EFFICACY OF A STAGE-BASED BEHAVIORAL INTERVENTION TO PROMOTE STI SCREENING IN YOUNG WOMEN: A RANDOMIZED CONTROLLED TRIAL Chacko MR, Wiemann CM, Kozinetz CA, von Sternberg K, Velasquez MM, Smith PB, DiClemente R.

Baylor College of Medicine, University of Texas Medical School at Houston, Houston,TX and Rollins School of Public Health, Emory University, Atlanta, GA Funding # 1R01A NIAID # T71MC00011 HRSA, MCHB

BACKGROUND Screening and treatment of asymptomatic and symptomatic CT and NGC infections is important to decrease the incidence of PID and tubal damage CT and NGC screening programs for young women have been directed to health providers Absence of interventions to promote client- initiated screening among young women

PURPOSE To determine the efficacy of a client-centered, motivational behavioral intervention promoting CT and NGC screening in response to high-risk sexual behavior in young sexually active minority women attending an urban community-based, free reproductive health clinic

HYPOTHESES Intervention group more likely than the Standard Care group to return for STI screening in response to high-risk sexual behavior over a 12- month period Number of episodes of CT or NGC infection over the 12-month period in the Intervention group similar to the Standard Care group

OUTCOME MEASURES Primary: Number of STI visits in response to high- risk sexual behavior Secondary: Number of episodes of CT and NGC

ELIGIBILITY CRITERIA Females 16 to 22.5 years English speaking Not pregnant/not trying to conceive Not legally or common law married HIV negative Not intoxicated on alcohol or illicit drugs at enrollment Able to understand consent form Agree to participate for 12 months

ENROLLMENT 770 eligible Higher refusal rate by Hispanic young women Reasons for refusal: –Disinterest, no reason –Plan to move –Working, no time –Changed health care provider –Too many phone calls and questions –Breach in confidential care –Too busy

ENROLLMENT 376 (49%) enrolled Mean age 18.5 years 67% African American, 18% Hispanic, 11% non Hispanic whites and 4% other No differences in demographic and behavioral characteristics between groups at baseline

PROCEDURES Standardized questionnaire Urine for CT and NGC testing Random assignment Intervention plus Standard Care ( N = 192) Standard Care (N =184)

INTERVENTION Motivational counseling guided by the Trans Theoretical Stages of Change Model Provided by trained health counselor Two motivational counseling sessions At enrollment At 2 weeks A brief booster session at 6 months

HIGH-RISK SEXUAL BEHAVIORS Partner has other partners Sex with more than one partner Sex with a new partner Inconsistent condom use Condom slipped/broke Think she may have a STI Thinks partner has STI

FOLLOW UP Scheduled visits: 6- and 12- month assessments Standardized questionnaire Urine for CT and NGC testing STI visits: Baseline to 6 months and 6 to 12 months Reason for visit questionnaire

SCHEDULED VISITS 2-week Intervention: 69% 6- month assessment: Intervention 70% Vs Standard Care 82% (p- value < 0.01) 12-month assessment: Intervention 61% Vs Standard Care 68% 5.6% dropped out of the study

DATA ANALYSIS Comparison of distribution of > 1 STI visit for three time periods (baseline to 6-months, 6- to 12-months, baseline to 12-months ): Chi-square analysis Comparison of distribution of CT/NGC episodes for three time periods: Chi-square analysis Longitudinal analysis using generalized estimating equations (GEE)

STI VISITS Total # STI visits 168 Intervention 78/168 (46%) Vs Standard Care 90/168 (54%) Range Intervention 1-4, Standard Care 1-5 Main reasons for STI visit: –Sex without a condom 79% –Sex with a new partner 42%

GEE ANALYSIS Multivariate Modeling Consistent condom use Multiple partners New partners Other partners Partner refusing condom use * Significant OR Likelihood of a STI if condom not used >5 partners in lifetime Birth control at last sexual encounter Thinking/being pregnant* STI during lifetime

CT AND NGC INFECTION Intervention Standard Care Baseline 20% 24% 6-month 10% 11% 12-month 13% 16% The distribution of CT/NGC episodes between groups did not differ across time (p = 0.43, 0.95, 0.67)

STI RISK INDEX To evaluate association between STI risk behavior and STI visits Sex with >1 partner, sex with new partner, inconsistent condom use, prior STI, early sexual debut Higher risk index was significantly associated with seeking screening in the Standard Care group between 6 and 12 months No such association was observed in the Intervention group

SUMMARY Did not observe a larger number of STI visits in the Intervention Group Did not observe a difference in CT and GC episodes between groups High risk within the Standard Care group was significantly associated with more STI visits

LIMITATIONS Young women were already seeking services in clinic Study sample may have been too broad Loss of subjects at follow up

CONCLUSIONS First attempt at examining the effectiveness of a motivational behavioral intervention to promote STI screening in young women A closer look at potential explanations for the observed primary outcome is warranted Future studies should target young women with high risk behaviors at STI clinics Consider redesigning intervention – fewer target behaviors