Primary Prevention 223counseling recommendations (Kamb et al., 1998). Both inter-
ventions were implemented with adults during interactive,
one-on-one sessions at “ve public STD clinics; theenhanced
intervention involved four sessions whereas thebriefinter-
vention involved only two. Both interventions were compared
to a standard care (didactic messages only) control group. The
sample consisted of 5,758 heterosexual, HIV-negative pa-
tients. Evaluations at 3, 6, 9, and 12 months assessed self-
reported condom use; the evaluations at 6 and 12 months also
assessed new diagnoses of STDs with laboratory tests. The
“ndings revealed that, at the 3- and 6-month follow-ups, con-
dom use was higher in both the enhanced and brief counseling
groups compared with participants in the control group. At the
6-month interval, new STDs were less common in both the en-
hanced (7%) and brief counseling (7%) arms compared with
those in the control group (10%). This “nding was replicated
at the 12-month assessment. This study lends support to the
notion that brief, theoretically based counseling that uses per-
sonalized action plans can increase condom use and prevent
new STDs even in busy public STD clinics. Because there was
not a pattern favoring the enhanced intervention, these results
suggest that even a two-session counseling intervention could
lead to risk reduction in downstream settings. Materials
from this study are also available at http://www.cdc.gov/hiv
/projects/respect/.
Downstream interventions in STD clinics have also been
evaluated with adolescents.Metzler, Biglan, Noell, Ary, and
Ochs (2000) recruited 339 adolescents, aged 15 to 19 years,
from public STD clinics. They implemented and evaluated a
“ve-session intervention to reduce sexual risk behavior using
a RCT. Their intervention, which was in”uenced by social
cognitive theory (Bandura, 1986) and the Information-
Motivation-Behavioral Skills model (Fisher & Fisher, 1992),
targeted (a) decision making about safer sex goals, (b) social
skills for achieving safer sex, and (c) acceptance of negative
thoughts and feelings, and was compared to a standard care
control condition. Results at the 6-month follow-up indicated
that adolescents who received the behavioral intervention
reported fewer sexual partners, fewer nonmonogamous part-
ners, and fewer sexual contacts with new or anonymous
partners in the past 3 months, and less use of marijuana be-
fore or during sex. Treated adolescents also performed better
on a role-play assessment of skill in handling dif“cult sexual
situations.
Overall, the results from downstream settings suggests
that interventions guided by theory reduce risk behavior and
incident STDs, especially among patients who test positive
for HIV. Encouraging “ndings have been obtained in one or
two sessions with adults, and with longer interventions with
adolescents. Continued development of such interventions
to enhance the magnitude of the behavior change, and to
facilitate their incorporation into busy settings will be needed.
Also needed is work demonstrating the effectiveness of such
programs in family planning/pregnancy prevention programs.Drug Abuse Treatment SettingsBecause HIV is often transmitted through sharing of injection
equipment, sites that provide treatment for injection drug
users (IDUs) provide another excellent opportunity to pre-
vent HIV transmission. (Later in this chapter, we discuss
other approaches to HIV risk-reduction strategies for drug-
using populations including community-based outreach and
network approaches, as well as needle exchange programs
(Needle, Coyle, Normand, Lambert, & Cesari, 1998).
Drug abuse treatment can reduce HIV risk behavior both
directly and indirectly. Direct effects can result from treat-
ment components that target HIV risk behavior, including
both risky sex and IDU. Indirect bene“ts might result from re-
ducing drug use, which leads to a reduction in sexual risk be-
havior. A recent review examined the associations among
treatment participation, HIV risk reduction, and HIV infection
and concluded that IDUs who are in treatment demonstrate
lower rates of drug use and related risk behaviors (Metzger,
Navaline, & Woody, 1998). An illustrative study was reported
by Avins et al. (1997). They conducted a prospective cohort
study of 700 alcoholics recruited from “ve public alcohol
treatment centers, all of which included HIV risk-reduction
counseling. At the time of entry to alcohol treatment program
and again about one year later, the patients received an HIV
antibody test and took part in an interviewer-administered
questionnaire. Compared to baseline, at follow-up there was a
26% reduction in having sex with an IDU partner and a 58%
reduction in the use of injection drugs. Respondents also
showed a 77% improvement in consistent condom use with
multiple sexual partners and a 23% improvement in •partner
screening.ŽNot surprisingly, patients who remained abstinent
showed greater improvement than those who continued to
drink. Other studies conducted in drug abuse treatment set-
tings con“rm that needle use risk behaviors tend to decrease
following treatment; however, changes in sexual risk behavior
are less consistently observed (Metzger et al., 1998).
The overall effect of various downstream preventive inter-
ventions targeting IDUs on HIV prevalence was the focus of
a study reported by Des Jarlais et al. (2000). They accumu-
lated a sample of more than 5,000 IDUs from two locations
in New York City, a drug detoxi“cation program or a store-
front in a high drug-use area; and analyzed trends in HIV
risk behaviors over the period 1990 to 1997. Their results
indicated that injection and sexual risk behaviors declined