Jennifer S. Lin, MD, MCR; Evelyn Whitlock, MD, MPH; Elizabeth O'Connor, PhD; Vance Bauer, MA
Acknowledgment: The authors thank Taryn Cardenas, BS, and Kevin Lutz, MFA, for their invaluable help in preparing this manuscript; Daphne Plaut, MLS, for conducting the literature searches; and Tracy Beil, MS, for help in conducting the evidence review. They also thank David Meyers, MD, the staff at AHRQ and the USPSTF; and the expert reviews for their contribution to this evidence review.
Grant Support: This study was conducted by the Oregon Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality, Rockville, Maryland (contract no. 290-02-0024, task order 1). It was also supported by the Oregon Clinical and Translational Research Institute (grant no. UL1 RR024140) from the National Center for Research Resources, National Institutes of Health.
Potential Financial Conflicts of Interest: None disclosed.
Corresponding Author: Jennifer S. Lin, MD, MCR, Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227; e-mail, firstname.lastname@example.org.
Requests for Single Reprints: Reprints are available from Agency for Healthcare Research and Quality Web site (www.preventiveservices.ahrq.gov).
Current Author Addresses: Drs. Lin, Whitlock, and O'Connor and Mr. Bauer: Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227.
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 “at-risk” 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 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?
Table 1. Summary of Inclusion and Exclusion Criteria for Key Questions 1 through 4
Study flow diagram.
KQ = key question; SER = systematic evidence review. * Articles for KQ3 and KQ4 were reviewed from articles from KQ1 and KQ2.
Table 2. Effectiveness of Behavioral Counseling Interventions to Reduce STIs in Adults and Adolescents Based on Randomized, Controlled Trials (Key Question 1)
Appendix Table 1. Effectiveness of Behavioral Counseling Interventions
Table 3. Summary of Evidence
Summary of findings: intervention intensity vs. population risk and setting.
+ = 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. Studies in Progress
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Jennifer S. Lin, Evelyn Whitlock, Elizabeth O'Connor, Vance Bauer. 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.
Guidelines, Infectious Disease, Sexually Transmitted Infections.
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