Data on incident STDs were available from 10 RCTs that included 10 944 participants. The aggregated effect size was marginally significant (OR = 0.88, 95% CI = 0.72, 1.07), indicating that the intervention groups had a 12% reduction in the odds of incident STD compared with comparison groups. The homogeneity test (Q 10 = 18.61, P < 0.03) indicated heterogeneity between trials. Sensitivity tests indicated that excluding one trial  made the intervention effect significant (OR = 0.82, 95% CI = 0.69, 0.98, N = 9). However, none of the studies significantly reduced the overall heterogeneity. Additional sensitivity tests showed that marginally significant intervention effects were observed in studies with follow-ups longer than 12 months (OR = 0.77, 95% CI = 0.59, 1.00, N = 7), but the intervention effect was not significant in trials with follow-ups less than 12 months (OR = 1.00, 95% CI = 0.82, 1.21, k = 3).
On the basis of the linear regression test, we found evidence of publication bias for 35 trials that provided unprotected sex/condom use outcomes (t = −2.614, P = 0.013). The funnel plot was asymmetrical, suggesting that fewer studies with negative interventions effects and large variance were identified in this study (figure not shown). There is no evidence of publication bias for the STD outcomes (t = −0.631, P = 0.546).
Our study shows that behavioral interventions can significantly and positively influence sexual risk behaviors among heterosexual African Americans. The reduction in unprotected sex remained significant up to 6 months following the completion of interventions. Our overall finding (OR = 0.75) is comparable to the findings of other meta-analyses evaluating HIV prevention interventions for heterosexual adults  and adolescents . We also found a marginally significant effect on incident STDs (OR = 0.88), especially at follow-ups greater than 12 months after intervention. However, the effect became significant when eliminating the trial of the lowest methodological quality . This evidence suggests that behavioral interventions can be not only efficacious in changing unprotected sex behaviors but may also reduce incident STDs in heterosexual African Americans.
We identified a number of intervention components associated with risk reduction. Greater efficacy was found for interventions that utilized peer education and aimed to influence social norms about safer sex. Our findings suggest that the influence of peers and the perception of the norms of one's peers should be considered in developing effective interventions for heterosexual African Americans.
When exploring differences between interventions with a particular characteristic to those without that characteristic for the sex outcomes, we identified several patterns that may provide additional information for prevention efforts. Consistent with the findings of previous qualitative studies [16,18,19], cultural tailoring appears to be an important component for reducing sex risk behaviors among heterosexual African Americans. Intriguingly, we did not find any differential efficacy for the particular components of culturally tailored interventions. It is plausible that our inclusion criteria, which stipulated that trials be comprised of at least 80% African–American participants, reduced the variance necessary to detect an effect. More research is needed to assess which specific cultural tailoring components are the active ingredients underlying behavior change.
Additional intervention components that are likely to contribute to behavior change are skills training and negotiation. Utilizing skills training is typical of interventions guided by social cognitive theories, which represent a majority of the interventions in this analysis. There is also evidence of a dose–response relationship regarding number of sessions, time span, and duration of interventions. The independent contributions of these intervention characteristics cannot be disentangled within these data, as the majority of the interventions utilized multiple components and sessions over multiple days. However, the overall findings suggest that behavioral interventions are more likely to be successful if they incorporate skills training and provide opportunities for practicing skills. In addition, future interventions may benefit from utilizing multiple sessions over multiple days, lasting several hours in total length.
The findings of our study must be viewed within the context of the limitations of the available evidence. Interventions we reviewed primarily addressed heterosexual transmission of HIV, although some portions of men may have participated who also engaged in same-sex behavior but did not identify themselves as homosexual. Recent studies have indicated that nongay identified men who have sex with men are more likely to have a female partner and have had unprotected vaginal sex . Additionally, the majority of the trials were unblinded and relied on self-reported sexual behavior, which may result in social desirability bias . However, several factors reduce the likelihood of this being an undue influence. First, the majority of interventions made efforts to reduce this effect by techniques such as ensuring confidentiality. Second, our findings with behavioral outcomes are similar to our outcomes from STDs, which corroborates the self-reported sex behavior findings. Future research should include biological assessment as well as self-reported sexual behavior, as this would increase our ability to evaluate the impact of interventions. Finally, all the trials had a comparison group and the assignment method was randomization, which reduced the likelihood that individual characteristics influenced the intervention effect. Our findings were also limited in that the majority of interventions (23/26) did not distinguish between primary and secondary partners in their analysis. Given that condom use has been found to differ between these types of partners , we recommend that future studies examine these partner-level differences both when assessing and reporting episodes of unprotected sex and condom use. Our meta-analysis was also limited by the fact that we only included individual-level and group-level interventions. There were only a few randomized community-level and structural-level interventions available in the literature [73–75]. However, given that many risk factors associated with HIV risk-taking in heterosexual African Americans are structural (e.g., poverty, access to care), future research should evaluate community-level and structural-level interventions when more RCTs become available.
Despite these limitations, our findings also pointed out several implications for future research. It is encouraging to see that several of the intervention studies [47,48] in our study were conducted with heterosexual African–American men, an understudied group [8,76]. Although studies targeting African–American adolescents were well represented in this study, few of these studies focused on younger adolescents. It is possible that the approach for HIV sex risk reduction among younger African–American adolescents may be different from older adolescents (e.g., interventions may emphasize delay of sexual initiation). We also did not identify any trials that examined prison populations, which have a high HIV prevalence compared with the general population .
Although our findings offer some evidence for factors associated with intervention efficacy in reducing HIV-risk sex behavior in heterosexual African Americans, to make a real impact on the HIV/AIDS epidemic, it is important to translate and disseminate evidence-based research. Some progress has been made in translating scientific-based knowledge into user-friendly intervention packages for dissemination through two CDC projects – Replicating Effective Programs (REP) and Diffusion of Effective Behavioral Interventions (DEBI). Several interventions for heterosexual African Americans have been packaged or are in the process of packaging (see PRS efficacy Web site http://www.cdc.gov/hiv/topics/research/prs/about.htm) . However, translating research findings into effective interventions in real-world settings remains challenging. Although additional research needs to be conducted with regard to this translation, and some limitations to our methodology have been discussed, our findings for both behavioral and biological outcomes suggest that the behavioral strategies utilized in the included interventions can reduce the frequency of HIV risk behaviors in heterosexual African Americans. Thus, we suggest that the following efficacious intervention components identified in this study should be incorporated into the development of future interventions and further evaluated for effectiveness: cultural tailoring, social norms in promoting safer sex behavior, peer education, skills training on correct use of condoms and communication skills needed for negotiating safer sex, and multiple sessions and opportunities to practice skills. Future interventions that are aimed at African–American heterosexual participants should take the unique needs of the community into account.
Other members of the HIV/AIDS Prevention Research Synthesis (PRS) Team who contributed to this review are (listed alphabetically) Julia Deluca, Jeffrey H. Herbst, Angela K. Horn, Linda Kay, Elizabeth Jacobs, Mary Mullins, Warren Passin, Sima Rama, Sekhar Thadiparthi, and Lev Zohrabyan.
L.A.D., G.E.K. and G.W.R. were supported in part by grants from the Office of AIDS, California Department of Health Services, and the Office of Minority Health, US. Department of Health and Human Services, and L.A.D. by NIH grant K08 MH 072380. The work of N.C. and C.M.L. was supported by the Prevention Research Branch, Division of HIV/AIDS Prevention, US. Centers for Disease Control and Prevention, and was not funded by any other organization.
All authors contributed to review concept and synthesis method. L.A.D. led the writing of Introduction and Discussion, scope screened studies, contacted authors for additional information, and abstracted qualitative data. N.C. led the writing of Methods and Results, abstracted qualitative and quantitative data, and conducted meta-analysis. C.M.L. abstracted qualitative and quantitative data, helped with quantitative analysis, and provided critical review of the manuscript. G.E.K. helped out screening studies, abstracted qualitative data, and provided critical review of the manuscript. G.W.R. provided critical review of the manuscript.
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
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