226 AIDS/HIV
knowledge, and frequency of protected intercourse. Other
studies have also provided evidence that cognitive-behavioral
interventions facilitate risk reduction in this population
(e.g., Kalichman, Sikkema, Kelly, & Bulto, 1995; Kelly,
McAuliffe, et al., 1997).
Community-Based Programs
Community-based interventions have attempted to reduce
risky behavior in a variety of populations, including adoles-
cents, men who have sex with men (MSM), and urban
women. Participants are typically recruited through impres-
sive outreach efforts to social service, recreational, and busi-
ness settings. The interventions may be organized into small
group approaches, community-wide interventions, or media
approaches.
Small Group Approaches. Perhaps the most in”uential
approach to HIV prevention is the behavioral skills approach,
initially developed by Kelly and his colleagues. After several
successful evaluations of his approach, Kelly (1995) subse-
quently published a detailed manual that describes how to
implement his approach. The key components of the inter-
vention are: risk education and sensitization (e.g., improving
recognition of their vulnerability to HIV), self-management
training (e.g., having condoms available, reducing alcohol
and drug use before sexual behavior, enhancing awareness of
mood states that might lead to risky behavior), sexual asser-
tion training (e.g., how to negotiate with partners for safer
sex, how to refuse unsafe sex), and developing social support
networks. Kelly•s intervention also identi“es when safer sex
is not necessary, and seeks to promote pride, self-esteem, and
empowerment, especially among traditionally disenfran-
chised groups such as gay men and ethnic minorities.
In an initial evaluation of the effectiveness of this
approach, Kelly, St. Lawrence, Hood, and Bras“eld (1989)
recruited 104 gay men with a history of frequent HIV-risk
behavior and then randomly assigned them to the skill-based
behavioral intervention or to a control group. All participants
completed self-report, self-monitoring, and behavioral
measures related to HIV-risk at several assessment occasions
pre- and postintervention. The results demonstrated that
participants who received the skills intervention increased
their knowledge and behavioral skills for refusing sexual
coercion; they also reduced the frequency of high-risk sexual
practices. These changes were maintained at the 8-month
follow-up.
The small group approach developed by Kelly has been
replicated with other populations in a variety of settings (e.g.,
Kelly et al., 1994; St. Lawrence et al., 1995), and has been the
object of extensive research. For example, Kalichman,
Rompa, and Coley (1996) conducted an experimental com-
ponent analysis to examine the separate and combined effects
of sexual communication and self-management skills train-
ing. Low-income women were randomly assigned to one
of four small-group interventions: (a) sexual communication
skills training, (b) self-management skills training, (c) both
sexual communication and self-management skills, or
(d) HIV education and risk sensitization. Women in all four
intervention conditions increased their knowledge and inten-
tions to reduce risk behaviors, but only those in the commu-
nication skills training reported higher rates of risk reduction
conversations and risk refusals. Perhaps most important,
those in the combined skills training condition showed the
lowest rates of unprotected sexual intercourse at the 3-month
follow-up.
Based on theoretical developments in health psychology,
which recognized that individuals differ in their •readiness-
to-change,Ž and that action-oriented skills programs may not
be optimal for precontemplators (Prochaska, DiClemente, &
Norcross, 1992), we sought to strengthen the motivational
component of existing skills-based approaches to HIV risk
reduction. We reasoned that a motivationally enriched inter-
vention would be more attractive to individuals with lower
initial interest due to competing life concerns, and that a mo-
tivational component may help such persons to understand
the implications of HIV for other life goals and allow them to
bene“t from skills-oriented components. This approach was
also consistent with the information-motivation-behavioral
skills model of HIV risk reduction (Fisher & Fisher, 1992).
Our initial project evaluated the motivational intervention
with 102 low-income women in a RCT (Carey, Maisto, et al.,
1997). Women were recruited using street outreach, and in-
vited to attend four, 90-minute group sessions. During the
“rst two sessions, they received personalized feedback re-
garding their HIV-related knowledge, risk perceptions, and
sexual behavior; viewed a motivational videotape of an HIV-
infected woman from the community; participated in exer-
cises to clarify the pros and cons of risky sex; and discussed
HIV relative to other concerns. The “nal two sessions were
devoted to the development of personalized action plans, ed-
ucation, and skills training. Results indicated that treated
women increased their knowledge and risk awareness,
strengthened their intentions to practice safer sex, communi-
cated their intentions to partners, reduced substance use
proximal to sexual activities, and engaged in fewer acts of
unprotected vaginal intercourse. These effects were observed
immediately and most were maintained at the follow-up.
Comparison of these results with those obtained in similar tri-
als suggested that the motivational approach yielded a larger
effect size relative to skills-based approaches. In a second
RCT (Carey et al., 2000), we strengthened our earlier design