The Role of Behavioral Counseling in Sexually Transmitted Disease Prevention Program Settings

Abstract

Background 

Behavioral counseling for sexually transmitted disease (STD) prevention is recommended for persons at risk, and the body of evidence yields numerous interventions that have STD preventive efficacy. What is needed is a review of the subset of these interventions that could be feasible in clinical settings, especially settings in STD prevention programs.

Methods 

We reviewed existing systematic reviews of the literature and abstracted from them studies that fit the following criteria in that the interventions: (1) used no more than 60 minutes of contact time in 1 to 2 sessions, (2) were individual level and face to face, (3) took place in a clinical setting, (4) had STD outcomes available, (5) were based in the United States, (6) were peer reviewed, and (7) had a control group.

Results 

From 6 reviews (published 2006–2014) covering 91 studies, we found 13 analyses representing 11 intervention studies that fit the selection criteria. Of these 13, 5 returned lower STD rates in the intervention group at follow-up; one study reported a higher rate of STD in one subset of the intervention group (men who have sex with men). Studies with effects on STD at follow-up were quite similar to studies across populations, settings, and follow-up periods, although successful interventions were more likely to demonstrate behavioral effects as well (5/5 vs. 2/5 among 10 interventions measuring behavior change).

Conclusions 

Counseling is likely to benefit some STD clinic attendees, although unlikely to benefit men who have sex with men. The balance of costs and benefits of implementing behavioral counseling in STD programs is unclear, but feasibility would be improved if behavioral counseling were implemented in the context of other prevention efforts. Because populations outside typical STD clinic settings could also benefit, programs may exercise a valuable role through partnerships.

The Centers for Disease Control and Prevention (CDC) estimates that approximately 20 million new cases of sexually transmitted diseases (STDs) occur every year in the United States, and nearly 50% of those cases occur among those aged 15 to 24 years.¹ In addition to increasing a person's risk for HIV infection, STDs can lead to severe reproductive health complications, such as infertility. In 2010, the inflation-adjusted direct medical costs of STDs (including HIV) were $16.9 billion in the United States.²

As the scope of review articles in this issue demonstrate, STD prevention programs can consider options from an extensive array of linked interventions for STD prevention. Behavioral counseling in STD prevention programs usually follows some other intervention that uncovered an infection or exposure risk (e.g., screening and partner notification). This context differs from behavioral counseling in many primary care settings in that virtually all persons seen by an STD program have high individual-level risk. In this article, we review behavioral counseling interventions in that context: a clinic-based one-on-one intervention with an individual who has been diagnosed as having an STD or who is at least at high risk for infection. Although we will concentrate on behavioral counseling delivered by STD program staff, we will also discuss using partnerships and technical assistance to improve counseling done elsewhere.

In 2001, the Surgeon General issued a call to action to promote sexual health and healthy sexual behavior.³ Strategies mentioned in the report include increasing awareness, implementing and strengthening interventions, and expanding the research base regarding effective sexual health activities. At present, CDC recommends that health care providers promote prevention of STDs for their patients through awareness of risk, protection, and treatment. Specifically, CDC and other national organizations promote an interactive, empathic, and nonjudgmental approach, tailored to the patient's personal risk.^4–6 The American Academy of Pediatrics recommends a similar approach to counseling for healthy development of sexuality among adolescents, albeit with more focus on delaying or reducing sexual activity.⁷ Finally, the US Preventive Services Task Force (USPSTF) recommends high-intensity behavioral counseling for adolescents and adults at risk for STDs.⁸

Constraints on Behavioral Counseling in Clinical Settings

Rates of repeat infections in STD clinics and of incident STD infections in HIV care settings illustrate that there is a potential benefit for behavioral counseling in these and similar settings serving high-risk populations.^9,10 There are, however, 3 substantial constraints to consider with respect to behavioral counseling clinical settings, especially busy STD clinic settings. First are the closely related issues of time and cost. Clinicians consistently report that time constraints are the central barrier to taking sexual histories and providing STD/HIV education or counseling during a patient visit. High-intensity behavioral counseling, the most consistently supported version of this intervention, is defined as greater than 2 hours of contact time with recipients.⁸ This is a commitment that would seem to be largely untenable in most STD clinics.

Second, little is known about the balance of adaptation and fidelity. That is, behavioral interventions may need to be altered based on specific populations and settings seen in STD clinics and related settings, but some core elements in almost any intervention need to be retained. Programs may be able to be retained in full for specific populations within certain settings, but it is plausible that the adaptation most effective for a given program will depend on key characteristics of both the (1) intervention itself and the (2) specific needs of the setting and/or population of interest.

Given the challenges of time, cost, and adaptation, the goal of this review is to provide an overview of brief behavioral interventions that could be conducted in 1 or 2 short sessions (≤30 minutes per session, or about 60 minutes of total contact time). A review of effective and brief 1 to 2 session behavioral counseling interventions will allow for the identification of core components within the interventions, while detailing setting and population specifics. By understanding common core elements, the aim of the review is to shed light on both how and why specific behavioral counseling interventions are effective, and under which conditions such studies may be replicated. We aim to make this review relevant for the field and specifically for practices and programs that may want to integrate a behavioral counseling into their services, to prevent STD.

METHODS

We reviewed existing review articles published since 2000 that focused on behavioral counseling interventions. We reviewed each review article's citations and included them in the present review if all of the following criteria were met: (1) the interventions comprised 1 to 2 sessions at 20 to 30 minutes each or 60 minutes of total contact time; (2) they were one-on-one face-to-face sessions (no groups, no videos); (3) settings must be within health centers or other clinics; (4) STD outcomes available, even if not necessarily biomarkers; (5) intervention based in the United States; (6) peer-reviewed published work; and (7) must have a control or treatment as usual group. We did not constrain eligibility to counseling conducted in STD clinics because some primary care settings serve similar populations for similar purposes (sexual health care) under similar conditions.

We examined 91 articles from 6 reviews^8,11–15 published between 2006 and 2014: 21 (23.1%) appeared in more than 1 review. One review was the basis for Community Guide to Preventive Services recommendations for men who have sex with men (MSM),¹³ and 2 were bases for USPSTF behavioral counseling recommendations.^8,14 Thirteen of the 91 peer-reviewed articles (representing 11 studies) met all 7 of the above listed criteria and were included in the review.^16–28 These articles are abstracted in Table 1. They covered 22,947 participants from 14 to 45 years of age, in a variety of clinical settings (7/11 studies included STD clinics). Where race, sexual orientation, and sex were reported, African Americans and heterosexual persons were most likely to be a majority or plurality, but participants were drawn from across the spectrum of these constructs. More studies enrolled only women than only men, but overall proportions by sex were close to even. Follow-up rates, where given, were typically greater than 70%.

TABLE 1: Elements of Behavioral Counseling Interventions Included in Review

RESULTS

Of the 13 articles included in Table 1, 4 found statistically significant reductions in STD at follow-up in the behavioral counseling group compared with the control group.^18,21,24,26 A fifth study¹⁹ reported reduced signs of STD infection (6.8% vs. 0, P < 0.05) in the intervention group at 9 months postintervention. The remaining 8 studies measured and found no differences between the intervention and control groups in STD infection (gonorrhea, chlamydial infection, HIV, except for bacterial vaginosis in one study²⁷). In some circumstances, infections in the intervention and control groups both declined over the course of the studies.²⁵

The 5 studies with significant intervention effects on STD rates had similar characteristics to the other 8 studies in most respects. Studies in both categories took place in STD and other clinic settings, used mostly follow-up periods of 6 months or greater (9/13 studies), and addressed variation in age, sex, and sexual orientation. Seven of 10 studies measuring behavior changes found at least 1 significant behavior change by condition, although this includes 2 studies that had inconsistent findings by either the behavior measured or the follow-up period. Moreover, there was greater consistency for behavior change effects among the studies with significant STD effects (5/5 vs. 2/5). Five studies (6 articles) had active control groups: none of these studies were efficacious, compared with 5 of 6 studies (7 articles) with passive controls.

Outcomes

Crosby et al.²⁶ used a medical-records chart review to assess the study's primary outcome of STD acquisition. Jemmott et al.²⁴ examined STD rates via specimens collected and analyzed in the hospital-based laboratory. Kamb et al.¹⁸ examined incident STDs via laboratory tests, including HIV. Bolu et al.²¹ conducted a secondary analysis of the RESPECT data of Kamb et al.; thus, the same outcome measures were assessed. Effect sizes were small to moderate in magnitude, and certainly meaningful in practical terms (i.e., Cohen d = 0.20 in 1 study; odds ratios of approximately 0.50 in 2 others).

For studies with positive findings on STD at follow-up, outcomes such as proportion of sex acts with a condom or amount of sex without condoms favored the intervention groups. Boekeloo et al.¹⁹ found protective intervention effects on condom use at 3 months, but not at 9 months. In terms of behavioral self-reported outcomes, Crosby et al.²⁶ measured condom use during the last act of penetrative sex, number of sexual partners in the past 3 months, and proficiency of using condoms as measured via direct observation on a life-sized rubber penile model. Jemmott et al.²⁴ investigated the self-reported proportion of protected sexual intercourse, frequency of unprotected sexual intercourse, and condom use during most recent intercourse. Kamb et al.¹⁸ and Bolu et al.²¹ examined the behavioral outcomes of condom use with vaginal sex, number of sex partners, risks of their sex partners, participants' and partners' condom use beliefs, intentions, attitudes, and perceived norms regarding the consistent use of condoms.

Two studies produced antagonistic effects for male subsets of participants. One follow-up to Project RESPECT that tested a booster session and rapid test found no overall increase in STD rates at follow-up, but did find higher rates at 12 months among men receiving rapid testing (risk ratio [RR], 1.34; 95% confidence interval [CI], 1.06–1.70).²² In 2013, another randomized controlled trial (RCT) randomized participants to receive either (1) rapid HIV testing with brief patient-centered risk reduction counseling (Rapid RESPECT) or (2) rapid HIV testing with information only.²⁸ This study found no differences on STD at follow-up overall, or among heterosexual men or women. However, the study found an increased risk of STDs at 6 months among MSM receiving counseling (RR, 1.41; 98.3% CI, 1.05–1.90 [the unusual CI corrects for multiple comparisons]).

Target Populations and Follow-up

The participants in efficacious short behavioral counseling interventions were at high risk for acquiring new STD, either through design or empirically. Jemmott et al.²⁴ sampled African American women aged 18 to 45 years seeking care at an outpatient women's clinic; 20% tested positive for at least 1 STD (empirically a high-risk population). Participants of Crosby et al.²⁶ were African American heterosexual men aged 18 to 29 years who were newly diagnosed as having an STD at a publicly funded STD clinic (high risk through design). Kamb et al.¹⁸ sampled HIV-negative heterosexual men and women 14 years and older; approximately one-third reported a previous STD at enrollment. Bolu et al.²¹ used the same sample of participants as Kamb et al., but looked specifically at the subpopulation which reported a history of intravenous drug use, history of exchanging sex for money or drugs, an STD diagnosis at enrollment, or a previous HIV test at enrollment. Boekeloo et al.¹⁹ sampled young adolescents (12–15 years); these were sexually active and thus at high risk by definition at those ages.

Three of the 5 studies^18,21,24 examined outcomes after a 12-month follow-up period, the longest time frame examined in any of the investigations. Boekeloo et al.¹⁹ went to 9 months; Crosby et al.²⁶ reviewed STD outcomes at 6 months and behaviors at 3 months postintervention. The remaining 8 studies, however, also used follow-up times longer than 6 months. The shortest follow-up was 2 months in a brief counseling study in an adolescent health clinic.¹⁶

Facilitator Characteristics and Costs

Crosby et al.²⁶ used lay health advisors to administer the intervention, with the overarching conceptualization that the most effective facilitators are those from the community, most like those for whom the intervention is intended. Specifically, Crosby and colleagues recruited a young African American man who grew up and resided in the targeted community. Jemmott et al.²⁴ prioritized similar factors and selected African American women from the study catchment area. However, the facilitators hired were nurses with a median of 14 years' nursing experience and a 10 years' experience working with African American women. Kamb et al.¹⁸ and Bolu et al.²¹ do not discuss their facilitator characteristics within their studies, but do note that behavioral counseling was conducted with a trained HIV counselor or clinician.

Cost data were not identified explicitly in most studies. One study estimated intervention counseling costs at $8 ($12 in 2015 dollars) over control conditions, which they noted would be cost-saving at preventing 145 HIV infections per 241,000 people counseled (<0.1% prevalence). Another study provided the average costs (2010 dollars) per patient counseled in intervention and control arms: $56 and $23, respectively ($60 and $25 in 2015 dollars).²⁸ We also estimated the resources required to operate the intervention in terms of staffing and visit context. All studies except one²⁷ recruited participants in the context of an existing clinic visit for care. Nine studies delivered the intervention through existing staff (2 physicians, 2 nurses, 5 counselors), 2 used research staff, and 1 other used a lay health advisor model.

Intervention Theory and Other Key Elements

In a 20-minute 1-time intervention, Jemmott et al.²⁴ used social cognitive theory as the underpinnings for Sister-to-Sister and strove to present behavioral counseling in a culturally sensitive and gender-appropriate frame, delivered over the course of a routine medical visit. Prioritizing empowering and educating woman through the teaching of behavioral skills, this intervention was designed to increase condom use skills, including practice with an anatomical model. The intervention also used role playing as a tactic to increase self-efficacy and negotiation of condom use with partner. Crosby et al.²⁶ prioritized condom education through the Information, Motivation, and Behavioral Skills model.²⁹ The intervention was designed to promote quality, correctness, and consistency of condom use. The facilitators emphasized condom skill acquisition and initiating condom use in a one-time, 45- to 50-minute session. RESPECT^18,21 was an individual-level, client-focused intervention, consisting of 2 brief, 20-minute interactive counseling sessions—the 2-session version was as efficacious as the 4-session version. Based on the Theory of Reasoned Action and Social Cognitive Theory,^30,31 the provider determined what behaviors place the client at increased risk and used a “teachable moment” to increase the client's concern about his/her personal risk and develop a risk reduction strategy. This early version of RESPECT used a standard HIV test, necessitating days between the initial discussion and follow-up. Most studies, whether efficacious or not, were based on principles of social cognitive theory.

DISCUSSION

We reviewed studies to find interventions that were both efficacious and feasible in time-constrained clinical settings, delivered principally by existing staff under existing patient care conditions. Thus, we reviewed interventions that could be implemented within 60 minutes of total contact time in a one-on-one interaction within a clinic setting. We found 13 analyses that fit our criteria, with 5 showing evidence of efficacy with respect to STD infection rates at follow-up. There was more consistency with respect to behavior change, and behavior changes were associated with lower STD incidence in all 5 studies showing an effect on STD at follow-up. This low proportion of efficacious studies, however, is somewhat at odds with other reviews, and we emphasize that the discussion pertains to a select group of interventions, not to all behavioral counseling. In the remainder of this discussion, we focus upon key factors of behavioral counseling interventions, consider approaches that may improve feasibility, and comment on potential future action.

Key Factors in Short Behavioral Individualized Counseling

In some respects, the sample characteristics of interventions varied little according to the success of the intervention. The populations were typically high risk in comparison with the general population in that most either were STD infected or had been previously diagnosed as having STD (but not HIV). They were not especially high risk compared with STD clinic attendees in general. More salient is that nearly all participants were heterosexual males and females (including adolescents) and that effects were generally strongest for these populations. Gay, bisexual, and other MSM and women who have sex with women were largely absent from the studies, appearing in 4 of 13.^22–24,27 Moreover, intervention STD effects were typically weaker for MSM, with one study even producing an antagonistic effect on incidence.²⁸ Tailoring and personalized counseling approaches seemed to be a necessary condition, but most effective if matched with practical skills around condom use (the study by Carey et al.²⁵ was the principal exception to this rule). Matching the facilitator at least by race and sex seemed consistently helpful, although the effect of this moderator was not empirically measured. Finally, the composition of control groups should not be overlooked: RCTs with active controls were far less likely to be efficacious (sometimes active controls were chosen for good reason because that condition represented the standard of care). If we restrict conclusions to studies with minimal interventions in control groups, conclusions are far more favorable to behavioral counseling.

In sum, a short behavioral counseling intervention for heterosexual clinic patients with known risk behaviors, perhaps facilitated by those who can establish ready rapport with clients through similarity^24,26 or training (RESPECT studies),^18,21 and using a behavioral skills approach and interactive and personalized discussions on how to decrease risk, has the best potential to result in sexual risk reduction and decreased rates of reinfection. Some of these points are reflected in other areas of STD prevention in program settings. For example, a 2012 review of interventions with African American men named male facilitators as reinforcers of effectiveness,³² and the value of interactive counseling has been established with partner notification across several studies.³³

Moving Forward With Behavioral Counseling

The first consideration is cost, whether measured directly or in terms of resource allocation. Most efficacious studies used existing staff and visits, although one required hiring a lay health advisor. Although these conditions minimize hiring and outreach costs, the interventions still require training and take time. If we take the $60 per session estimated from Project AWARE as a reasonable metric for a 2015 counseling session, a program has to decide whether this money is best spent averting infections through counseling, or seeking infections through, say, expanded screening. This, in turn, is partly dependent on STD/HIV prevalence in the targeted population. Efficacious interventions were spread across clinical settings, so community prevalence around intervention venues could vary.

Three related logistic considerations relevant to STD programs seem to play a significant role in counseling effectiveness: contact time, repeat contact, and testing circumstances. Contact time, which is the indicator the USPSTF uses for “intensity,” allows for more skills practice and interaction. These are theoretically based and empirically confirmed features of successful counseling across numerous topic areas.³⁴ The successful interventions reviewed here show that these components can be delivered in 60 minutes or fewer, and that to do so requires no particular disciplinary specialty. Delivery, however, does require specialized training and the ability to move beyond didactic instruction.

The second issue is repeat contact (e.g., multiple sessions). Repeat contact provides an opportunity to reinforce content and commitment, maintain interaction and rapport, and adjust behavior change plans—in the short term. Project RESPECT's 2 sessions were delivered over a 7- to 10-day period; adding a booster session 6 months later had no effect in a later RCT.²² An STD program that has the capacity to follow up with patients or that does so for purposes like reinterviews (i.e., if partner notification is involved) may use such opportunities to implement counseling. Retesting is another opportunity, but this typically occurs more than 10 days after initial treatment.

Third, there is the issue of HIV testing, which has changed over the period of this review. Project RESPECT was conducted before the advent of rapid HIV testing and did not include MSM in its initial RCT¹⁸; MSM account for nearly two-thirds of new HIV infections in the United States. Later studies based on RESPECT have shown either no differences for MSM^22,23 or antagonistic effects on STD incidence.²⁸

A case for targeting behavioral interventions is thus made more complex as one of the most vulnerable populations, MSM, seem to receive the least benefit in terms of STD incidence. We hypothesize that many MSM in STD clinics know they are at high risk, know generally why this is so (a combination of behaviors, community prevalence, and effects of stigma), and have been at risk for some time. Clinically based behavioral counseling is a difficult avenue for successful intervention under these circumstances, especially as the magnitude of change required to affect incidence increases with high community prevalence. The evidence suggests that many of these factors also apply to heterosexual men in STD clinics, although we found evidence that social cognitive interventions that used lay counselors who are representative of the affected communities remain effective for heterosexual men.²⁶

Moreover, the bulk of counseling interventions and the recommendations on which they are based are specific to a subset of prevention behaviors—condom use, reductions in numbers of partners, and, less often, partner selection criteria (e.g., seroadaptative choices). These are not necessarily attractive options as intervention targets. More promising, however, is the advent of preexposure prophylaxis³⁵; a different behavioral outcome from those in this review, but certainly emerging as a component of prevention program action with substantial behavioral counseling ramifications. Interestingly, a recent pilot of doxycycline prophylaxis for HIV-infected MSM engaging in risky sexual behavior showed promise for reducing STD among this select population,³⁶ although there remain significant practical and ethical considerations.³⁷

To augment the efficacy of behavioral counseling interventions, health departments may consider integrating behavioral counseling with other prevention efforts. Integration serves multiple purposes and thereby increases cost efficiency as well as overall prevention effectiveness. For example, a second behavioral counseling session combined with a retest reminder and check on partner treatment is testable in many program settings in an experimental or a quality improvement framework. There is more reason for research and development: the reasons why a select number of such interventions were shown to be effective bears further investigation. Finally, there are behavioral counseling examples that diverge from sexual behavior as a topic, but that still affect STD at follow-up. For one example, an evaluation of counseling to prevent alcohol-exposed pregnancies in 2 clinics had effects on sexual behavior, although it did not measure STD.³⁸

Finally, there is a potential role for STD programs in indirect action on behavioral counseling. Programs may take a role in providing guidance or technical assistance for STD prevention counseling in settings outside STD clinics. Many of the people for whom interventions seemed most efficacious are seen outside STD clinic settings. CDC's Division of STD Prevention is in the process of trying to fill this gap by developing feasible and sustainable behavioral counseling interventions that can fit within health care settings such as community health centers with minimal adjustments to current practice. The Division of STD Prevention is also attempting to develop a successful mechanism by which behavioral counseling meets reimbursement requirements, thus furthering the opportunity for sustainable behavioral counseling.

CONCLUSIONS

Short behavioral counseling interventions are appropriate for many STD clinic populations and for primary care settings serving vulnerable populations (e.g., community health centers in high-prevalence areas). They require, however, attention and resources to sustain and may be most efficiently managed if they are combined with other prevention activities. Such activities require research or evaluation, as those combinations have not been clearly analyzed to date—some combinations are visible in studies, but not formally evaluated. High-risk MSM do not seem to benefit from behavioral counseling as currently construed. That noted, behavioral counseling topics extend beyond condom use and numbers of partners, so there is clearly scope for continued efforts to find the best interventions to use for reducing STD incidence.