|Behavioural counseling to prevent sexually transmitted infections
|Lin J, Whitlock E, O'Connor E, Bauer V
This review assessed the evidence for behavioural counseling interventions to prevent sexually transmitted infections (STIs). The authors concluded that interventions with multiple sessions, in primary care or STI clinics, reduced STI incidence in at-risk adult and adolescent populations. The authors' conclusions are likely to be reliable.
To review the evidence for behavioural counselling interventions to prevent sexually transmitted infections (STIs) in adolescents and adults (non-pregnant and pregnant).
MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews were searched from 1988 to December 2007. The Centers for Disease Control and Preventions' Prevention Research Synthesis Project database was also searched to August 2006. Search terms were reported. Experts in the field were contacted. Reference lists of relevant systematic reviews were also searched. Only English language papers were eligible for inclusion.
To be eligible, trials had to be controlled and evaluate a primary care behavioural counselling intervention, or one that is feasible in primary care, which addressed change in sexual behaviour (e.g. risk reduction or avoidance) with the primary intention of preventing STI transmission. Trials with men or women (including pregnant women) aged 12 or over were eligible. Studies with a greater than 40% attrition rate, or no outcome assessment beyond three months, were excluded.
Of the included trials, eight included only women, and most populations were considered at high risk of STIs. Most trials were conducted in primary care or STI clinics. A range of counselling interventions were used, including AIDS risk reduction model; many interventions were culturally-tailored. The total duration of sessions ranged from 40 minutes (two sessions) to 18 hours (nine sessions). Usual care, often involving short, standard counselling sessions, formed the basis of many treatments in the comparator groups. There were many different outcomes reported (often self-reported) including STI incidence, sexual behaviour, and pregnancy.
Two reviewers independently selected studies for inclusion.
Assessment of study quality
The authors used the US Preventive Services Task Force quality criteria to assess study quality, which included examining the following: method of randomisation, allocation concealment, losses to follow-up, use of intention to treat analyses, clear definition of interventions, consideration of confounders, and all important outcomes. Studies rated as poor quality were excluded.
Two reviewers independently assessed study quality.
Interventions were classed as low intensity (single visit lasting less than 30 minutes), moderate intensity (more than 30 minutes but less than 2 hours), or high intensity (multiple visits requiring more than 2 hours in total). Relevant outcome data for the intervention and comparator groups were extracted, including odds ratios, 95% confidence intervals, and p values, when available.
Data were extracted by one reviewer and checked by another.
Methods of synthesis
Due to substantial clinical heterogeneity between the studies, a narrative synthesis was undertaken, with study details tabulated and differences between studies also discussed in the text.
Results of the review
Fifteen randomised controlled trials were included in the review (n=14,444). Sample sizes ranged from 219 to 5,758 participants. All trials were judged to be of good or fair quality (but most were fair). Poor quality trials were excluded from the review.
Adults: Eight trials (n=10,462) examined the effectiveness of counselling interventions on reducing STI incidence in adults. Most results suggested a moderate decrease in bacterial STIs at 12 months among high-risk adults receiving moderate to high-intensity interventions. Of the three trials which assessed self-reported risky sexual behaviours or protective sexual behaviours, only one showed any benefit of behavioural counselling.
Adolescents: Four trials (n=2,187) examined the effectiveness of counselling interventions on reducing STI incidence in adolescents. Two trials were in girls receiving high-intensity counselling. Most trials showed a moderate decrease in STI incidence at 12 months.
No significant adverse effects were found after using the interventions in adults and adolescents. Further results were reported.
Behavioural counselling interventions with multiple sessions, conducted in STI clinics and primary care, effectively reduces STI incidence in at-risk adult and adolescent populations.
The review addressed a clear question and was supported by appropriate inclusion criteria. Attempts to identify relevant studies were undertaken by searching electronic databases and checking references, although the restriction to research published only in English means some relevant studies may have been missed. Suitable methods appear to have been used throughout the review to minimise the risks of reviewer error and bias (although details of how disagreements were resolved for the study selection and quality assessment processes would have been useful). Study quality was assessed (but more details of individual results would have been informative) and was used in interpreting the results of the review. Sufficient study details were provided and an appropriate narrative synthesis of the data was undertaken. Despite the possibility that relevant studies may have been missed, the authors' conclusions are likely to be reliable.
Implications of the review for practice and research
Practice: The authors did not state any implications for practice.
Research: The authors stated that trial evidence is needed for both lower intensity behavioural counseling interventions and lower risk populations. Methodologically rigorous trials are needed on the effectiveness of primary care behavioural counselling to prevent STIs (particularly for men and male adolescents, pregnant women and certain high-risk populations).
Agency for Healthcare Research and Quality, Oregon Evidence-based Practice Center contract; Oregon Clinical and Translational Research Institute, grant number UL1 RR024140.
Lin J, Whitlock E, O'Connor E, Bauer V. Behavioural counseling to prevent sexually transmitted infections. Rockville, MD, USA: Agency for Healthcare Research and Quality. Evidence Synthesis; 64. 2008
Other publications of related interest
Lin JS, Whitlock E, O'Connor E, Bauer V. Behavioral Counseling to Prevent Sexually Transmitted Infections: A Systematic Review for the U.S. Preventive Service Task Force. Ann Intern Med 2008;149:497-508
Subject indexing assigned by NLM
Adolescent; Adult; Behavior Therapy; Humans; Primary Health Care; Sex Counseling; Sexually Transmitted Diseases /prevention & control /transmission; Unsafe Sex
Database entry date
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.