RESEARCH ON PREVENTION counseling has focused primarily on demonstrating that counseling is effective in reducing risk behaviors. Little research has focused on specific demographics or characteristics of the counselor, or the counselor–client dyad, which could influence the effectiveness of counseling. As evidence is collected documenting the effectiveness of prevention counseling as an intervention to prevent HIV and sexually transmitted diseases (STDs), 1–3 it is important to identify characteristics of effective counseling sessions and the circumstances under which counseling sessions are likely to reduce risk behavior.
HIV/STD prevention counseling is a brief behavior change intervention focused on risk. Counselors help clients understand their risk pattern, and triggers and then motivates them to reduce risk. The client and counselor explore risk-reduction options to identify a single step to which the client will commit to reduce their risk. One model of prevention counseling that has been proven effective is client-centered counseling. 1,4 Client-centered HIV prevention counseling is an interactive, one-on-one intervention in which the counselor encourages the client to play an active role in developing a personalized HIV risk-reduction plan. Preferably, clients develop their own risk-reduction goals by developing a series of concrete, achievable, risk-reduction steps. The model was developed by counseling experts and has been recommended by the Centers for Disease Control and Prevention (CDC) since 1993 for use with HIV counseling and testing in public clinic settings. 5 Client-centered HIV prevention counseling is adapted to client’s culture, sensitive to issues of sexual identity, developmentally appropriate, and delivered in the client’s primary language. 4
An integral part of prevention counseling involves counselor training and ongoing supervision and feedback to maintain the quality and effectiveness of the counseling. Although the 2001 CDC revised guidelines for HIV prevention counseling highlight the skills and attitude counselors need, they do not identify specific demographics or characteristics counselors or counselor–client dyads must possess to be effective. 4
The psychologic literature identifies counselor characteristics that influence intervention effectiveness to empathic understanding, positive regard, genuineness, appropriate self-disclosure, spontaneity, confidence, intensity, openness, flexibility, commitment, and credibility. 6,7 The theory of social influence postulates that counselor credibility, attractiveness, and influence depend on similarity between the counselor and client. 7–9 Therefore, it is believed that counselors of the same ethnicity or gender as their clients are better able to understand and serve their clients. On the other hand, counselors who subscribe to the crosscultural or cross-gender counseling theories believe sensitive counselors transcend differences between themselves and their clients, including cultural and gender differences. 7,8,10
Many HIV prevention researchers believe outcomes improve if intervention counselors are matched with clients according to gender, ethnicity, and sexual orientation. However, this effect has not been demonstrated. 11 Intervention completion is one outcome that could measure the counselor’s ability to connect with the client. Although a number of elements likely contribute to intervention completion, a client’s initial interaction with and perception of the counselor could be an important one. For a client to be motivated to complete the intervention, interactions with the counselor should be perceived as positive. However, because the goal of prevention counseling is the prevention of new STDs, including HIV, the main measure of effective counseling should be the ability to prevent STDs. Although there are many characteristics that likely influence counseling, we were limited to those collected as part of Project RESPECT. We assessed whether demographics or specific characteristics of counselor or counselor–client dyads influenced the effectiveness of prevention counseling in Project RESPECT as measured by intervention completion and incident STD after counseling.
We evaluated data from Project RESPECT, a multicenter, randomized, controlled trial conducted from 1993 through 1996. Project RESPECT evaluated the efficacy of 3 HIV prevention counseling models in increasing condom use and preventing incident HIV and STDs. 1 Participants were recruited from STD clinics in Baltimore, Denver, Long Beach, Newark, and San Francisco. Heterosexual, HIV-negative men and women aged 14 or older who visited one of the clinics for an STD examination and agreed to an HIV test were eligible to participate. Participants were randomly assigned to 1 of the 3 HIV prevention strategies: a brief 2-session client-centered model, an enhanced 4-session client-centered model, and 2 sessions of brief informational messages.
Once enrolled and randomly assigned a prevention strategy, participants met with the next available counselor. Clients were not matched with counselors according to gender or race. For participants assigned to brief client-centered counseling, at the initial visit, the counselor and client assessed the client’s risk and perception of risk, identified barriers to risk reduction, and negotiated a risk-reduction plan. At this visit, counselors helped clients identify and commit to one step they could take to reduce their risk. At the last session, scheduled for 7 to 10 days later when HIV test results would be available, the counselor delivered test results and reviewed progress with the plan set forth at the initial visit and, if appropriate, negotiated a new plan.
Participants assigned to enhanced prevention counseling were asked to attend a 4-session intervention based on behavioral prediction and change theory. 12 The first session was identical to the brief counseling intervention. The remaining 3 sessions took place over the next 3 weeks and lasted approximately 1 hour each. These sessions were designed to address issues around attitude change, self-efficacy, and perceived norms regarding safe sex and included such skills as latex condom use, attitudes toward condom use, self-efficacy toward condom use, and perceived norms concerning condom use. 12 At each session, an incremental risk-reduction plan was developed.
Incentives were offered to participants in Project RESPECT. Free condoms were offered at every visit and $15 for each session attended after the first session (ie, for enhanced prevention counseling, a maximum of $45; and for brief prevention counseling and informational messages, a maximum of $15). 1
To ensure quality counseling sessions, Project RESPECT counselors attended a required intervention training course; were provided detailed, partially scripted protocols; and were regularly observed and received feedback. Additionally, participants completed semistructured postintervention surveys regarding their perceptions of the experience and activities. 12
Project RESPECT demonstrated that both brief and enhanced counseling increased condom use and prevented new STDs compared with a third intervention group that received informational messages. 1 STD reduction in brief and enhanced counseling intervention groups were similar. Our analysis includes participants who were randomly assigned to either brief or enhanced counseling and completed at least one follow-up STD examination over the ensuing 12 months.
Intervention completion was defined as clients who attended all counseling sessions to which they were assigned (ie, enhanced prevention counseling: one 20-minute session and 3 hourly sessions; brief prevention counseling: two 20-minute sessions).
The incident STDs measured for this study included chlamydia, gonorrhea, syphilis, trichomoniasis (women only), and HIV. Incident STDs were defined by laboratory tests, with chlamydia defined as a positive Chlamydia trachomatis polymerase chain reaction test from an endocervical specimen for women or a urine specimen for men. Gonorrhea was defined as a positive culture for Neisseria gonorrhoeae or, for men, Gram-negative intracellular diplococci seen with Gram stain of a urethral swab. Syphilis was defined by a suggestive history and physical examination with supportive treponemal and nontreponemal antibody test results. Trichomoniasis (women only) was defined by detection of typical motile trichomonads on microscopic examination of a saline-suspended vaginal sample. HIV was defined by a repeatedly reactive enzyme immune assay for HIV antibody with a positive confirmatory test result. Each participant was counted only once in the dataset, and only the first infection was included in this analysis.
After univariate analysis, we computed adjusted odds ratios using generalized estimating equations (GEE) using Proc GENMOD in SAS Version 8.02 (SAS Institute, Inc., Cary, NC). Our computations allowed for correlated outcomes because each counselor could affect multiple outcomes. A GEE model allows for fixed and time-varying covariates. Fixed covariates in this analysis included the variables age, study site, gender, and having an STD at baseline. Time-varying covariates included counselor experience. This technique also was used to examine groups of clients and counselors that shared the same demographics (gender, race, and both gender and race). All multivariate analyses were adjusted for study site and for demographics and characteristics of the client (race, gender, age, type of counseling, STD at baseline, education); counselor (degree, race, gender, and experience); and counselor–client dyad (same counselor, same race, same gender, and same race and gender). Results were described as statistically significant when P values were less than or equal to 0.05.
Demographics and Characteristics of the Sample
The 32 counselors were racially and ethnically diverse (41% white, 41% black, and 13% Hispanic). Most were female (69%). Most (59%) of the counselors had a college education, an additional 19% had attended graduate school, and the remaining 19% had completed high school. Each counselor conducted between 2 and 731 HIV/STD risk reduction counseling sessions in Project RESPECT, with a mean of 223.6 and median of 188. Counseling experience was defined as having conducted at least 75 sessions in Project RESPECT; 72% (n = 23) of the counselors were classified as experienced.
Of the 2885 participants randomized to receive brief or enhanced counseling, 2239 (78%) had at least one STD examination over 12 months and were eligible for inclusion in this analysis. Of these clients, 58% were black, 19% were white, and 16% were Hispanic. A little over half (56%) of the participants were male. Nearly half (47%) of the participants were between the ages of 20 and 29 years, 16% were between the ages of 19 and 14, and 37% were 30 or older. Only 8% of the clients had graduated from college, 24% had some college education, 41% had a high school diploma, and 27% had not finished high school. Most clients (97%) had the same counselor for all prevention counseling sessions.
Demographics and Characteristics Associated With Intervention Completion
Most clients (88%; n = 2239) completed the intervention. Failure to complete the intervention was slightly higher for black clients (13%) than Hispanic (11%) or white (8%) clients. Clients younger than 20 were less likely to complete the intervention (22%) compared with clients between the ages of 20 and 29 (12%) or older than 30 (6%). Clients who had an STD at the baseline examination were less likely to finish the intervention (17%) than were clients who did not have an STD at baseline (9%). Clients who did not complete the intervention were more likely to acquire a new STD infection (31%) by the 12-month follow-up visit than were clients who completed the intervention (19%).
Counselor demographics and characteristics were not associated with client failure to complete the intervention. A similar number of clients failed to complete the intervention whether their counselor was black 12%, Hispanic 11%, white 11%, or other 6%. Compared with white counselors, black counselors were slightly more likely to have clients fail to complete the intervention (adjusted odds ratio [ORa], 1.6; 95% confidence interval [CI], 0.9–2.9). Male and female counselors had similar numbers of clients who did not complete the intervention. Counselor education and experience were not associated with client failure to complete the intervention (Table 1).
In 54% of all counseling sessions, the client and the counselor were of the same race. There were 889 black dyads, 49 Hispanic dyads, and 212 white dyads. In 47% of the sessions, the client and the counselor were the same gender, with 724 female dyads and 289 male dyads. Client and counselor were of the same race and gender in 26% of the counseling sessions. No dyad demographics (same race, same gender, same gender and race) were associated with client failure to complete the intervention (Table 1).
Multivariate analysis found most predictors of client failure to complete the intervention were demographics and characteristics of clients rather than counselor characteristics. Client demographics and characteristics associated with failure to complete the intervention included intervention type, age, STD at baseline examination, and education. Failure to complete the intervention was more likely for clients who were randomly assigned to enhance 4-session counseling (ORa, 3.0; CI, 2.2–4.0 compared with brief 2-session); aged 14 to 19 (ORa, 3.8; CI, .2.4–5.9 compared with 30 and older) or 20 to 29 (ORa, 2.4; CI, .1.6–3.5 compared with 30 and older); had an STD at the baseline examination (ORa, .2.2; CI, .1.6–2.9 compared with no STD at baseline examination); and had less than a high school education (ORa, .1.8; CI, .1.2–2.9 compared with some college) or a high school education (ORa, .1.7; CI, .1.2–2.6 compared with some college).
Demographics and Characteristics Associated With New Sexually Transmitted Diseases
Nearly one third of the clients (31%; n = 700) had an STD at enrollment, and 20% of the clients (n = 448) had received a diagnosis of a new STD by the 12-month visit. New STDs were more commonly diagnosed among black (27%) clients compared with Hispanic (13%) or white (9%) clients. More female than male clients returned with a new STD (25% vs. 16%). Clients with less education than high school were more likely to return with a new STD (27%) than were clients with a high school education (22%), some college education (14%), or a college degree (5%).
Black counselors had 1 in 4 of their clients return with a new STD within 12 months, slightly more than counselors of other races. However, this difference did not exist after multivariate analysis (ORa, 1.1; 95% CI, 0.6–1.9) (Table 2). Female counselors had 19% of their clients return with a new STD, whereas male counselors had 25% return with a new STD (ORa, 0.9; CI, 0.7–1.2) (Table 2). A majority of the counselors had a college education (n = 19; 59%). Clients of counselors with a high school education (ORa, 0.8; CI, 0.4–1.6) or college education (ORa, 0.9; CI, 0.5–1.6) were no more likely to acquire a new STD infection than were clients of counselors that had a graduate education. Inexperienced counselors were no more likely to have a client develop a new STD than counselors who had conducted at least 75 sessions (ORa, 1.1; CI, 0.8–1.5). Most clients had the same counselor for all sessions (97%) so we could not assess the effect of changing counselors on the likelihood of becoming infected with a new STD. No dyad characteristic was associated with clients acquiring a new STD in Project RESPECT (Table 2). Clients who did not complete the intervention were more likely to develop a new STD (ORa, 1.7; CI, 1.2–2.4).
Multivariate analysis found most predictors of new STDs were demographics and characteristics of the client rather than counselor. 14 Client demographics and characteristics associated with a new STD included study site, race, gender, education, and having an STD at the baseline examination. Persons were more likely to develop a new STD if they lived in Newark (ORa, 2.7; CI, 1.4–4.9, compared with San Francisco), were black (ORa, 2.0; CI, 1.3–3.2 compared with all other races), were female (ORa, 2.2; CI, 1.7–2.9), had less than a high school education (ORa, 1.7; CI, 1.2–2.4 compared with some college) or a high school education (ORa, 1.5; CI, 1.1–2.0 compared with some college), and had an STD at baseline (ORa, 2.4; CI, 1.9–3.0).
We did not identify specific counselor or counselor–client dyad demographics or characteristics that influenced the effectiveness of prevention counseling. Variables associated with failure to complete the intervention and acquiring new STDs were more client-related than counselor-related, including client race, gender, education, and having an STD at baseline. 14 Clients who completed the intervention were less likely to acquire a new STD infection, as would be expected because the original study 1 showed the intervention was effective. Efforts to encourage counseling completion such as client incentives, follow-up reminders, and convenient hours should be explored. However, HIV prevention counseling should focus on risk reduction and not on asking the patient to return for the next session.
Matching clients and counselors for HIV prevention counseling sessions could be more likely to appeal to a client’s preference than to result in a direct client benefit. Other studies in general counseling research have found counselor characteristics associated with positive client perception of the client–counselor relationship to include similar personality, attitude, and socioeconomic background; similar age or older; and more education. 8,10,13,15,18 In other studies, clients most strongly preferred counselors with similar gender and ethnicity. 16 Given this similarity, clients like their counselors more, perceive the counselor–client relationship as more helpful, and perceive their counselor as more understanding and empathic. 8,10,13,16 Ethnic similarity is especially preferred by black and Mexican-American clients and has been associated with commitment to remain in an intervention. 10,13,15,16 Although clients could use similarities to establish trust with their counselor, these similarities are not directly related to outcome. 13 Counselors could be perceived as more credible when they exhibit crosscultural knowledge, and this would likely be an important variable for intervention effectiveness as opposed to variables such as shared counselor and client ethnicity. 17 Matching clients and counselors based on race/ethnicity could still result in cultural mismatches if a client and counselor from the same ethnic group have different values, lifestyles, and experiences.
Our study had some limitations. First, clients were randomly assigned to intervention groups and not to counselors. Once enrolled and assigned to an intervention, participants met with the next available counselor without concern for the client or counselor’s gender or race. Second, Project RESPECT was limited to HIV-negative heterosexual clients attending STD clinics. Although this population is at high risk, findings might not be generalizable to other populations such as men who have sex with men, intravenous drug users, commercial sex workers, or persons who are HIV-positive where peers influence outcomes. Third, Project RESPECT studied only one possible approach to HIV prevention counseling: client-centered HIV/STD prevention counseling models. In other approaches to HIV prevention counseling, such as small group counseling sessions or psychotherapy, counselor demographics could be more salient to the client. Fourth, the small number of counselors in the study limited our power to detect a statistically significant difference. Fifth, other characteristics not measured as part of Project RESPECT could contribute to HIV prevention counseling outcomes. Sixth, Project RESPECT did not systematically collect client satisfaction data. Seventh, we do not know about STDs in persons who did not return to the clinic.
Finally, quality assurance was an important part of Project RESPECT, but because it was so important and such an integral part of the prevention counseling models, it possibly made the counseling more homogenous than it would have been otherwise.
The client-centered counseling studied by Project RESPECT can prevent STD. 1 Although we did not identify specific counselor or dyad demographics or characteristics associated with acquiring a new STD or intervention completion, these results should not be interpreted as showing that other counselor characteristics are unimportant. There are several characteristics thought to be associated with counseling that we did not study, the most prominent of which are the abilities of the counselor. 4 HIV/STD prevention counseling programs should strive to hire and retain skilled counselors. A good prevention counselor believes counseling can make a difference and has a genuine interest in the counseling process. Good counselors are active listeners, able to use open-ended questions, negotiate rather than persuade, and foster a supportive atmosphere for the client. Good counselors feel comfortable discussing specific HIV risk behaviors such as explicit sex or drug behaviors. Lastly, good counselors remain focused on risk-reduction goals with the client. 4 When hiring and training counselors, we recommend focusing on these skills and not on matching counselors and clients by gender or race.