Jennifer S. Lin, MD, MCR; Evelyn Whitlock, MD, MPH; Elizabeth O'Connor, PhD; Vance Bauer, MA
Despite advances in prevention and treatment, sexually transmitted infections (STIs) remain an important cause of morbidity and mortality in the United States.
To systematically review the evidence for behavioral counseling interventions to prevent STIs in adolescents and adults (nonpregnant and pregnant).
English-language articles in MEDLINE, PsycINFO, the Centers for Disease Control and Prevention's Prevention Synthesis Research Project database, and Cochrane databases (1988 through December 2007), supplemented with expert recommendations and the bibliographies of previous systematic reviews.
Reviewers included 21 articles representing 15 fair- or good-quality randomized, controlled trials that evaluated behavioral counseling interventions feasible in primary care and 1 fair-quality and 1 good-quality controlled trial with study samples representative of primary care populations in English-speaking countries. Comparative effectiveness trials that did not include a true control group were excluded.
Investigators abstracted, critically appraised, and synthesized 21 articles that met inclusion criteria.
Most evidence suggests a modest reduction in STIs at 12 months among high-risk adults receiving multiple intervention sessions and among sexually active adolescents. Evidence also suggested that these interventions increase adherence to treatment recommendations for women in STI clinics and general contraceptive use in male adolescents and decrease nonsexual risky behavior and pregnancy in sexually active female adolescents. No evidence of substantial behavioral or biological harms for risk reduction counseling was found.
Significant clinical heterogeneity in study populations, interventions, and measurement of outcomes limited the reviewers' ability to meta-analyze trial results and to suggest important intervention components.
Good-quality evidence suggests that behavioral counseling interventions with multiple sessions conducted in STI clinics and primary care effectively reduces STI incidence in â€œat-riskâ€ adult and adolescent populations. Additional trial evidence is needed for both lower-intensity behavioral counseling interventions and lower-risk patient populations.
KQ = key question. Key question 5 (Do sexual behavior changes lead to a reduced incidence of STI, or related morbidity and mortality?) is not addressed in this article; please see the full evidence report (available at http://www.ahrq.gov/clinic/uspstfix.htm).
Is there direct evidence that primary care counseling to reduce risky sexual behavior can reduce STI incidence or related morbidity and mortality?
Does primary care behavioral counseling to prevent STI result in safer sexual behaviors among those counseled?
Does primary care behavioral counseling to prevent STI result in benefits other than safer sexual behaviors and reductions in STI incidence?
Are there harms from primary care behavioral counseling to prevent STI?
Do sexual behavior changes lead to a reduced incidence of STI or related morbidity and mortality?
KQ = key question; SER = systematic evidence review. * Articles for KQ3 and KQ4 were reviewed from articles from KQ1 and KQ2.
Appendix Table 1.
+ = positive findings; Beh = behavioral outcomes; NS = non–statistically significant findings; STI = sexually transmitted infection (biological outcomes); STI-s = self-reported STI. * Low- and high-intensity intervention groups were not analyzed separately.
Appendix Table 2.
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Lin JS, Whitlock E, O'Connor E, Bauer V. Behavioral Counseling to Prevent Sexually Transmitted Infections: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149:497-508. doi: 10.7326/0003-4819-149-7-200810070-00011
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Published: Ann Intern Med. 2008;149(7):497-508.
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