Clinic-based service programs for increasing responsible sexual behavior.

Clinic-based service programs for increasing responsible sexual behaviors offer advantages that complement community-based prevention programs. Clinic clients are often at higher risk than persons in the general population. Clinic staff may be seen as authoritative sources of prevention information. Clinic visits may serve as important cues to action that serve as a basis for behavior change. The purpose of this paper is to review issues relevant to effective, clinic-based programs that address responsible sexual behaviors.

Clinic-based prevention programs encompass a variety of clinical settings, target populations, and desired outcomes. For the purpose of this summary, programs located in any type of U.S. health-care facility are included even if located within a larger organization. For example, school-based clinic interventions are addressed even though they take place within the larger context of schools. Programs are included without regard to target population. Outcomes of interest are both behavioral (e.g., increased condom use or reduction in number of sexual partners) as well as biological (e.g., reduction in rates of sexually transmitted diseases).

The clinic-based programs were separated into three categories for conceptual clarity: (a) clinic-based educational/ counseling programs, (b) school clinic-based condom or contraceptive distribution programs, and (c) clinic-based STD/HIV screening programs. Education/counseling programs and condom/contraceptive distribution programs encourage responsible sexual behavior before any adverse outcome may have occurred, and are examples of primary prevention efforts. STD/HIV screening programs may be seen as attempts to encourage responsible behavior by reducing disease transmission and by prevention of sequella.

CLINIC-BASED EDUCATIONAL/COUNSELING PROGRAMS

Several evaluations of programs show increased responsible sexual behavior, reduced adverse outcomes of sexual behavior, or both. Successful clinical interventions have several elements in common. Similarities include:

1. The successful interventions have a clear theoretical basis and are grounded in the empirical lessons of earlier research. The importance of theory for successful behavioral interventions is the delineation of modifiable factors that are associated with a specific behavior, as well as an understanding of factors required in order to change the behavior.

2. Successful interventions require an investment of effort and time (Kalichman, Carey, & Johnson, 1996). Each program requires specific commitment of staff effort as well as additional time from clients. Such commitments entail costs that may be difficult to reimburse.

3. The most successful interventions are tailored to individuals rather than limited to generic education, recommendations, or advice.

4. Successful interventions include skill-building exercises as well as education and counseling components. Skill building includes behaviors such as negotiation practice with potential partners or practice of correct condom use (Exner, Seal, & Ehrnhardt, 1997).

A variety of approaches to risk-reduction counseling have been used. These approaches include brief (less than 20 minutes) didactic counseling during one visit; brief, personalized counseling over a 7 to 10 day period; and extensive individual or small-group counseling sessions during an interval of several weeks. Populations addressed by studies of risk reduction in clinical settings include interventions targeting adolescents, high-risk women, racial/ethnic minorities (primarily African American and Hispanic), and sexual minorities. Condom use is the most frequently used outcome but incident sexually transmitted infections (including HIV) and behaviors such as number of new sexual partners are also often measured.

Current standards for clinical practice include at least some risk reduction counseling for at-risk persons (U.S. Preventive Services Task Force, 1996). This standard is equivalent to brief, didactic, risk-reduction messages. In clinical samples, preintervention levels of consistent condom use are often less than 20%. Most studies show that brief risk-reduction messages are associated with increases in consistent condom use compared to preintervention levels of use (Cohen, Dent, & MacKinnon, 1992; Cohen, Dent, MacKinnon, & Hahn, 1991; Kamb et al., 1998; Mansfield, Conroy, Emans, & Woods, 1993). This level of condom use may be sustained for up to 12 months following the counseling session although decay of effects over time is almost universal (Kamb et al., 1998). Thus, most authorities believe that additional sessions are required to maintain desired behaviors.

Sexual risk behaviors other than condom use may also be influenced by brief clinic-based interventions. Number of recent sex partners (Cohen et al., 1992; Mansfield et al., 1993) and incident sexually transmitted infections (Cohen et al., 1992; Kamb et al., 1998) are also reduced.

A few studies of single-session counseling--such as that provided during HIV pretest counseling--demonstrate no influence of counseling on subsequent levels of self-reported condom use or sexually transmitted infections (Clark, Brasseux, Richmond, Getson, & D'Angelo, 1998; Wenger et al., 1992) These clinical interventions may typically represent highly didactic prevention messages that may seem inappropriate to many patients. Such differences may explain the relative success of more individualized behavior change approaches.

More extensive counseling (either individual or in small groups) may produce an additional 10% to 15% increase (compared to brief, single-session counseling) in consistent condom use. This level of additional condom use is most evident within 6 months of the intervention. Afterwards, levels of condom use become similar to that seen for patients receiving single-session didactic counseling (Boyer, Barrett, Paterman, & Bolan, 1997; Kamb et al., 1998; Shain et al., 1999). However, the optimal time and extent of intervention sessions is not established (Exner et al., 1997; Kalichman et al., 1996).

Some studies employing a multisession extensive counseling approach failed to show significant increases in condom use, compared to more limited interventions (O'Leary et al., 1998; Orr, Langerfeld, Katz, & Caine, 1996; Smith, Weinman, & Parrilli, 1997). These studies focused on high-risk women attending sexually transmitted diseases clinics.

Levels of incident sexually transmitted infection are also lower among patients receiving more extensive counseling compared to those receiving only brief didactic messages. The magnitude of difference between the two types of counseling is usually less than 5%. These statistically significant differences are small, but could represent substantial reductions in incidence rates if applied on a large scale. In a single study reporting a larger difference, participants received up to 12 hours of small-group counseling and training (Shain et al., 1999).

The amount of time required to conduct effective counseling for responsible sexual behavior is of key importance in busy clinical settings constrained by space and resources. Brief counseling conducted in two sessions over a 7 to 10 day interval may be as effective as more extensive counseling conducted over a period of several weeks (Kamb et al., 1998). An obvious limitation of multiple session approaches is the failure to return by some patients and the resources required to prompt patients about follow-up counseling appointments. More extensive multi-session interventions may be appropriate for some settings, but likely require resources well beyond those available in most clinics.

CLINIC-BASED CONDOM/CONTRACEPTIVE DISTRIBUTION PROGRAMS

Programs that make condoms more easily available may remove a barrier to responsible sex behaviors. For example, embarrassment associated with purchase of condoms may prevent their use by some people. Community-based condom distribution programs subsidize costs of condoms and increase access in nontraditional commercial venues such as hair salons (Cohen, Nsuami, Martin, & Farley, 1999). Concerns have been expressed, however, that unlimited access to condoms may increase sexual activity, especially among unmarried adolescents. Such an increase in sexual activity could paradoxically lead to increases in rates of sexually transmitted diseases because of inherent failure rates of condom protection. Concern is also expressed that simply making condoms more available will remove opportunities for counseling regarding responsible sexual behavior. In fact, most clinic-based condom-distribution programs include some forms of abstinence and risk-reduction counseling (Kirby & Brown, 1996)

Condom distribution programs within school-based clinics are well accepted by adolescents, parents, and school personnel (Guttmacher et al., 1995; Kirby et al., 1999) Adolescents will use school-based sources to obtain condoms (Wolk & Rosenbaum, 1995). Formats for condom distribution include provision of condoms in baskets within a clinic, condom vending machines, and provision of small quantities of condoms after counseling (Kirby & Brown, 1996). Direct availability of condoms is associated with distribution of more condoms than vending machines or dispensing of a small number of condoms after counseling (Kirby et al., 1999).

Several studies have addressed the potential influence of school-based condom distribution programs on adolescents' sexual and contraceptive behaviors. None of these studies demonstrate any change in level of sexual behavior. Condom use was reported to increase in two studies (Guttmacher et al., 1997; Schuster, Bell, Berry, & Kanouse, 1998), was unchanged in one study (Furstenberg, Geitz, Teitler, & Weiss, 1997), and decreased in one study (Kirby et al., 1999). The results from the study in which condom use decreased also showed that relatively few condom nonusers began using condoms because of their availability. Rather, students shifted their source of condoms from other clinics or commercial outlets and began to obtain condoms from the school clinic. Differences between samples as well as methodological differences may explain these divergent results.

No studies examine potential effects of school-based condom distribution programs on rates of sexually transmitted infections among students attending schools where condoms were distributed.

CLINIC-BASED STD/HIV SCREENING PROGRAMS

A significant proportion of sexually transmitted infections are asymptomatic. Screening programs allow at-risk individuals to express responsible behavior by determining their infection status. Appropriate treatment can be provided for those infected. Potential advantages of these programs are a reduction in the consequences of untreated infection, reduction in disease transmission to others, and the opportunity to reinforce risk-reduction counseling. Obtaining appropriate health care is also a form of responsible sexual behavior centered in clinical settings.

Patient compliance is an important barrier to successful implementation of clinic-based screening programs. Many patients delay in seeking care even when symptomatic (Fortenberry, 1997; Leenaars et al., 1993). Low literacy and high levels of stigma about sexually transmitted diseases act as barriers for obtaining STD-related screening tests (Fortenberry et al., 2002, 2001). No interventions directed toward these issues were identified.

Appropriate assessment by clinicians of sexual risk is an essential aspect of STD screening programs although such sexual risk assessment is often omitted during routine clinic visits (Boekeloo et al., 1991; Ellen, Lane, & McCright, 2000). Mailed educational materials combined with direct feedback increases physicians' sexual risk behavior assessments during clinical encounters (Rabin et al., 1994). Routine screening for sexually transmitted infections has been shown to reduce the incidence of some sexually transmitted infections, especially those due to Chlamydia trachomatis. Chlamydia prevalence rates among young women decrease by 2% or more after implementation of routine chlamydia screening (Fortenberry & Evans, 1989; Katz, Blythe, Van Der Pol, & Jones, 1996). When implemented on a large scale, routine chlamydia screening is associated with decreased chlamydia prevalence among all age groups of females and males. The magnitude of this reduction is up to 41% for some groups of women and up to 14% among men (Hillis et al., 1995; Scholes et al., 1996). The incidence of new infections among women decreased by up to 50%. Routine chlamydia screening reduces the incidence of pelvic inflammatory disease. The magnitude of this reduction in two different states was 33% and 58%. These reductions represent important health improvements for women.

Schools and school-based clinics can be used as a forum for STD screening programs. Use of state-of-the-art nucleic acid amplification tests allows use of easily obtained specimens such as urine or self-obtained vaginal swabs. Evaluations of such school-based screening programs demonstrate their acceptability to students, parents, and faculty, and are associated with reductions in disease prevalence over time (Cohen et al., 1998; Cohen, Scribner, Bedino, & Farely, 1999).

Screening for sexually transmitted infections could affect subsequent risk behaviors of those tested. Knowledge of a negative screening test may be associated with reductions in risk behaviors (Fox, Okada, Brookmeyer, & Polk, 1987). Other studies suggest that HIV and STD testing has no effect on subsequent STD/HIV risk including condom use, number of sex partners, and subsequent infection (Weinhardt, Carey, Johnson, & Bickham, 1999; Wenger et al., 1992; Wilson, Jaccard, Levinson, Minkoff, & Endias, 1996). However, counseling and testing is an effective secondary prevention method as HIV-positive individuals and members of sero-discordant couples show significantly increased condom use, reduced number of partners, and reduced levels of STD in the post-test period (Weinhardt et al., 1999). A substantial proportion of persons receiving screening tests do not receive the results and cannot be influenced by that information (Schwebke, Sadler, Sutton, & Hook, 1997). These data suggest that STD/HIV screening must be used as an adjunct to other clinical interventions rather than a substitute for such counseling.

SUMMARY AND CONCLUSIONS

Clinic-based programs can successfully increase responsible sexual behavior. More successful programs provide multiple sessions over time, and address relational issues as well as knowledge and skills. The overall effect size, however, is modest at best, and behavior change is limited to a few months after the intervention. These findings support a more general concept that promotion of responsible sexual behavior requires a sustained dialogue that promotes risk reduction within the context of healthy sexuality.

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J. Dennis Fortenberry
Indiana University

Address correspondence to J. Dennis Fortenberry, M.D., M.S., Riley Outpatient Parking Garage, Room 070, 575 N. West St., Indianapolis, IN 46202; e-marl: [e-mail].