Program Components

• Enhanced counseling intervention in four sessions
• Interactive sessions lasting 200 minutes for all four sessions together

OR

• Brief counseling intervention in two sessions
• Interactive sessions lasting 40 minutes for both sessions together

• For either program, personalized risk reduction plans

For Use With

• HIV-negative, heterosexual males and females seeking STI testing and treatment
• Adolescent and adult males and females seeking STI testing and treatment

Evaluation Methodology

• Experimental, randomized, controlled trial with two treatment and two control conditions, conducted in inner-city STI clinics in Baltimore MD, Denver CO, Long Beach CA, Newark NJ, and San Francisco CA
• Participants (n=5,758) randomly assigned to one of four conditions: intervention #1 (Enhanced Counseling, n=1,438); intervention #2 (Brief Counseling, n=1,447); control #1 (didactic messages in two sessions, n=1,443); and control #2 (didactic messages in two sessions with no scheduled follow-up visits, n=1,430); median age 25 years
• Three-, six, nine- and 12-month follow-up

Evaluation Findings

• Reduced incidence of STIs (enhanced counseling and brief counseling)
• Reduced incidence of unprotected sex (enhanced counseling)

Evaluators' Comments: In subgroup analyses, efficacy was highest in the subgroups with the highest risk. The relative effectiveness of counseling was greatest for patients aged 20 years or younger (vs those older), patients reporting no prior HIV test (vs those reporting a test), and patients who had an STD diagnosed at the enrollment visit (vs. those with no STD)... Project RESPECT demonstrated that interactive, client-centered HIV/STD counseling resulted in an overall reduction in STD incidence...
Source: Kamb, Fishbein, Douglas et al., 1998

Program Description

Both enhanced and brief counseling interventions are based in the theory of reasoned action and in social cognitive theory. Interactive sessions are designed to encourage each client to develop a personal risk reduction plan and to enhance attitudes and skills that will help the client to stick to her/his plan. Client-centered counseling also promotes condom use skills, self-efficacy, and healthy attitudes and norms.

Enhanced Counseling

The first enhanced counseling session includes assessing personal risk, identifying barriers to risk reduction, and negotiating one small risk reduction step that is achievable within a week. Clients also receive appropriate STI/HIV testing in response to their acknowledged risk factors and symptoms. At the second enhanced session, client and counselor together explore condom use attitudes, discuss the prior week's behavior change successes and barriers, and devise a plan for further risk reduction prior to the next session. At the third enhanced session, clients receive HIV test results, discuss the previous week's behavioral goal and condom use successes and barriers, build condom use self-efficacy, and devise a plan for taking another risk reduction step. At the fourth enhanced session, client and counselor together discuss social norms and support for condom use, discuss the prior week's behavioral goal successes and barriers and devise a long-term strategy for consistent condom use.

Brief Counseling

The brief counseling intervention lasts only two sessions. At the first, client and counselor together assess personal risk, identify barriers to risk reduction, and negotiate one small risk reduction step that is achievable within a week. Clients also receive appropriate STI/HIV testing in response to their acknowledged risk factors and symptoms. At the second and final session, clients receive their HIV test results, discuss changes in risk behaviors, identify support for and barriers to changes, and develop a long-term plan for risk reduction.

Evaluation Methodology

The evaluation was conducted from July 1993 through September 1996 among clients from inner-city, public STI clinics in Baltimore MD, Denver CO, Long Beach CA, Newark NJ, and San Francisco CA. Eligible participants were HIV-negative males and females, ages 14 and older, who came to the clinics for a full diagnostic STI examination and who also agreed to have an HIV test. Males who had a male sex partner within the past 12 months or who self-identified as gay or bisexual were excluded as were those who tested positive for HIV at baseline; also excluded: anyone with limited English and those who refused to participate.

After excluding 75 patients with positive baseline HIV test results, participants included 3,269 men and 2,489 women assigned to one of four study arms: enhanced counseling intervention (n=1,438); brief counseling intervention (n=1,447); didactic message control group #1 (1,443); and didactic message control group #2 (n=1,430). Control groups #1 and #2 both received counseling messages similar that currently being offered in most STI clinics. In other words, the client only listened and was not actively engaged in identifying risks or protective behaviors. In addition, participants in control group #2 were not scheduled for return visits.

Study participants resembled the clinics' populations in that they were: 1) young (median age 25 years); 2) minority (59 percent black, 19 percent Latino, 16 percent white and 6 percent other); and low income (54 percent unemployed, 42 percent with annual income of less than $5,000). At baseline, 43 percent of participants in all four conditions were female. The intervention arms were similar at baseline with respect to demographic characteristics, risk behaviors, condom use, and STI diagnoses at enrollment. Compared to those who refused to participate, study participants were more likely to be female, to have had an STI at enrollment, and to have been previously tested for HIV.

Of 5,759 enrolled participants, 82 percent completed all assigned intervention sessions. Completion was lower (P<.001) for those in the four-session enhanced counseling arm (72 percent) than for those in the brief counseling arm (85 percent) or either didactic message control group (85 percent). Of the 4,328 participants assigned to follow-up visits every three months, 71 percent returned for the 3-month visit; 70 percent returned for the 6-month visit; 64 percent, for the 9-month visit; and 66 percent, for the 12-month visit. Return for follow-up did not differ significantly between evaluation conditions.

At the 6- and 12-month follow-up visits, participants in intervention arms #1 and #2 as well as those in control arm #1 received laboratory tests for gonorrhea, Chlamydia, syphilis, and HIV. Control condition #2 participants were tested for gonorrhea and syphilis at any time they voluntarily returned to the clinic. In addition, participants in the enhanced and brief counseling interventions and in control group #1 were surveyed about condom use during vaginal and anal sex, number of sex partners, risks of their sex partners, and their own and partners' condom use attitudes, beliefs, and intentions.

Participants were offered free condoms at every counseling session and $15 for each session attended after the first one. Participants who returned for scheduled follow-up visits were offered $15 for each questionnaire and $25 for each STI examination. No incentives were offered for voluntary (unscheduled) STI examinations, including those completed at the scheduled 3- and 9-month visits (when STI and HIV tests were not part of the evaluation protocol).

Evaluation did not test for nor report on changes in knowledge and attitudes.

Outcomes

• Behaviors –
  • Reduced incidence of unprotected sex – Evaluators found that enhanced counseling participants were more likely than brief counseling participants or controls to report 'no unprotected sex' (P=.02) at 12-months follow-up.

Notes:

1. Analysis showed that, compared to brief counseling and controls, enhanced counseling participants reported significantly less unprotected vaginal intercourse at 3-month follow-up. However, this effect dwindled to insignificance at later follow-up periods.
2. Throughout, enhanced counseling participants tended to report more condom-related safe behaviors than did brief counseling participants or controls. However, brief counseling participants tended to report safe behaviors unrelated to condom use (no casual partners and no new partners) more often than did enhanced counseling participants or controls. These findings never attained statistical significance.

Long-Term Impact

• Reduced incidence of STI—About 30 percent fewer intervention participants (either enhanced or brief counseling) had new STIs at the 6-month visit compared to controls. About 20 percent fewer intervention participants had new STIs at the 12-month visit compared to controls. Fewer enhanced or brief counseling interventions participants developed new STIs compared with controls (11.5, 12.0, and 14.6 percent, respectively). The two interactive counseling interventions had very similar cumulative incidence of STIs through the 6- and 12-month visits, and the number of participants counseled per STI averted was 31 for enhanced counseling and 38 for brief counseling. Consistently, at all five study sites, fewer participants in the counseling intervention arms had new STIs compared with those in the didactic message arms.

Notes:

1. Considering specific STI as outcomes, counseling was equally effective in preventing gonorrhea and Chlamydia.
2. In subgroup analyses, efficacy was highest in the subgroups with highest risk (i.e., highest STI incidence). The relative effectiveness of counseling was greatest for clients ages 20 years and younger, clients who had no prior HIV test, and clients who had an STI when they enrolled in the study. 

For More Information, Contact

• Ken Hunt, Centers for Disease Control & Prevention, 1600 Clifton Road, NE Mail Stop E-37, Atlanta GA 30333; phone 404.639.2058; fax 404.639.1950; e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it