Primary Prevention 225whether sex education should occur in the school or in
the home, and whether abstinence is the only appropriate
outcome, continues to challenge the routine integration of
effective sex education and HIV risk reduction programs in
many schools.
Clinic-Based Programs
Primary care settings afford a unique opportunity to reach
thegeneralpopulation with HIV-risk reduction programs.
Gerbert, Bronstone, McPhee, Pantilat, and Allerton (1998)
developed a brief screening instrument for use in primary
medical care settings. Their measure (the HIV-Risk Screen-
ing Instrument, or HSI), contains 10 items (e.g., number of
sexual partners, condom use, STD history); the HSI is reli-
able, valid, and can be administered quickly, even by busy
physicians. Patients who participated in their studies report
that they felt it was important that their physician know this
information about them, and that they wished to discuss their
answers with their physician. This screen can serve to •break
the iceŽ for health care providers who might otherwise “nd
it dif“cult to inquire about socially sensitive behaviors. We
have also found that screening can be achieved easily in
mental health settings (Carey et al., 1999, 2001). Given that
screening instruments can be used during the routine intake
assessments, it is feasible to identify risk behavior in practice
and to implement targeted interventions for patients identi-
“ed as being at elevated risk for HIV.
Primary (Medical) Care Setting. Several interventions
have been tested in primary care settings. For example, Kelly
et al. (1994) evaluated the effectiveness of an HIV interven-
tion group for womenin urban clinics. Women who engaged
in high risk behavior (N197) were recruited and assigned
to either an HIV-risk reduction group or a health promotion
comparison group. The HIV-risk reduction intervention was
modeled after Kelly•s (1995) successful group-based pro-
gram, initially developed in community samples of gay men
(described later in the chapter), and was implemented in “ve
small-group sessions. Key intervention components involved
HIV education; training in condom use, sexual assertiveness,
problem-solving, and self-management skills; and peer
support. At a 3-month follow-up, HIV group participants in-
creased their sexual communication and negotiation skills as
well as their condom use (from 26% to 56%) while reducing
occasions of unprotected sexual intercourse.
The value of Kelly•s (1995) model has also been demon-
strated with menin primary care settings. The NIMH Multi-
site HIV Prevention Trial (1998) targeted 3,706 high-risk
men and women at 37 clinics (mostly primary care but also
some STD clinics) across the United States. This ambitious
study evaluated the ef“cacy of an intervention based on Kelly
et al.•s approach when administered to small groups during
seven sessions. Participants who received the intervention re-
ported fewer unprotected sexual acts, had higher levels of
condom use, and were more likely to use condoms consis-
tently over a 12-month follow-up period. Although clinic
records revealed no difference in overall STD reinfection rate
between participants in the intervention and control condi-
tions, men recruited from STD clinics who received the
intervention had a gonorrhea incidence rate that was one-half
that of the control group. Participants who received the
intervention also reported fewer STD symptoms over the
12-month follow-up period.
Boekeloo et al. (1999) drew on social-cognitive theory
and the theory of reasoned action to develop an of“ce-based
intervention for adolescentsseen in primary care settings.
They evaluated the intervention with 12- to 15-year-old pa-
tients (N215; 81% ethnic minorities) who were receiving
a general health examination in a managed care setting.
Both the risk behavior and the educational intervention were
administered with a private audiotape. This intervention
occurred during the course of a normal of“ce visit. One
promising “nding was that sexually active adolescents in the
intervention group were more likely to report condom use at
3 months compared to control participants. Also, at the
9-month follow-up, there were more signs of STD reported
by the controls (7/103) than the intervention group (0/94).
This clever intervention approach affords an attractive and
private option, especially for teens. It may also facilitate
discussion of sexual health issues between teens and their
health care providers.Mental Health Care Clinics. Evidence indicating that
men and women who are receiving treatment for a severe
mental illness (SMI) are at elevated risk for infection with
HIV (Carey, Weinhardt, & Carey, 1995; Carey, Carey, &
Kalichman, 1997) has lead to the development of risk reduc-
tion programs that are tailored for this population. One of our
studies examined whether training women with a SMI to be
assertive in sexual situations would decrease their risk for
HIV infection (Weinhardt, Carey, Carey, & Verdecias, 1998).
Twenty female outpatients received either a 10-session as-
sertiveness intervention or a control condition. All women
completed measures of HIV-related information, motivation,
skills, and sexual risk behavior pre- and postintervention and
at two follow-ups. Compared with controls, women in the
intervention group increased their assertiveness skill, HIV