfection. At each visit a
targeted physical examination was performed, with
collection of specimens for microbiologic testing,
including N. gonorrhea, C. trachomatis, syphilis, and
Trichomonas vaginalis. At each visit, participants were
offered a test-of-cure after treatments and HIV testing.
The primary outcome of the study was subse-
quent reinfection with C. trachomatis or N. gonorrhea.
Secondary outcomes included the presence or ab-
sence of risky sexual behaviors. At baseline and 6 and
12 months, a trained research assistant interviewed
each participant regarding sexual risk behaviors, con-
dom use, physical symptoms, partner-specific data,
depression and emotional stressors, perception of
their risk for STD and HIV acquisition, and other
sociodemographic and psychosocial questions. For
this analysis, we divided the participants into adoles-
cents (aged 14 to 18 years) and adults (aged 19 years
or older). We chose to subdivide the teens at age 18
because we hypothesized that age 18 often marks
several transitions, including graduation or leaving
school and moving away from home.
18
Bivariate relationships between independent vari-
ables first were explored using Pearson’s
2
test. We
analyzed behavioral changes from baseline at 0 to 6
months, 6 to 12 months, and cumulative intervals
using mutivariate logistic regression analysis and ad-
justed P values for group differences for baseline
behaviors, when these baseline measures were avail-
able. In the final analysis, we used multivariate logistic
regression to determine the relative effect of each
behavior on reinfection compared with “no infec-
tion.” In presenting these results, we retained all
behavioral risk measures in the analyses to maintain
model symmetry.
RESULTS
There were 164 teens and 313 adults in the SAFE
study with complete infection and behavioral data at
baseline, 6, and 12 months’ follow-up.
1
Because the
goal of this study was to examine reinfection and
high-risk sexual behaviors, we used this subset of the
SAFE cohort for our analysis. We excluded sixteen
14- to 15-year-old girls who had a history of sexual
abuse (defined as coital debut before age 11 and/or
reporting that they had had “bad sexual experiences
like rape or sexual abuse in the past,” and/or that their
first episode of vaginal or anal sex was involuntary).
Secondary analysis of infection data (not shown)
found that the SAFE intervention was effective even
for females with an abuse history, except for those
who were 14 to 15 years old at intake. In addition, this
small subset was disproportionately represented in
the intervention group (12 of 16) and had high rates of
reinfection (9/16, 56.3% cumulatively) and ongoing
high-risk behaviors; their inclusion would cloud our
understanding of reinfection and behavior patterns.
Thus, 148 teens and 313 adults (n461) remained for
analysis. Attrition rates did not differ significantly
between groups for any subgroup analysis. Interven-
tion participation rates (before the 6-month visit) were
92% for at least one session, 82% for at least two
sessions, and 79% for all three sessions. Among the
adolescent and adult study groups, 79.5% and 78.9%
attended all three sessions, respectively.
Table 1 shows the baseline characteristics of
adolescents versus adults. The groups were not differ-
ent with respect to the following baseline risky sexual
behaviors: multiple sexual partners, recent unsafe sex,
recent anal sex, douching after sex, binge drinking
(defined as drinking five or more alcoholic beverages
at a party), illicit drug use, and being in a nonmonoga-
mous, nonsteady relationship. Significantly more
teens lived in impoverished homes, defined by the
household income being below the federal poverty
threshold for the year the individual enrolled in our
study. The teens and adults were similar in their
baseline prevalence of N. gonorrhea (10.2% versus
8.5%, P.83) or C. trachomatis (53.0% versus 54.9%,
P.70); however the adults were significantly more
likely to have an index infection of either T. vaginalis
or syphilis. When asked the question, “Do you plan to
make any changes in your life to lower your chances
of catching another STD or the AIDS virus,” 97.0% of
teens and 95.5% of adults responded affirmatively
(P.44). In addition, few teens or adults perceived
any barriers to making behavioral change, such as
upsetting a man they really liked, messing up their
relationship, losing their man, fear of being alone, or
embarrassment about discussing condom use (data
not shown). Most teens (83.5%) and adults (82.3%)
(P.74) reported that they sought medical attention
“right away” for “female symptoms.” Only 16.6% of
teens and 16.1% of adults (P.90) reported that being
VOL. 111, NO. 6, JUNE 2008 Thurman et al Recurrent Sexually Transmitted Diseases 1419
Page 3
in a relationship with a man was the “most important
thing” in life. The teens and adults were similar in
their responses to “it is a good idea to have a man on
the side” (9.9% versus 12.1% P.71), “I could support
myself financially without a man’s help” (72.2% ver-
sus 74.0% P.67), and “I feel discriminated against
based on my ethnicity” (26.5% versus 29.3% P.53).
Cumulatively, 33.1% of teens (49/148) and 14.4%
(45/313) of adults had a recurrent STD (P.001,
relative risk 2.30, 95% confidence interval 1.62–3.28).
However, Table 2 shows that teens in the study group
responded well to the SAFE intervention; they had
significantly lower reinfection rates than teens in the
control group at 0 to 6 months and, cumulatively, 0 to
12 months, with a strong trend toward lower reinfec-
tion rates at 6 to 12 months (P.06). None of the
participants tested positive for HIV during the study.
Of note, among the larger subset of 533 women for
whom we have complete infection but not behavioral
data,
1,2
significant reductions in reinfection rates are
evident for teens and adults in the study group versus
those in the control group (cumulative re-infection in
study versus control teens24.1% versus 40.2%,
P.02); cumulative re-infection in study versus con-
trol adults10.4% versus 18.6%, P.03).
Table 3 illustrates how adolescents and adults
modified high-risk sexual behaviors at each interval.
At baseline, those in the study and control groups
were not different in high-risk behaviors, except the
teens in the study group were significantly more likely
Table 1. Baseline Characteristics of Adolescents Compared With Adults
Variable
Teens
14–18 Y Old
(n148) (%)
Adults
19 Y and Older
(n313) (%)
2
P
Hispanic 100 (67.6) 218 (69.6) .62
Married 11 (7.4) 74 (23.6) .001
Household income less than federal poverty level 127 (85.8) 233/312 (74.7) .01
Lives with a sex partner 34 (23.0) 100 (31.9) .06
Coital debut at age less than 15 y 60 (40.5) 67 (21.4) .001
Abuse history 36 (24.3) 97 (31.0) .14
Average number of partners per year of coital activity 3.6 1.8 .001
Pregnant at intake 54 (36.5) 80 (25.6) .02
Index STD Trichomonas vaginalis 9 (6.1) 54 (17.3) .001
Index STD syphilis 2 (1.4) 16 (5.1) .03
History of STDs 41 (27.7) 127 (40.6) .03
Current use of any illegal drug 24 (16.2) 37/312 (11.9) .19
Current marijuana-only use 19 (12.8) 34 (10.9) .28
Current illegal drug use (except marijuana) 10 (6.8) 6/312 (1.9) .01
5 or more alcoholic drinks consumed at a party 29 (19.6) 77/312 (24.7) .14
Currently in a not-steady relationship 67 (45.3) 134 (42.8) .62
Anal sex in past 3 months 14 (9.5) 36 (11.5) .70
Oral sex in past 3 months 34 (23.0) 122 (39.0) .001
“Unsafe sex” in past 3 months 62 (41.9) 123 (39.3) .59
Douching after sex 38 (25.7) 106 (33.9) .08
No condom use with at least one partner 66 (44.5) 192 (61.3) .001
Multiple partners in past 3 months 38 (25.7) 90 (28.7) .49
Multiple partners in past 6 months 53 (35.8) 99 (31.6) .32
Multiple partners in past 12 months 86 (58.1) 159 (50.8) .14
Yes, I will stop having sex until treatment is completed. 140 (95.1) 289/311 (92.9) .35
STD, sexually transmitted disease.
Table 2. Reinfection Rates Based on Age and Study Group
Reinfection
Time Frame
Teen
Study (%)
Teens
Control (%) P OR (95% CI)
Adults
Study (%)
Adults
Control (%) P OR (95% CI)
0–6 mo 8/66 (12.1) 21/82 (25.6) .04 2.50 (1.03–6.08) 14/171 (8.2) 17/142 (12.0) .26 1.53 (0.72–3.21)
6–12 mo 10/66 (15.2) 23/82 (28.0) .06 2.19 (0.95–4.99) 10/171 (5.8) 14/142 (9.9) .18 1.76 (0.76–4.10)
0–12 mo* 16/66 (24.2) 33/82 (40.2) .04 2.11 (1.03–4.30) 20/171 (11.7) 25/142 (17.6) .14 1.61 (0.85–3.05)
OR, odds ratio; CI, confidence interval.
* If a subject is reinfected at the 0–6 month interval and at the 6–12 month interval, she is counted as one reinfection occurrence for the
cumulative rate.
1420 Thurman et al Recurrent Sexually Transmitted Diseases OBSTETRICS & GYNECOLOGY
Page 4
Table 3. Percent of Study and Control Subjects With Behavioral Risk Factors at Baseline, 6, and 12 Months’ Follow-up and Cumulatively
Risk Factor
Baseline 0–6 Months 6–12 Months 0–12 Months
Teen Adult Teen Adult Teen Adult Teen Adult
SCP SCP SCP*SCP*SCP*SC P*SCP*SC P*
Unprotected sex
with untreated
partner
NA NA NA NA NA NA 15.2 19.5 .49 6.4 15.5 .01 NA NA NA NA NA NA 15.2 19.5 .49 6.4 15.5 .01
Not mutually
monogamous
68.2 69.5 .86 69.0 60.6 .12 37.9 48.8 .18 35.7 47.2 .01 33.3 53.7 .01 36.8 39.4 .38 57.6 69.5 .12 50.9 57.7 .07
Unsafe sex 39.4 43.9 .58 42.7 35.2 .18 16.7 29.3 .09 19.9 28.2 .04 36.4 43.9 .40 25.7 42.3 .001 36.4 43.9 .40 25.7 42.3 .001
Rapid partner
turnover
NA NA NA NA NA NA 12.1 23.2 .08 21.1 22.5 .75 12.1 29.3 .01 10.5 19.7 .02 21.2 35.4 .06 26.9 31.0 .43
Douches after sex 36.4 17.1 .01 37.4 29.6 .14 6.1 15.9 .01 8.8 17.3 .09 6.1 11.0 .11 6.4 10.6 .09 9.1 18.3 .01 11.7 18.3
The study group (S) received SAFE behavioral intervention training (teen study group n66, adult study group n171).
The control group (C) received individual Centers for Disease Control and Prevention sexually transmitted disease risk reduction counseling (teen control group n82, adult control group
n142).
* P values for group differences reflect adjustment for baseline values (behaviors in the previous follow-up interval for nonmutually monogamous, unsafe sex, and douching after
sex) via logistic regression. There were no comparable baseline variables for unprotected sex with an untreated partner and rapid (less than 3 months) partner turnover, and
thus P values for differences are based on
2
analysis.
VOL. 111, NO. 6, JUNE 2008 Thurman et al Recurrent Sexually Transmitted Diseases 1421
Page 5
to douche after intercourse than were teens in the
control group. Teens in the study group showed
significant reductions in several high-risk behaviors,
at various time intervals, as compared with teens in
the control group. Despite beginning with higher
rates of douching, teens randomized to SAFE had
significantly lower cumulative douching rates than
those in the control group. Teens in the study group
did not maintain the safe sex behaviors they achieved
at 0 to 6 months and conversely did not attain
significant improvements (versus those in the control
group) in mutual monogamy and rapid partner turn-
over until 6 to12 months. Importantly, teens in the
study group were not different from teens in the
control group in avoiding unprotected sex with un-
treated partners (P.05 at each follow-up interval).
Cumulatively, the adults in the study group main-
tained significant reductions or strong trends (nonmu-
tually monogamous relationships [P.07]) in all high-
risk behaviors compared with adults in the control
group, except rapid partner turnover, which took 6
months to reduce significantly.
Contrast Table 3, which shows how the cohorts
behaved at each follow-up interval, with Table 4,
which demonstrates how each high-risk behavior
predicted reinfection. The adjusted (for each behavior
in the model) odds ratios (ORs) in Table 4 show the
degree to which each behavior predicted reinfection.
For teens as a group, unprotected sex with untreated
partners was consistently associated with the highest
adjusted ORs for reinfection. Table 3 illustrates that
the SAFE intervention did not sufficiently influence
this behavior in teens in the study group. Cumula-
tively (0 –12 months), reinfection in teens was signifi-
cantly predicted by unprotected sex with untreated
partners, rapid (less than 3 months) partner turnover,
and nonmonogamy. Unprotected sex with untreated
partners also was associated with the highest risk for
reinfection in adults. Cumulative reinfection in adults
was significantly associated with unsafe sex, rapid
partner turnover, and douching after sex. Analysis of
the attributable risk of behaviors (risk of those with
behavior minus risk of those without) were consistent
with the ranking of behavioral risks based on adjusted
OR. Attributable risk was the highest for unprotected
sex with untreated partners: .40 for teens and .27 for
adults after adjusting for other factors in the model.
Cumulative regression analysis for teens pre-
dicted 75.0% of reinfections and correctly classified
74.5% of teens who were not reinfected and 75.9% of
teens who experienced recurrent N. gonorrhea or C.
trachomatis. In the teen multivariate logistic regression
model, we used forward-step multivariate logistic
regression analysis to also test the effect of pregnancy,
illegal drug use, poverty status, early coital debut, and
abuse on reinfection, but only the five behavior
Table 4. Logistic Regression Model of Behavioral Variables Predicting Infection at 6 and 12 Months and
Cumulatively (n461)
Variable
0–6 Mo 6–12 Mo
Adolescents Adults Adolescents
n%*
aOR
(95% CI) P n%*
aOR
(95% CI) P n%*
aOR
(95% CI) P
Unprotected sex with an untreated partner
No 122 13.1 7.68 (3.25–18.16) .001 280 6.8 7.54 (3.09–18.40) .001 122 20.5 10.54 (4.37–25.42) .001
Yes 26 50.0 33 36.4 26 30.8
Nonmutually monogamous
Yes 65 36.9 5.96 (1.93–18.36) .002 128 16.4 0.75 (0.25–2.23) .60 66 37.9 2.20 (0.82–5.89) .12
No 83 6.0 185 5.4 82 9.8
Unsafe sex
Yes 35 40.0 1.71 (0.71–4.10) .23 74 24.3 4.08 (1.64–10.17) .01 60 31.7 1.88 (0.81–4.35) .14
No 113 13.3 239 5.4 88 15.9
Rapid (less than 3 mo) partner turnover
No 121 17.4 0.81 (0.31–2.09) .66 245 6.1 3.89 (1.48–10.25) .01 116 12.1 3.28 (1.23–8.76) .02
Yes 27 29.6 68 23.5 32 59.4
Douche after intercourse
No 131 17.6 1.94 (0.68–5.55) .22 279 7.5 3.77 (1.47–9.66) .006 135 20.7 0.53 (0.11–2.56) .43
Yes 17 35.3 34 29.4 13 38.5
aOR, adjusted odds ratio; CI, confidence interval.
* Percent reinfected with Neiserria gonorrhea or Chlamydia trachomatis.
Odds ratio adjusted for nonmonogamous relationship, unprotected sex with an untreated partner, rapid partner turnover, douching after
sex, and unsafe sex.
1422 Thurman et al Recurrent Sexually Transmitted Diseases OBSTETRICS & GYNECOLOGY
Page 6
variables were independently associated with recur-
rent infection in teens (data not shown). For adults,
the cumulative regression model predicted 70.6% of
reinfections and correctly classified 70.1% of adults
not reinfected and 73.3% of adults who were rein-
fected. Similarly, in the adult multivariate logistic
regression model, we used forward-step logistic re-
gression to also test the impact of abuse, lives with a
sexual partner, and pregnancy on reinfection, but
none of these variables was independently associated
with recurrent N. gonorrhea or C. trachomatis (data not
shown).
DISCUSSION
Although not specifically designed for adolescents,
the SAFE intervention not only significantly de-
creased recurrent C. trachomatis or N. gonorrhea, the
primary biologic outcome, but also reduced risky
sexual behaviors among adolescents. However, teens
in the study group had higher reinfection rates than
corresponding adults because the behavior that was
most highly and consistently associated with recurrent
infection in teens—unprotected sex with untreated
partners—was not sufficiently modified by the SAFE
intervention. Additionally, teens in the control arm
continued high-risk sexual behavior throughout the
study at levels that were higher than adults random-
ized to the control group.
At baseline, our adolescent participants demon-
strated significantly higher rates of poverty, early
coital debut, multiple sexual partners, teen preg-
nancy, and illegal drug use (excluding marijuana),
factors associated with risky behavior and recurrent
STDs.
19
This analysis extends our understanding of
which risk-reduction strategies should be emphasized
to adolescent girls with an STD, as compared with
their adult counterparts, to decrease their risk of
reinfection. Unprotected sex with untreated partners
was associated with a 6- to 10-fold increased risk of
reinfection in teens. This suggests a powerful mes-
sage: the health care professional who diagnoses an
STD in a teen can have a significant impact on
reducing reinfection by explaining to the adolescent
that she must avoid intercourse until she and her
partner(s) are completely treated. Other issues such as
rapid partner turnover and mutual monogamy must
be stressed, but the adjusted ORs for these behaviors
were not as high.
Our findings suggest that some teens either did
not understand that they had to avoid intercourse
until all infected partners were treated, or they as-
sumed they were protected by antibiotics. Alterna-
tively, the teens may have been more concerned
about maintaining the relationship than becoming
reinfected. It is possible that the teens’ partners were
less likely to be treated than the adults’ partners.
20–25
Finally, the partners of teens may have been inher-
ently more risky than the partners of adults in terms of
their acquisition of new STDs or other risk factors
which we did not measure.
26,27
Many of the adults and teens reported abuse at
intake. Self-efficacy and relationship power are im-
Table 4. Logistic Regression Model of Behavioral Variables Predicting Infection at 6 and 12 Months and
Cumulatively (n461) (continued)
6–12 Mo 0–12 Mo
Adults Adolescents Adults
n%*
aOR
(95% CI) P n%*
aOR
(95% CI) P n%*
aOR
(95% CI) P
280 6.1 6.82 (2.93–15.85) .001 122 27.0 5.58 (2.61–11.95) .001 280 11.4 4.90 (2.19–11.00) .001
33 21.2 26 61.5 33 39.4
119 16.0 1.07 (0.44–2.63) .88 95 46.3 5.14 (1.79–14.73) .01 169 21.9 1.71 (0.64–4.52) .28
194 2.6 53 9.4 144 5.6
104 15.4 3.09 (1.36–7.06) .01 60 46.7 1.52 (0.77–2.97) .23 104 26.9 2.18 (1.05–4.52) .04
209 3.8 88 23.9 209 8.1
267 5.2 2.00 (0.73–5.49) .18 105 22.9 2.02 (1.01–4.05) .05 223 8.5 3.13 (1.46–6.75) .01
46 21.7 43 58.1 90 28.9
287 7.3 2.06 (0.73–5.77) .17 127 29.9 1.58 (0.71–3.52) .26 267 11.6 2.41 (1.12–5.17) .03
26 11.5 21 52.4 46 30.4
VOL. 111, NO. 6, JUNE 2008 Thurman et al Recurrent Sexually Transmitted Diseases 1423
Page 7
portant components of a woman’s ability to convince
her partner(s) to complete treatment and use con-
doms.
10,11,25,28
It has been shown that inconsistent
condom use is more common in teens with lower
self-efficacy scores.
10,12,28
SAFE was designed to em-
power minority women to make positive changes in
their lives. Although the teens had higher rates of illegal
drug use, drug use was not independent in predicting
reinfection in the multivariate regression analysis. Pre-
vious authors found that behavioral intervention, even
in adolescent substance abusers, can improve knowl-
edge of STD risk and increase condom use.
14
A limitation of our study is that we did not
involve the teens’ parents or partners in the interven-
tion, who may be able to support the adolescent in
changing high-risk sexual behaviors and reducing
recurrent infection.
29
However, a third SAFE RCT,
currently underway, enrolls the male sexual partners
of the index female patients. The major strength of
our study was that it was a RCT with a primary
biologic outcome. Other RCTs designed to prevent
HIV or STDs in adolescents have used self-reported
behaviors, such as condom and contraceptive use,
alcohol consumption, gang involvement, number of
sexual partners, or HIV risk-reduction knowledge as
primary outcomes, which may be confounded by
reporting or recall bias and are difficult to vali-
date.
30–34
It has been shown that adolescent reports of
STD status and other high-risk sexual behaviors are
subject to bias.
33
Our findings suggest that the teens in
the study group benefited from their interactions with
the adult subjects in the intervention sessions. Maybe the
teens learned from the adults’ experiences or other-
wise bonded with the young adults in the study. It has
been shown that minority populations benefit from
ethnically matched group facilitators and that adoles-
cent’s perceptions of group norms are important in
determining individual high-risk behaviors.
7,12
Our
study population was primarily Mexican American,
the fastest growing segment of the United States,
according to the Census Bureau. Other RCTs de-
signed to prevent high risk sexual behaviors in ado-
lescents, such as the SISTA intervention or the Sister-
to-Sister: The Black Women’s Health Project, which
included biologic outcomes, have focused primarily
on African-American women.
31,35–37
The SAFE inter-
vention is also unique because we emphasized seek-
ing medical attention for signs and symptoms of an
STD. It is known that a history of an STD is a strong
risk factor for recurrent STDs
4
and that the sequela of
STDs can be prevented by routine screening.
38
In a
review of behavioral interventions to decrease high
risk teen sexual behavior, Kirby found that effective
programs focused on reducing specific behaviors and
included activities that addressed social pressures that
influence sexual behavior, which is part of the SAFE
intervention.
6
In conclusion, teens randomized to the SAFE
intervention had significant decreases in recurrent N.
gonorrhea and C. trachomatis. Intervention designed to
prevent recurrent STDs in teens needs to emphasize
skills to help teens ensure their partners are treated
or to otherwise refuse intercourse. Understanding
how each age group’s reinfection rates are influ-
enced by specific behaviors will help health profes-
sionals communicate age-appropriate STD risk-
reduction strategies.
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  • Source
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    Full-text · Article · Jun 2009 · Sexually transmitted diseases
  • Source
    [Show abstract] [Hide abstract] ABSTRACT: We compared the male sexual partners of teen girls of age 15 to 19 years, currently infected with a sexually transmitted infection (STI) versus the male partners of adult women of age 20 to 41 years, with an STI to determine risk factors in these high-risk sexual dyads related to the male partner. Interview of 514 men who were partnered with 152 teen girls and 362 adult women, enrolled in Project Sexual Awareness for Everyone, a randomized controlled trial of behavioral intervention to reduce recurrent STIs. Compared to the male partners of adult women, male partners of teen girls were significantly more likely (P < 0.05) to be infected with any STI at intake. Men partnered with teens were younger and had significantly more sexual partners per year sexually active, shorter relationship length, and shorter length of monogamy with the index girls. They were more likely to report that it was "really important" for the teen to have their baby (P = 0.04) and were slightly more likely to be the father of her children (P = 0.17). Young age independently predicted STI infection in men. Although all women had an STI at intake, important differences were noted among the male partners of teens versus adults. Clinicians with similar populations may use this data to understand the characteristics of male partners of teens with STIs, in order to more effectively counsel adult and teen women on partner notification, treatment and STI prevention.
    Full-text · Article · Aug 2009 · Sexually transmitted diseases
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