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Behavioral Intervention Reduces Recurrent Sexually Transmitted Infections in Teens

Posted to the Web: Sunday, April 06 , 2008
A behavioral intervention called SAFE (Sexual Awareness for Everyone) was significantly effective in reducing recurrent sexually transmitted infections in African American and Mexican American teens, according to the results of a randomized controlled trial reported in the June issue of Obstetrics & Gynecology.

"In a previous randomized controlled trial, we found that ... the SAFE behavioral intervention significantly reduced the rate of recurrent Neiserria gonorrhea and Chlamydia trachomatis infections among reproductive-age Mexican-American and African-American women," write Andrea Ries Thurman, MD, from the University of Texas Health Sciences Center San Antonio, and colleagues.

"Subsequently, we found that risk reduction was largely explained by five modifiable behaviors: unprotected sex with untreated partners, lack of mutual monogamy, 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 incorrect or problematic condom use), rapid (less than 3 months) partner turnover, and douching after intercourse."

The goal of this trial was to determine the efficacy of the SAFE behavioral intervention in teenagers compared with adult rates of reinfection with N gonorrhea or C trachomatis cervicitis and to identify behaviors associated with recurrent infection.

Mexican American and African American females aged 14 to 18 years with a nonviral sexually transmitted infection were randomized to receive the SAFE intervention or to the control group. All participants were interviewed and examined at baseline, 6 months, and 12 months. The main end point was reinfection with N gonorrhea or C trachomatis, and secondary end points were changes in risky sexual behavior.

Compared with teens in the control group, those randomized to participation in SAFE had a reduced incidence of recurrent N gonorrhea and C trachomatis at 0 to 6 months (52%; P = .04) and cumulatively (39%; P = .04). As a group, teens had higher cumulative rates of reinfection (33.1%) than did adults (14.4%; P < .001).

In adolescents, reinfection was attributed to unprotected sex with untreated partners (adjusted odds ratio [OR], 5.58), nonmonogamous behavior (adjusted OR, 5.14), and rapid partner turnover (adjusted OR, 2.02). In adult women, reinfection was associated with 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 [sexually transmitted diseases] in teenagers," the study authors write. "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."

A limitation of this study is that it did not involve the teens' parents or partners in the intervention.

"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," the study authors conclude. "Understanding how each age group’s reinfection rates are influenced by specific behaviors will help health professionals communicate age-appropriate STD risk-reduction strategies."

The National Institute of Allergy and Infectious Diseases supported this study.

The authors have disclosed no relevant financial relationships.

Clinical Context Adolescents are the age group at highest risk for sexually transmitted infections, with an annual prevalence of approximately 25% among sexually active teenagers. The authors of the current study developed the SAFE intervention to reduce the risk for sexually transmitted infections among female patients. SAFE consists of 3 weekly sessions lasting 3 hours each that focus on behavioral and cognitive interventions.

In the current study, these sessions were led by a female facilitator of the same ethnicity as participants. The sessions use role-playing, interactive video, handouts, and group discussion to promote various strategies to reduce the risk for sexually transmitted infections.

Previously, the SAFE intervention was demonstrated to reduce the risk for sexually transmitted infections among Mexican American and African American women. The current secondary analysis of that study examines how SAFE affects minority adolescents with a previous history of sexually transmitted infection.

Study Highlights Subjects eligible for study participation were Mexican American and African American females between the ages of 14 and 45 years. The secondary analysis focused only on subjects between the ages of 14 and 18 years. All participants had received a diagnosis of N gonorrhea, C trachomatis, syphilis, or Trichomonas vaginalis prior to being contacted by study personnel. Women with a known history of sexual abuse were excluded from study participation.

Participants were randomized to receive the SAFE intervention or a control intervention, which consisted of 15 minutes of counseling by a nurse clinician.

The main study outcome was the incidence of sexually transmitted infections, particularly N gonorrhea and C trachomatis, at 6 and 12 months of follow-up.

There were 148 adolescents with data for analysis. The average number of partners per year of coital activity was 3.6. The baseline prevalence of N gonorrhea and C trachomatis were 10.2% and 53%, respectively.

Practice of risky sexual behaviors was similar in adolescent and adult women.

33.1% of adolescents experienced a recurrent sexually transmitted infection during the study period (compared with 14.4% of adults). The reinfection rate of sexually transmitted infection from 0 to 6 months was 2.5 times higher in the control group vs the SAFE group. While this result was statistically significant, the respective increased risk for sexually transmitted infection of 2.19 between 6 and 12 months was not significant. Overall, SAFE significantly reduced the risk for sexually transmitted infection during 12 months vs the control intervention.

Adolescents randomized to SAFE were less likely to douche after sex vs control group. However, rates of unprotected sex with untreated partners were similar in the SAFE and control groups. The biggest risk factor for reinfection among adolescents was unprotected sex with untreated partners (adjusted OR of reinfection, 5.58). Multiple sexual partners (adjusted OR, 5.14) and partner turnover in less than 3 months (adjusted OR, 2.2) were also risk factors for reinfection with sexually transmitted infection. Unsafe sex and douching after intercourse were not significantly associated with the risk for reinfection.

Among adults, unprotected sex with untreated partners, unsafe sex, rapid partner turnover, and douching were predictive of reinfection.

Pearls for Practice SAFE consists of 3 weekly sessions lasting 3 hours each that focus on behavioral and cognitive interventions. In the current study, these sessions were led by a female facilitator of the same ethnicity as participants. The sessions use role-playing, interactive video, handouts, and group discussion to promote various strategies to reduce the risk for sexually transmitted infections.

In the current study, SAFE reduced the risk for reinfection with sexually transmitted infection among adolescents. Unprotected sex with untreated partners was the most important risk factor for reinfection with sexually transmitted infection.